• Cessna 172 Maintenance, Impairment

    CEN18FA336
    Rhome, TX August 16, 2018
    Fatal: 1, Serious: 3

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    CEN18FA336 NTSB Photo

    The following is from the NTSB accident report. The commercial pilot was taking family members for rides in his airplane; the accident flight was the third flight of the evening. After the second flight, the pilot landed and taxied the airplane back to his property, where three family members boarded the airplane while the engine continued to run. The pilot taxied back to the runway and departed. A pilot-rated witness stated that the takeoff roll was longer than expected, and, once airborne, the airplane pitched "very high" nose-up to about 50 ft above ground level (agl), then the nose came back down. The airplane appeared to accelerate down the runway until it climbed to about 300 ft agl, then made a left turn and descended out of view. The airplane impacted several trees and continued into a field, where it came to rest inverted. Damage to the propeller was consistent with a lack of engine power at the time of impact.

     

    Examination of the airplane revealed evidence of a longstanding pattern of inadequate maintenance, including a rodent's nest in the leading edge of the left wing, a large mud dauber nest on the oil cooler, and cobwebs in the engine compartment. An automotive hydraulic hose was used in place of the main fuel line from the gascolator to the carburetor. The gascolator fuel strainer contained 3 large pieces of organic debris similar to insect cocoons, which were the same size as the hydraulic hose and associated fuel fitting. It is likely that the fuel line was removed for an extended period of time and eventually replaced with the automotive hydraulic hose, during which time the fuel system was exposed, which allowed insects to nest inside; because there were no maintenance records associated with the airplane, it could not be determined when the hose was replaced. During the accident flight, it is likely that the organic material became dislodged and restricted fuel to the carburetor, which subsequently starved the engine of available fuel and resulted in a total loss of engine power.

     

    The autopsy of the pilot revealed evidence of hypertension and coronary artery disease; however, it is unlikely that these conditions contributed to the accident. Toxicological testing indicated that the pilot had been using alcohol before the accident and had levels considered impairing; it is likely that alcohol impaired the pilot's decision making and his ability to operate the airplane. Toxicological testing also revealed evidence that the pilot had used marijuana before the accident; however, it could not be determined if the concentrations would have been impairing or would have affected his performance.

     

    The NTSB probable cause finding states, "The pilot's inadequate maintenance of the airplane, which resulted in a total loss of engine power due to fuel starvation when organic debris restricted available fuel to the carburetor, and the pilot's impairment due to the ingestion of alcohol, which affected his ability to safely operate the airplane following the loss of engine power."

    CEN18FA336 NTSB Photo

    Above: organic debris in fuel fitting (NTSB Photo)

    Left: Empty beer can (NTSB Photo)

    Mud dauber's nest in oil cooler (NTSB Photo)

    Rodent nest in wing (NTSB Photo)

    The pilot, age 63, was a commercial pilot rated for both single and multiengine airplanes. He had approximately 8,000 hours. The NTSB report indicates that he was an "occupational pilot" which implies that he made his living by flying. A local news outlet reported that the pilot owned a sky diving operation.Two of the seriously injured passengers were children, ages 9 and 14.

     

    Some accidents are truly puzzling. The airplane was not even close to being airworthy. The pilot was experienced, having 8,000 hours. We all know that a pilot can become complacent about many things, including aircraft maintenance. But the condition of this airplane was absurd. If he had always been this cavalier about maintenance, it is doubtful that he would have made it to age 63 with 8,000 hours. Then there is the impairment due to alcohol and possibly also due to marijuana. Did the impairment lead him to fly an airplane in this condition? That seem unlikely because this family outing had been planned in advance. It is more likely that the impairment interfered with his ability to handle the loss of engine power at a low altitude. In any case, it is sad that three people had to be seriously injured in an accident during a flight that should never have left the ground.

     

     

    Click here to see the NTSB report on the NTSB website.

  • Cessna 172 LOC-I

    ERA18FA037
    Pittsford, VT November 22, 2017

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    NTSB Photo

    The NTSB report includes the following: "The 89-year-old commercial pilot departed on a cross-country flight late on the day before Thanksgiving to visit relatives. He received two weather briefings in the 2 days before the flight, with the most recent briefing (the day before the flight) indicating widespread marginal visual flight rules conditions and mountain obscuration; the briefer advised the pilot that visual flight rules (VFR) flight was not recommended. Despite the conditions presented during the weather briefing, the pilot chose to conduct the flight under VFR and indicated to the briefer that he did not want to fly through clouds with potential icing conditions

     

    GPS track data downloaded from a unit onboard the accident airplane indicated that the flight began uneventfully, with the pilot following a highway, likely for route guidance. As the flight progressed, the airplane's altitude began to decrease. This is consistent with the reported weather conditions and the pilot attempting to remain clear of clouds since he was not on an instrument flight rules flight plan and did not want to fly through the clouds. Near a location where the highway turned west through a town and around terrain, the airplane continued straight and flew along a valley between two ridges. The airplane made two turns within the valley, then made a left turn to the west, possibly in an attempt to return to the highway. While heading toward the highway and after crossing the ridge, the airplane entered a descending right turn. The GPS data ended about 750 ft from the accident site and indicated that the airplane was about 425 ft above ground level. Examination of the airplane, engine, flight controls, and instruments did not reveal any preimpact anomalies that would have precluded normal operation.

     

    Toxicology testing indicated that the pilot had used diphenhydramine, a sedating antihistamine, at some time before the accident; however, the blood level of the potentially impairing medication was below the therapeutic and impairing level. Therefore, it is unlikely that the pilot's use of diphenhydramine contributed to the accident.

     

    Based on the available information, it is likely that the pilot inadvertently encountered instrument meteorological conditions while maneuvering the airplane in deteriorating light conditions near the end of civil twilight. Although the pilot was instrument rated, no determination of his recent instrument flight experience could be made. He was likely not prepared for the sudden entry into instrument conditions and the loss of visibility combined with the turns and varying altitudes while attempting to exit the valley resulted in spatial disorientation and a subsequent loss of airplane control."

    NTSB Graphic

    The NTSB Probable Cause finding states: "The pilot's decision to continue visual flight into instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation."

    NTSB Graphic

    Several common accident causal factors are illustrated by this accident. First, the accident happened on the day before Thanksgiving.The pilot was making the flight to spend the holiday with family. We know how powerful external factors can be on a pilot's decision making. His most recent weather briefing was two days prior to the flight. It would appear that he had already made up his mind that he was going to fly.

     

    The full NTSB report states that no records could be located regarding pilot recent experience, completion of a flight review, or aircraft inspections. His medical certificate had recently expired and he had not completed the requirements for Basic Med. His airplane had an upgraded engine, but no STC had been filed with the FAA. This perhaps indicates complacency regarding regulations and procedures. An attitude of complacency could have been responsible for the pilot believing that he could successfully complete the flight in the adverse weather.

     

    Click here to see the NTSB report on the NTSB website.

     

  • Cirrus SR22 Distraction

    ERA18LA124
    Lowville, NY April 8, 2018
    Uninjured: 3

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    The NTSB report includes the following: "The airplane was on a cross-country flight at 9,000 ft mean sea level, which was about 1,000 ft above clouds. At that time, the private pilot had the autopilot engaged and in navigation mode for the airplane to proceed directly to the next waypoint. An air traffic controller requested that the pilot turn right 20° or more, which the pilot complied with by switching the autopilot to heading mode and selecting the desired heading. Subsequently, the controller advised the pilot that he could proceed back on course. The pilot switched the autopilot back to navigation mode but did not select the next waypoint on the GPS. He realized immediately that he was returning to his previous navigation course and then selected the next waypoint on the GPS and again selected navigation mode on the autopilot. By the time he returned his attention to the primary flight display, the airplane was descending out of control through clouds, and the pilot subsequently activated the airplane's parachute system. The airplane descended via parachute and landed upright in a field, but wind gusts blew the parachute, which inverted the airplane. Examination of the wreckage revealed that during the hard landing, the nose landing gear collapsed and both main landing gear spread outward, which resulted in substantial damage to the primary structure of the airplane."

     

    "The primary flight display did not record any data. Thus, the investigation could not determine if the autopilot was engaged when the airplane departed controlled flight. However, regardless of whether or not the autopilot was engaged, it is likely that the pilot's attention was diverted to the GPS, which resulted in his failure to adequately monitor the airplane's attitude and maintain control of the airplane."

     

    The NTSB Probable Cause finding states: "The pilot's diverted attention, which resulted in his inadequate monitoring of the airplane's attitude and a loss of control in flight."

    NTSB Photo

    The pilot was age 49 with a private Pilot Certificate for airplane, single-Engine, Land. He had an instrument rating and was current in regard to all applicable regulations.

     

    This accident illustrates the importance of being thoroughly proficient in the use of any automation that might be in the airplane. It also demonstrates that the old warning to fly the airplane first, regardless of what else is going on. Perhaps this accident could have been avoided had the pilot simply asked the ATC controller for a vector as soon as he was aware that the autopilot was not taking where he needed to go.

    Excerpt from Cirrus Aircraft publication

    To the pilot's credit, he complied with Cirrus instructions to immediately activate the ballistic chute system in the event of a loss-of-control. His decision to take that bold action almost certainly was responsible for saving the lives of himself and his two passengers.

     

    Click here to see the entire NTSB report

  • Cirrus SR22 - Task Saturation

    Williamsburg, PA April 19, 2018
    Fatal: 2

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    The NTSB accident report contains the following:

     

    "The private pilot was conducting a personal, cross-country flight with one passenger onboard. According to air traffic control (ATC) communications and radar data, while en route to the destination airport about 5,425 ft mean sea level, the pilot reported to ATC that the airplane was accumulating ice, and he requested to divert to the nearest airport. However, due to the overcast cloud layer at 200 ft above ground level (agl) at the nearest airport, the pilot chose to attempt an instrument landing system (ILS) approach into another airport with a slightly higher overcast cloud layer of 500 ft agl. During the descent to intercept the localizer for the ILS approach, the pilot flew through the localizer path, and he did not realize it until the controller notified him that he had done so. The pilot subsequently requested additional vectors to attempt to intercept the localizer again, and the controller instructed the pilot to turn left. The airplane subsequently turned left toward the north. About 39 seconds into the turn, the airplane began to descend, and the airspeed increased. About 10 seconds later, the left turn tightened, and the airplane began to spiral until the radar data ended. The airplane subsequently impacted the ground in a steep, nose-low, wings-level attitude.

     

    A review of weather information current at the time of the flight revealed that the airplane likely encountered instrument meteorological conditions (IMC) about 500 ft agl on the initial climbout from the departure airport and remained in IMC and conditions favorable to icing for the rest of the flight. The airplane likely encountered some turbulence along the flight route in the cloud cover and would have had to climb above 10,400 ft msl to escape the IMC and icing conditions. Super-cooled liquid droplets (SLD) and icing conditions were likely present along the flight route throughout the flight.

     

    Before the flight, a forecast icing potential (FIP) indicated that light-to-moderate intensity icing existed near the accident site, and a current icing potential product indicated that SLD existed near the accident site; this information would have been available to the pilot before the accident flight departed.

     

    The pilot received a weather briefing via the ForeFlight application on his mobile device about 10 hours before the accident flight. At that time, the forecast showed cloud cover, snow showers, and instrument flight rules conditions. Since the AIRMET received in the weather briefing expired at 0500 the pilot should have requested an updated briefing with the valid AIRMET. In the time between the weather briefing and the accident, an AIRMET was issued for moderate icing, IFR/mountain obscuration, and low-level turbulence, and was valid until 1100. An updated AIRMET advisory was recorded via the flight plan identification number less than 2 hours before departure. No records were found indicating whether the pilot retrieved any other weather information before or during the flight. Therefore, although the pilot had sufficient weather forecast information available to him before departure to have known about the existing icing conditions along the flight route, the investigation could not determine whether he received all of the pertinent information before the flight.

     

    Although the pilot reported that the airplane had accumulated ice, the investigation could not determine if the airplane was significantly affected by structural icing during the approach. The airplane was not equipped with an anti-icing or deicing system, which prohibited the pilot from flying into known icing conditions per Title 14 Code of Federal Regulations Section 91.527, "Operating in Icing Conditions."

     

    Although postaccident examination of the wreckage was limited due to postimpact fire damage, the examinations of the airframe and engine did not reveal evidence of any preaccident mechanical malfunctions or anomalies that would have precluded normal operation. The examination revealed that the Cirrus Airframe Parachute System (CAPS) handle remained in its holder, and that its safety pin, which was supposed to be removed before flight, remained installed. The CAPS was found deployed, and the CAPS solid rocket propellant was expended. All evidence revealed that the CAPS was not activated in flight but rather that it deployed due to impact forces and thermal exposure.

     

    The autopsy of the pilot revealed that he had heart disease; however, this would not have affected his decision-making, his ability to identify and respond to icing on the plane, or his ability to fly the airplane in IMC; therefore, his heart disease did not contribute to the accident. Although toxicology testing detected ethanol in the pilot's liver tissue, no ethanol was found in his muscle tissue. Given that, after absorption, ethanol is uniformly distributed throughout all tissue and body fluids, it is likely that the ethanol detected in the liver occurred postmortem and did not contribute to the accident. The toxicology testing also detected two impairing psychoactive substances, diphenhydramine and clonazepam, in tissue specimens. These drugs alone or in combination could have affected the pilot's decision-making and/or slowed his detection of potential hazards and his reaction to them. However, antemortem levels of these two drugs could have been low enough to not have affected him, but, because antemortem levels cannot be calculated from tissue levels, it could not be determined whether effects from the pilot's use of diphenhydramine and clonazepam contributed to the accident.

     

    The radar data showed that the airplane was flying a relatively smooth and consistent flightpath with altitude and heading changes that were indicative of the pilot using the autopilot for a majority of the flight, until the final turn after flying through the localizer course. The pilot's failure to recognize that he had not intercepted the localizer is consistent with his failure to appropriately configure the avionics for the approach or with his attention being diverted from navigational tasks due to his workload while trying to conduct the approach. Conditions conducive to the development of spatial disorientation, including restricted visibility and IMC while maneuvering, existed. Further, the accident circumstances, including the spiraling radar track data and the subsequent high-velocity impact were consistent with the known effects of spatial disorientation. Therefore, the airplane's entry into a descending left turn while the pilot was being vectored back toward the localizer course, which subsequently tightened, was likely due to the pilot experiencing the effects of spatial disorientation due to a vestibular illusion referred to as a "graveyard spiral," which can occur when an airplane returns to level flight following a prolonged bank turn. The spatial disorientation resulted in the pilot's loss of airplane control and a high-velocity impact with terrain."

     

    The NTSB Probable Cause finding states, "The pilot's failure to obtain an updated weather briefing before the flight and his subsequent loss of airplane control due to spatial disorientation while maneuvering in instrument meteorological conditions during a diversion to an alternate airport after encountering forecast icing conditions."

    NTSB Photo.

    This is perhaps an example of a pilot operating at task saturation. As we approach that point, our brains begin to decide on our behalf what is most important and then focus on that, blocking out other perceptions. We know that we should always make flying the airplane our primary responsibility, but our brains sometimes focus our attention on something else.

     

    For some related content regarding task saturation, check out my video "Task Load vs. Capabilities"

    NTSB Photo showing CAPS T-handle with safety pin installed

    Even though the pilot lost control of the airplane, these people still perhaps could have been saved. This airplane was equipped with a ballistic parachute system. The system has saved many lives in the few years that it has been available. It is activated by pulling a T-handle located above the pilot. Checklist instructions from the aircraft manufacturer instruct the pilot to remove the safety pin from the T-handle before flight. One of the few recognizable parts in the wreckage was the safety pin still installed in the T-handle.

     

    Click here to see the NTSB report on the NTSB website.

  • Cessna 172 Wire Strike

    CEN18FA011
    Ramsey, MN October 13, 2017
    Fatal: 2

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    Analysis:

    After takeoff, the pilot proceeded south until reaching the Mississippi River when he proceeded to fly along the river at a low altitude. As the airplane approached a bend in the river, the pilot entered a shallow left turn to follow the river. The airplane subsequently struck power lines spanning the river that were located about 200 yards beyond the bend. Ground-based video footage and witness statements indicated that the airplane was at or below the height of the trees lining both sides of the river shortly before encountering the power lines. One witness initially thought that the pilot intended to fly under the power lines due to the low altitude of the airplane. Several witnesses also noted that the sound of the engine seemed normal and steady before the accident. A post-recovery examination of the airplane did not reveal any anomalies consistent with a preimpact failure or malfunction. The power lines were below the level the trees on either side of the river. Red aerial marker balls were installed on the power lines at the time of the accident. Weather conditions were good at the time of the accident; however, the sun was about 9° above the horizon and aligned with the river. It is likely that the position of the sun in relation to the power lines hindered the pilot's ability to identify the hazard as he navigated the bend in the river at low altitude. In addition, the location of the power lines relative to the river bend minimized the reaction time to avoid the lines. FAA regulations prohibit operation of an aircraft less than 500 feet above the surface in uncongested areas unless approaching to land or taking off, and at least 1,000 feet from obstacles in congested areas. They also prohibit operations in a reckless manner that endanger the life or property of another. Based on the available information, the airplane was less than 100 feet above the river and within 400 feet of the residences located along the river during the final portion of the flight. The pilot's flight instructor described the pilot as "reckless" because of his habit of low-level flying. While the location of the bend in the river and the position of the sun relative to the power lines may have hindered the pilot's ability to see and avoid the lines, it was the pilot's decision to operate the airplane along the river at a low altitude contrary to applicable regulations and safety of flight considerations that caused the accident.

     

    Probable Cause

    The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot's decision to fly along the river at a low altitude contrary to applicable regulations and safety of flight considerations which resulted in the impact with the power lines. Contributing to the accident was the pilot's inability to see the and avoid the power lines due to their proximity to a bend in the river and the position of the sun at the time of the accident.

     

    Lessons:

    Low-level flying is hazardous and should be avoided unless it is absolutely necessary. This accident illustrates the increased danger of striking objects such as wires. Additional hazards associated with low-level flying include increased bird activity and greater susceptibility to wind shear and other thermal anomalies. Flying at a higher altitude also provides more options to deal with an emergency situation.

     

    As noted in the photo, if low-level flying is necessary, be aware that wires are nearly invisible from the airplane. Watch for poles or transmission towers. Assume that there are wires running between them.

    The photo above shows the propeller blade with a visible gouge and evidence of electrical arcing.

    NTSB Photo

     

    Click here to see the entire NTSB report

  • Piper Comanche

    Evanston, WY July 29, 2018
    Uninjured: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    The eighty-year-old pilot was not injured when he landed his Piper Comanche with the landing gear still retracted. The airplane was substantially damaged.

     

    The NTSB accident report includes the following summary of the accident: “The pilot in the retractable landing gear-equipped airplane reported that, during the cross-country flight, the autopilot failed, and he struggled to use the sectional charts. He added that heat and wind made the flight uncomfortable, and smoke from wildland fires decreased visibility to about 5 statute miles, so he decided to land. He completed some of the GUMPS (gas [proper tank selected], undercarriage [gear down], mixture [full mix for landing], and propeller [high rpm setting]) checklist and decided not to extend the landing gear to have better control. Upon arrival at the airport, he decided to leave the landing gear retracted as he searched for the windsock on the airport, but he could not find it. Subsequently, he attempted to contact the airport on the Unicom frequency, but he later determined that he had used an incorrect frequency. He decided to land on runway 5, which he later identified was the incorrect runway given the wind direction. He forgot to extend the landing gear before landing.

     

    The NTSB Probable Cause finding states, “The pilot's failure to extend the landing gear during landing. Contributing to the accident were the pilot's distraction and his failure to complete the appropriate checklist before landing.”

     

    A pilot making an unintentional gear-up landing in a retractable landing gear airplane is nearly a daily occurrence in the U.S. It rarely results in injury to the airplane occupants, but it usually results in a very substantial repair bill and sometimes it is more economical to scrap the airplane.

     

    The frustrating aspect of this is how easy it is to prevent a gear-up landing. The before landing checklist certainly includes and item regarding gear down and locked. Interruptions to checklists are unavoidable. A proven method use following a checklist interruption is to go back three steps from where the checklist was interrupted.

     

    Also, the use of a mnemonic on final should be used. I like “GUMPS” (gas, undercarriage, mixture, props). “Gas” is to remind me to be using a tank or tanks with enough fuel quantity should a go-around be necessary. “Undercarriage” is to remind me to verify that the landing gear is down and locked. “Mixture” reminds me to set the mixture controls for a possible go-around, usually to the full rich position. “Props” reminds me to configure the propeller controls for a possible go-around, usually to the high RPM position.

     

    The single-pilot cockpit can be a busy and sometimes confusing place, especially when landing at an unfamiliar, non-towered airport. Checklist discipline and use of a mnemonic can go a long way toward making sure everything that needs to be done has been done before landing.

     

    Click here to see the accident report on the NTSB website.

  • Piper Arrow PA-28-201

    ERA16FA257
    Esperance, NY July 16, 2016
    Fatal: 3, Serious: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    This accident occurred on July 16, 2016 in Esperance, New York. The airplane was a Piper Arrow, PA-28-201. The pilot was seriously injured and his three passengers died in the accident.

     

    The NTSB accident report contains the following: “The private pilot and three passengers departed in the airplane from a 3,000-ft-long runway with a density altitude of about 3,000 ft and a light wind. Surveillance video showed that the airplane did not use the entire length of the runway for takeoff; the pilot began his takeoff roll where the paved section of the part turf/part asphalt runway began, resulting in 2,400 ft of available runway. During the ground roll, the nose of the airplane lifted off and then settled back onto the runway, and the airplane became airborne at 1,500 ft. Witnesses described the takeoff and initial climb as "slow" and "sluggish." The wings rocked, and the airplane climbed to about 100 ft in a continuous left turn before descending into trees 1,000 ft left of the runway centerline.

     

    Examination of the airplane and its engine revealed no evidence of preimpact mechanical malfunction or anomaly. An estimate of the airplane's takeoff weight indicated that it was about 66 pounds over the maximum allowable takeoff weight of 2,750 pounds. Review of performance charts revealed that the takeoff ground roll distance for the airplane at the maximum allowable gross weight was about 2,180 ft. Review of radar data showed that from rotation to the final radar target, the airplane's groundspeed (which was about the same as its airspeed given the light wind) varied between 61 and 67 knots, which was about the airplane's calculated stall speed of 60 knots. Further, the witness observations were consistent with the pilot failing to attain sufficient airspeed, which resulted in the airplane's wing exceeding its critical angle of attack and an aerodynamic stall.

     

    It is likely that the pilot lifted off prematurely at a speed lower than normal and was unable to accelerate or climb the airplane once it exited ground effect. A premature liftoff and a climb attempt at a speed significantly below best angle of climb speed (78 knots) placed the airplane in a situation where the power required for level flight was very near or exceeded the available power. To recover from this situation the pilot needed to lower the airplane's nose in order to accelerate the airplane to obtain a positive rate of climb. However, such an action is counterintuitive when low to the ground and requires accurate problem recognition, knowledge of the correct solution, and sufficient terrain clearance to accomplish.”

     

    The NTSB probable cause finding states, “The pilot's inadequate preflight weight and balance and performance planning, which resulted in the airplane being over gross weight. Also causal were the pilot's decision not to use the entire runway for takeoff, his premature liftoff, and his failure to attain adequate airspeed, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall.”

    NTSB Photo

    We do not know how much, if any, preflight planning the pilot did regarding calculating the weight and balance or the takeoff performance of the airplane prior to this flight. By the NTSB’s calculations, the takeoff weight was about 66 pounds over the maximum allowable takeoff weight of 2,750 pounds. If this is correct, the airplane was less than 3% over the maximum allowable weight. Though operating outside any aircraft limitation is never a good idea, the excess weight alone would not have caused a problem.

     

    Now we consider the calculated ground roll necessary and the runway length. The NTSB stated that 2,180 feet of ground roll would have been required at the maximum allowable takeoff weight. The airplane was slightly heavier than that so we would expect a slightly longer ground run. The runway was a mix of turf and pavement. The pilot elected to begin the takeoff run at the paved portion, leaving 2,400 feet of runway available. But the final 400 feet of the runway was also turf, leaving the pilot 2,000 feet of pavement. Many pilots, including myself, like to avoid operating airplanes with retractable landing gear on turf runways whenever possible. Perhaps the pilot, not being aware that nearly 2,200 feet of ground run would be necessary for the takeoff, rotated prematurely to avoid running onto the turf portion of the runway.

     

    We must also note that the NTSB report states that the flap handle was found to be in the 10-degree detent. The airplane procedures call for flaps set to 25 degrees for a short field takeoff and there is no performance information provided for a takeoff using flaps extended 10 degrees.

     

    We cannot know all the facts regarding the pilot’s preflight planning, only that the NTSB called it “inadequate.” Going with the NTSB’s finding, it can be assumed that complacency played a roll. We usually have plenty of runway remaining after our takeoff. This was a nice day with a light wind. A takeoff on a 3,000-foot-long runway should be easy so we tend to skip or be less-than-thorough in our planning. But adding a few factors such as not wanting to use all the runway, being slightly above maximum takeoff weight, and not using the recommended flap setting, can have an additive effect. We can get dangerously close to, or slightly beyond, the edge of the performance envelope. Good operating practice plus the regulations require us to do the takeoff performance calculations for every flight. Complacency can kill if we let it.

     

    Click here to see the entire NTSB accident report.

  • Piper PA 46-350

    CEN11LA327
    Chico, TX May 7, 2011
    Uninjured: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    The NTSB accident report includes the following: “According to a statement provided by the pilot, the airplane was in cruise flight at 4,500 feet mean sea level, when he detected a change in engine noise along with fluctuations in the engine speed. The pilot started to divert to the nearest airport, when the engine began to run rough. Shortly thereafter, the pilot smelled, and saw smoke enter the airplane cabin. The smoke increased and the pilot elected to perform a forced landing on a highway. The airplane's nose landing gear did not extend and the airplane slid to a stop on the main landing gear and fuselage nose section.”

    NTSB Photo.

    Regarding postaccident examination of the airframe and engine, the NTSB report states, "The examination revealed substantial damage was sustained to the airplane's forward fuselage and firewall. Distortion from heat was noted to the airplane's nose gear door, which impeded normal operation of the nose landing gear. Clamps on the turbocharger's intermediate exhaust crossover tube were found unsecured. The NTSB's fire investigator found signatures of thermal distress to the fuel flow transducer and fuel flow transducer line. No additional preimpact mechanical malfunctions or failures were found that would have precluded normal operation."

     

    The NTSB Probable Cause finding states, "The mechanic's improper installation of the turbocharger's exhaust balance system, which resulted in an in-flight fire.”


    The lesson to be learned here is that we need to be current on our knowledge of emergency procedures. This pilot acted appropriately and swiftly. Any confusion or uncertainty about what to do or how to do it could have led to a very different end.

     

    Click here to see the entire NTSB accident report.

  • Cessna 172 Exchange of Flight Controls

    CEN18CA323
    Greeley, CO August 8, 2018
    Uninjured: 2

    The NTSB Probable Cause finding states, "The mechanic's improper installation of the turbocharger's exhaust balance system, which resulted in an in-flight fire.”

    The NTSB Report includes the following: “The pilot and a safety pilot were practicing instrument maneuvers, approaches, and landings at different airports during the flight. The airplane entered the traffic pattern for a practice landing at an airport. According to the safety pilot, the airplane was high and slow during the final approach. About 10 ft above ground level, the airplane "floated a little longer," and the pilot initiated a go-around by applying full throttle. During the attempted go-around, both occupants applied conflicting "correction" inputs to the control yokes; the pilot applied back pressure, and the safety pilot applied forward pressure. The airplane stalled, the left wing impacted terrain, and the airplane came to rest upright adjacent to the runway.

     

    The NTSB Report also includes the following: “The pilot statements were conflicting regarding the accident details and sequence of events. Based on the statements and airplane damage, it is likely that the conflicting control inputs resulted in the pilots' failure to maintain a proper airspeed and that the airplane entered an aerodynamic stall during the attempted go-around. Neither pilot reported that verbal communication was established during the landing sequence.”

     

    The NTSB Probable Cause finding states: “The pilot's and safety pilot's conflicting control inputs during landing, which resulted in their failure to maintain a proper airspeed and resulted in an aerodynamic stall. Contributing to the accident was the lack of communication between the pilot and safety pilot during the landing and go-around.”

     

    The lesson to be learned from this accident is that only one pilot should be on the controls at a time. I learned early in my instructing career that it is essential to establish a clear method for the positive exchange of flight controls. This is best accomplished before engine start. There are several acceptable methods that can be used. I prefer one that goes like this. If the flying pilot is relinquishing control, he or she states, “You have the controls.” When the other pilot assumes control of the aircraft, he or she states, “I have control.” At that time, the pilot relinquishing control momentarily puts both hands in the air signaling that control has been transferred. In the non-flying pilot wishes to assume control, he or she states, I am taking control and the flying pilot follows the procedure for relinquishing control as stated above. In the case of a flight instructor taking control to “save the day” the instructor states firmly, “MY airplane” and the pilot receiving instruction immediately releases the controls and raises his or her hands into the air. The instructor immediately follows with, “I have the controls.”

     

    Whatever method or methods are to be used, they need to not only be discussed prior to the flight, but also practiced to make sure everybody is on the same page and will act correctly when the time comes.

     

    Click here to see the entire NTSB report

  • Piper PA-22 LOC-I

    ERA18FA232
    Island Pond, VT August 25, 2018
    Fatal: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    The NTSB accident report includes the following: “The private pilot was landing his airplane at his home airport at the conclusion of a local flight. The airplane was last seen flying normally on the left downwind leg of the airport traffic pattern, and the wreckage was subsequently discovered in a location consistent with a turn from the downwind to base leg of the traffic pattern. The airplane and engine sustained extensive impact damage and postimpact fire damage; however, examination revealed no discrepancies that would have precluded normal operation. A friend of the pilot, who flew with him often, said that the pilot tended to turn from the downwind leg onto the base leg of the traffic pattern "quite steep" (about 40° bank) and slow (62-63 knots). The friend said that he shared his concerns about stalling with the pilot, but the pilot did not share the same concern. The airplane was not equipped with a stall warning horn or angle of attack indicator.

     

    Postmortem toxicology testing revealed the presence of several medications, including diphenhydramine, a sedating antihistamine; however, given the low levels identified, there was no evidence that the pilot was impaired by his use of diphenhydramine or that it contributed to the accident.

     

    Given the amount of fuel onboard and the duration of the flight, it is unlikely that the airplane ran out of fuel. Although there were no witnesses to the accident, given the location of the accident site, lack of preimpact mechanical anomalies, and the pilot's reported habit of conducting traffic pattern turns at a slow speed in a steep bank, it is likely that the pilot exceeded the airplane's critical angle of attack while maneuvering for landing, which resulted in an aerodynamic stall and subsequent impact with terrain.”

     

    The NTSB Probable Cause finding states, "The pilot's exceedance of the airplane's critical angle of attack while maneuvering for landing, which resulted in an aerodynamic stall."

    The lesson to be learned from this accident is that we are only as good as our next flight. This pilot and the airplane both appear to be in full compliance with the regulations.  The NTSB report indicates that the pilot had nearly 1,300 hours total flight time, including 362 in this make and model. He was age 60, had a current FAA medical certificate and flight review. The airplane had a current annual inspection and the engine only had 168 hours since major overhaul. These facts are indicators that the pilot was conscientious. That fact was supported by his pilot friend during an FAA interview. Yet, he died in the crash of a very basic airplane with which he was quite familiar.

     

    We cannot know precisely what went wrong. Perhaps he was complacent about maintaining airspeed, especially during turns. The NTSB report includes the following: "Though the friend described the pilot as being conscientious, he said that the pilot tended to turn from the downwind leg onto the base leg of the traffic pattern "quite steep" (about 40° bank) and slow (62-63 knots). The friend shared his concern with the pilot, but the pilot did not seem to be concerned with stalling the airplane."

     

    The NTSB report indicated that the purpose of this flight was to practice for an upcoming flight review. Practice is good, but instruction is better. Could an hour of dual instruction from a competent CFI have prevented this accident? We don't know but perhaps steep turns in the traffic pattern would have prompted a bit of an aerodynamics review from an instructor.

     

    We should always thoughtfully consider any criticism of our flying when it comes from another pilot. We all have some degree of illusory superiority when it comes to our flying, so when another pilot brings something to our attention, we should take notice.

     

    Click here for the full NTSB accident report

  • Piper PA-46 350P

    Hartford, CT August 28, 2018
    Uninjured: 4

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    The NTSB accident reports includes the following, “The pilot reported that, during the approach, the tower controller instructed him to stay "high and close." Once he turned to final, he reduced the power, and the airplane began rapidly descending. He added that he applied some power and back pressure to arrest the descent rate as he began to flare, but the airplane landed hard and faster than normal. As the nose landing gear touched down, he applied reverse thrust and braked aggressively. Subsequently, the nose landing gear collapsed, and the airplane came to rest on the runway.”

     

    The report goes on to state, “The pilot reported that the primary cause of the accident was his failure to maintain a stabilized approach, which resulted in a hard landing and higher-than-normal ground speed upon touchdown.”

    NTSB Photo

    The NTSB probable cause states, The pilot's unstabilized approach and hard landing, which resulted in a nose landing gear collapse.”

     

    What lessons should we take away from this accident? The obvious lesson is, as I have been preaching for many years, NEVER continue an unstabilized approach. But this pilot fell into a common trap. He was attempting to comply with ATC’s request to stay “high and close.” This, of course, requires a higher rate of descent and a steeper glide path to reach the approach end of the runway. I have experienced similar situations and I have fallen into that trap several times. I was fortunate that it never ended badly for me, but it could have resulted in bent aluminum or worse.

     

    ATC has their job and they never intend to put us in harm’s way. But sometimes their workload causes them to become a bit over-zealous to accommodate the diverse needs of the aircraft they are controlling. We also have our job which is to oversee the safety of our flight. The FAA gives us the ultimate authority regarding the operation of our aircraft and we must not hesitate to exercise that authority when necessary. If we communicate a concern to ATC, they will almost always jump through hoops to find a solution. If not, we can always play our trump card with the single word, “UNABLE.” But if things are not working out to our satisfaction, we must be willing and able to execute an immediate go-around.

    Stabilized Approach Criteria

    An approach is considered to be stabilized if it meets the eight criteria listed. A larger PDF is available for download.

  • Cessna 210 "Get-There-Itis"

    CEN17FA136
    Hayden, AL March 25, 2017
    Fatal: 4

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    Analysis The official NTSB report states, "The private pilot and three passengers departed on an instrument flight rules cross-country flight. About 2 hours into the flight, the pilot began to deviate around areas of precipitation and climbed the airplane from its previous cruise altitude of 10,000 ft mean sea level (msl) to 12,000 ft msl. Shortly thereafter, the air traffic controller told the pilot that moderate to extreme precipitation was ahead of the airplane and advised the pilot to deviate as necessary around it. Shortly thereafter, the airplane began a series of descending right turns. The controller advised the pilot to climb and maintain 12,000 ft several times; however, the airplane continued to turn and descend, and radar contact was lost at an altitude of about 2,000 ft msl. A witness reported hearing an airplane flying above, then heard a loud "boom" and saw pieces of the airplane falling from the sky. The wreckage path was about 4,550 ft in length, consistent with an in-flight breakup. Examination of the airframe and engine revealed no anomalies that would have precluded normal operation.

     

    The pilot received a weather briefing before departing on the accident flight that included a forecast for scattered severe thunderstorms along the route of flight and marginal visual flight rules conditions at the destination airport, with wind at 20 knots gusting to 30 knots, 4 miles visibility, moderate rain, and an overcast ceiling with thunderstorms in the vicinity. Although there were no hazardous weather advisories or convective SIGMETs active at the time the pilot received his preflight weather information, two of the air traffic controllers who worked the flight broadcast convective SIGMETs while the pilot was on frequency that affected the pilot's intended route of flight and called for thunderstorms with tops exceeding 40,000 ft. One of these SIGMETs was broadcast about 1 hour into the flight, and the second about 2 hours into the flight (about 40 minutes before the accident occurred). The pilot chose to continue along the flight route as weather conditions deteriorated, consistent with a common behavioral trap known as "get-there-itis."

     

    Review of weather and air traffic control radar data indicated that the airplane flew into a line of convective echoes and likely encountered instrument meteorological conditions, icing (including the possibility of supercooled large droplets), and moderate or greater turbulence about the time the airplane began the series of descending right turns that ultimately resulted in the in-flight breakup. The reduced visibility conditions and likely turbulent airmass encountered by the pilot are conducive to the development of spatial disorientation, and the in-flight breakup is consistent with the known effects of spatial disorientation. Given the severe weather conditions encountered, it is possible that the pilot's spatial disorientation was the result of an in-flight upset and significant challenges maintaining attitude control combined with the limited visibility.

     

    Toxicology testing of the pilot revealed the presence of amphetamine in lung and heart tissue. The pilot reported no conditions on his most recent application for a medical certificate, and whether the pilot was using amphetamine medicinally or illicitly could not be determined based on the available information."

     

    Probable Cause

    "The pilot's decision to continue the flight into known adverse weather conditions, which resulted in spatial disorientation and a subsequent loss of airplane control and in-flight breakup."

     

    NTSB Photo

    Lessons

    Get-there-itis has been discussed in aviation safety publications for many years. In fact, the FAA published an Advisory Circular on the subject back in 1994. Wanting to complete a task, including a flight, is wired into our humanness. The tendency is called continuation bias in human factors work. The perceived importance of the flight and the perceived urgency of the task work to strengthen our determination to continue. This pilot did what we are all predisposed to do. He kept trying to complete the task. The amphetamine in his system may or may not have emboldened him to press on. We cannot know that, but we can know that we are all susceptible to "get-there-itis."

     

    There are some mitigation strategies to help us avoid the trap. Setting and sticking to defined criteria for weather minimums and other items is essential. These mininums are best included in our personal minimums checklist or a flight risk assessment tool (FRAT). Following the guidance of the I'M SAFE checklist can also be a help. Pre-establishing checkpoints along the route of flight to mark points or times to re-examine our situation and re-apply our defined minimums is recommended. Having a back-up plan to get ourselves or our passengers to the desired destination can help remove some of the pressure to continue. And finally, empowering passengers to speak up if they become uncomfortable can provide us with a reality check.

     

    Click here to see the entire NTSB report

  • Cessna 172 Night CFIT

    New Orleans, LA August 27, 2016
    Fatal: 2

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    The official NTSB Accident report states in part, Shortly after sunset, the pilot with two passengers departed on a local sightseeing flight of the city. The flight flew around the city, then proceeded back to the airport after civil twilight. The final portion of the flight and the landing approach were conducted over a lake. A review of radar's last return revealed the airplane about 0.6 miles from the airport at an altitude of 100 ft agl. The surviving passenger reported everything appeared normal during the flight, and as they neared the airport, it started to rain, and visibility was poor. The pilot pointed out 4 four red lights ahead of the airplane and stated to the passengers that was the airport. The passenger added that she could see out the side window and the airplane was about 4-6 ft. above the surface of the lake. Shortly thereafter, the airplane impacted the lake.

     

    Postaccident examination of the airplane did not reveal any anomalies that would have

    precluded normal operation. A review of weather information noted the presence of

    thunderstorm activity and isolated rain showers in the area at the time of the accident.

     

    The pilot's toxicology report was positive for ethanol and clomipramine. Due to a delay in the

    recovery, it is likely that most, if not all, of the ethanol was from postmortem production.

    Clomipramine is a tricyclic antidepressant used to treat symptoms of obsessive-compulsive

    disorder. Clomipramine is not considered impairing. Additionally, the pilot's actions and

    communication with the passengers also indicate that the pilot did not experience a seizure or

    incapacitation, so a reaction to his medication was not likely.

     

    With reduced visibility due to rain and night conditions, it is unlikely the pilot could see the

    water. The four red lights, consistent with the runway's precision approach path indicator

    (PAPI) that the pilot pointed out to the passengers, reflected the airplane's low approach path.

    The accident is consistent with the pilot continuing the descent, while already below a normal

    approach path to the airport, which resulted in the controlled flight into terrain.”

     

    The NTSB Docket includes a “Memo for Record” of a phone conversation between the FAA inspector and the NTSB inspector. The contents of the memo includes:

     

    Narrative:

    During the initial call, the inspector made the following points:

    • People said that he had the habit of flying too low [ on the approach]
    • Passenger reported the pilot said  four red lights – “that’s the runway” 

     

    During a follow-up email, the inspector reported a conversation with a individual:

    • Said pilot always flew low on the approach 
    • Pilot did not use flaps for landings 

    NTSB probable cause: “The pilot's improper decision to continue a descent during a night visual approach a for landing which resulted in controlled flight into terrain. Contributing to the accident was the reduced visibility and pilot's disregard of the PAPI indications that the airplane's approach

    path was excessively low.”

     

    For our analysis of this accident I must say that I find it puzzling. The flight was conducted as an air tour flight with paying passengers. The pilot held a commercial pilot certificate with an instrument rating, current flight review and a current medical certificate. On his application for his medical certificate about three moths prior to the accident, he reported having more than 9,000 hours total flight time with 170 hours in the previous six months. The report does not indicate how much flying the pilot had done in the previous 24 hours so we can neither include nor eliminate fatigue as a factor.

     

    It was a dark night. According to information from the United States Naval Observatory, at the time of the accident, both the sun and the moon were more than 15° below the horizon. Those conditions are tricky for an inexperienced pilot, but this experienced pilot should have known to do two things. First, know the elevation of the lake, add a comfortable margin (200 feet for me) and do not go below that altitude until landing is assured. Second, the PAPI was clearly indicating that the pilot was dangerously low. Seeing four red lights should be a cause for an immediate go-around regardless of distance from the airport.

    Of course, the pilot was instrument rated and the Pilot/Operator report states that the airplane was instrument equipped. Had the rain showers and the associated reduced visibility been an issue, the option to request and instrument clearance was an option. It was supposed to be a sight seeing flight and going IFR does not fit that mission, but disappointing passengers is always preferable to killing them. There was no information provided as to whether the pilot was instrument current. If he was not, that might have been his reason for remaining VFR.

     

    There are several lessons that can be learned from this.

    1. We cannot allow ourselves to become complacent regardless of how fat our logbook has become.
    2. Each flight must be carefully planned, including an alternate course of action if things are not going as expected, such as rain showers reducing visibility.
    3. Night VFR flights are much more challenging and require more planning than day VFR flights.
    4. Never fly lower than what is reasonable and necessary. Altitude is our friend.
  • Cirrus SR22 Spatial Disorientation - Impaired

    WPR15FA082
    Tooele, UT January 9, 2015
    Fatal: 1
     
    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.
     
    Analysis The official NTSB accident report states, "The noninstrument-rated private pilot departed during the late afternoon and flew over the southern portion of the Great Salt Lake. According to data recovered from the airplane's avionics system, which did not capture altitude, the duration of the flight was about 9 minutes. During the final minute of the flight, the airplane conducted a gradual left turn at an engine power setting of about 2,200 rpm. Shortly thereafter, the airplane impacted the lake. Postaccident examination of the airplane revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation."
     

    "Local meteorological observations indicated that restricted visibility and fog were forecast throughout the area about the time of the accident. It is likely that the pilot encountered these conditions inflight and lost visual reference to the ground and/or horizon. Given the pilot's lack of an instrument rating and of recent instrument flight experience, the loss of visual reference likely resulted in spatial disorientation."

     

    "Toxicological testing on the pilot revealed the presence of bupropion, an antidepressant; hydrocodone, an opiod analgesic; and diphenhydramine, a sedating antihistamine. The investigation was unable to determine if the use of bupropion or the cognitive effects of any underlying depression contributed to the accident. Because the hydrocodone was found in the urine but not the blood, it no longer caused systemic effects and played no role in the accident. However, it is likely that the effects of diphenhydramine impaired the pilot's cognitive and psychomotor performance at the time of the accident, and contributed to his spatial disorientation."

     

    Probable Cause

    "The non-instrument rated pilot's decision to depart into low visibility conditions, which resulted in spatial disorientation and a loss of control. Contributing to the accident was the pilot's impaired performance due to his use of the sedating antihistamine, diphenhydramine."

     

    Lessons

    This pilot, like so many others have done, apparently overestimated his ability to fly the airplane low visibility conditions. The NTSB full report indicates that the pilot did not have an instrument rating, though he did begin instrument training a couple of years earlier. His last instrument training flight occurred about 18 months prior to the accident flight.

     

    As stated in the NTSB accident report, "However, it is likely that the effects of diphenhydramine impaired the pilot's cognitive and psychomotor performance at the time of the accident, and contributed to his spatial disorientation." The cognitive impairment may have contributed to the pilot's decision to begin the flight in the low visibility conditions. The pilot was a medical doctor and most certainly was aware of the impairing effects of diphenhydramine. The NTSB has recommended that a pilot not fly for a minimum of 60 hours after the last dose of diphenhydramine. Yet, the pilot decided to fly. Perhaps his decision making was so heavily influenced by his impairment that his medical knowledge was simply overpowered. We cannot know what influenced his decision, but we must be aware of the negative effects of flying while impaired. In case you are not familiar with diphenhydramine, it is the active ingredient in many OTC cold and allergy medications.

  • Luscombe 8F Hand Propping

    Vicksburg, MI March 20, 2017
    Fatal: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path..

    The NTSB roport includes the following: "On March 20, 2017, about 1644 central daylight time, the pilot of a Luscombe 8F, N2007B, was struck by the airplane's propeller as he attempted an engine start at Thrall Lake Airport (7MI3), Vicksburg, Michigan. The commercial pilot was fatally injured, and the airplane did
    not sustain damage. The airplane was registered to a private individual and operated by the
    pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight.
    Visual meteorological conditions prevailed for the flight that was originating when the accident
    occurred, and no flight plan was filed.


    According to the local police report, on the afternoon of the day of the accident, the pilot's wife
    called a friend of the pilot to inquire about the whereabouts of her husband. After attempting
    to contact the missing pilot, the friend drove to the airport where he observed the pilot lying on
    the grass under the nose of the airplane with a fatal head injury. The friend reported the
    accident to the police about 1844.


    The airport owner responded to the airport at the request of the police; he thought the pilot
    was attempting to start the airplane by hand propping it when he was injured. The magneto
    switch was in the "Both" position; the throttle was at idle; the primer was in the unlocked
    position; and the fuel tank selector "was in the 'ON' position." Additionally, the owner stated
    that it appeared that the pilot was intending to fly the airplane given that the airplane was
    refueled, and the left tire was chocked as the pilot always did when preparing for a flight.
    According to the airport owner, the accident occurred after his employees left the airport about
    1600.


    The owner of the airplane stated that the pilot had been flying the airplane for about 15 years.
    He believed that the pilot "had extensive knowledge of the use and precautionary measures
    needed" to hand prop the engine, which was the normal starting procedure for the airplane.
    According to the owner, there were no known malfunctions or failures with the propeller,
    airframe, or engine that would have precluded normal operation.


    The Federal Aviation Administration's (FAA) Airplane Flying Handbook states that hand
    propping an airplane "is a critical procedure never [to] be attempted alone. And propping
    should only be attempted when two properly trained people, both familiar and experienced
    with the airplane and hand propping techniques, are available to perform the procedure." The
    handbook describes the recommended procedure and communication/commands to be used
    when hand propping.


    The Department of Pathology, Western Michigan University, Kalamazoo, Michigan, performed
    an autopsy of the pilot and determined that the cause of death was craniocerebral injuries. The
    FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed
    toxicology testing on specimens from the pilot. The toxicology results were negative for ethanol
    and drugs."

     

    NTSB Probable Cause: "The pilot's inadvertent contact with the propeller while hand propping the engine, which resulted in a fatal injury."

     

    The lesson here is simple, but sometimes difficult to follow. Hand propping an airplane is extremely dangerous, but sometimes it is necessary. In the case of this pilot, the airplane was an antique that was normally started by hand propping. If he wanted to fly, somebody had to hand prop the airplane. The procedure probably seems strange to many, but when I learned to fly in the Piper Cub and in the Piper PA17 Vagabond, that was the only to start the airplane. I have hand propped many other airplanes over the years because of dead batteries.

     

    But all that being said, it is a very dangerous operation. The risk can be mitigated substantially by following a few simple rules and being trained by someone who is experienced in the procedures. Preferably, a qualified pilot is at the controls holding the brakes while someone else who is qualified spins the prop. It is also preferable to have the airplane tied down just in case the brakes don't hold, the surface is slippery allowing the tires to skid, or a foot slides off a brake pedal at a bad time. It is never a good idea to attempt this as a solo operation. As I look back, I did not always follow those rules which means I was very lucky. I would not violate any of those practices today.

     

    Here is something else to think about. In the case of a dead battery, there may also be a problem with flying an airplane with a compromised battery. For example, a retractable landing gear system often requires battery power in addition to alternator power to operate.

     

    Click here to see the NTSB report on the NTSB website.

  • Piper Malibu Improper Fueling

    Spokane, WA Feb. 22, 2015
    Fatal: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    The NTSB accident reports includes the following, “The pilot was conducting a cross-country flight from Canada to California and had landed to clear customs into the United States and to refuel his airplane. The pilot then departed to continue the flight. During the initial climb after takeoff, the engine experienced a total loss of power, and the pilot attempted to make an off-airport forced landing. The right wing struck railroad tracks at the top of a hill, and the airplane continued down an embankment, where it came to rest adjacent to the bottom of a railroad bridge.

     

    Postaccident interviews revealed that, when requesting fuel from the fixed-base operator (FBO), the pilot did not specify a grade of fuel to be used to service the airplane. The refueler mistakenly identified the airplane as requiring Jet A fuel, even though the fuel filler ports were placarded "AVGAS (aviation gasoline) ONLY." The fueler subsequently fueled the airplane with Jet A instead of aviation gasoline. Additionally, the fueling nozzle installed on the fuel truck at the time of the refueling was not the proper type of nozzle. Jet A and AvGas fueling nozzles are different designs in order to prevent fueling an airplane with the wrong type of fuel.”

    NTSB Graphic showing fuel placard

    “Following the fueling, the pilot returned to the FBO and signed a receipt, which indicated that the airplane had been serviced with Jet A. There were no witnesses to the pilot's preflight activities, and it is unknown if the pilot visually inspected or obtained a fuel sample before takeoff; however, had the pilot done this, it would have been apparent that the airplane had been improperly fueled.”

    NTSB Graphic Excerpt showing fuel receipt

    The NTSB probable cause states, A total loss of engine power due to the refueler's incorrect refueling of the airplane. Contributing to the accident was the fixed-base operator's improper fueling nozzle, which facilitated the use of an incorrect fuel, and the pilot's inadequate preflight inspection.”

     

    What lessons should we take away from this accident? Don’t dismiss this being unrelated to your flying just because you may not fly an airplane that can be confused with a turboprop. Incorrect fueling can take several forms. Fueling with the incorrect type of fuel is only one. Water or other contaminates can be in the fuel provided by an FBO. This is not common, but it does happen on occasion. There have been accidents caused because a fueler topped off the wrong airplane and the pilot did not check the fuel level before departure. Another accident was caused because a pilot ordered a “top off” but the fueler was confused with another order and only added five gallons per side. On the other side of that, there was an accident in which a fueler topped off an airplane that was only supposed to receive a few gallons per side due to weight restrictions. The pilot did not detect the error and ran off the end of the runway while attempting an overweight takeoff. And of course the classic and much more common error is to either leave off the fuel cap or not properly secure it. It is a good idea to always specify the type and quantity of fuel when placing the fuel order.

     

    Personally, I have had several problems related to fueling over the years and yet I am still here running my mouth and keyboard about safety. I am not smarter than most pilots, just a bit more paranoid. I always personally observe the fueling and I always visually look in the tanks and I always sample the tanks after fueling. Also, I always make time to allow the fuel to settle for a few minutes so that if any water is present, it will show itself by having at least a few drops reach the fuel tank drains. Of course this all takes extra time and sometimes other things are pressing. But when we fly, our primary job is to be as good a pilot as we can be and everything else must be secondary.

     

    Click here to see the accident report on the NTSB website.

  • Beech Bonanza - Decision Making After Power Loss

    WPR15FA222
    Riverside, CA July 26, 2015
    Fatal: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    Analysis The official NTSB accident report states, “The private pilot was receiving vectors for an instrument landing system approach during daytime visual flight rules conditions when he advised the controller that the engine had lost power and that he needed to land at a nearby airport located northeast of his position. The controller responded with the distance and direction from the airport and asked the pilot if he had the airport in sight, which he acknowledged. The controller advised the pilot to proceed inbound to the airport, told him that he could land on the runway of his discretion, and asked him to tell him which runway he was going to use; however, the pilot only responded that he was going to land into the wind. The controller repeated that the runway was at his discretion and the pilot repeated that he was going to land into the wind. Shortly after, the controller provided the pilot with the current weather conditions at the airport, which included wind from 280° at 12 knots gusting to 18 knots, and he then cleared the pilot to land on runway 27. Subsequently, the pilot responded that he was not going to make it to the airport. No further radio communications were received from the pilot.”

    The radar plot of the flight indicated that the airplane was at about 1,644 feet above ground level and on a heading of 094 degrees when the pilot reported that engine power was lost. The approach end of Runway 34 was only 1.65 nm northeast of the airplane’s position. The approach end of Runway 09 was 1.74 nm northeast of the airplane’s position. The approach end of Runway 27, the pilot’s choice for the landing was 2.3 nm to the northeast. The pilot had about a 12-knot headwind to reach any runway, but a landing on Runway 34 would have required only about a 90-degree turn to line up, while Runway 27 would have required about a 180-degree turn to line up. However, the pilot did not attempt to fly directly toward either of the runways, but flew what appears to be an attempt at a normal left hand traffic pattern for Runway 27.

    Also, the pilot operating handbook for the F35, section III, Emergency Procedures, page 3-6 states in part:

    "MAXIMUM GLIDE CONFIGURATION
    Landing Gear – UP
    Flaps – UP
    Cowl Flaps – CLOSED
    Propeller – LO RPM
    Airspeed – 105 Knots/121 MPH

    Glide distance is approximately 1.7 nautical miles (2 statute miles) per 1,000 feet of altitude above terrain."

    The NTSB determined that the flaps were extended to about the 20-degree position and that the landing gear was down. This configuration would have significantly decreased the glide distance.

     

    Probable Cause

    The National Transportation Safety Board determines the probable cause(s) of this accident to be:“The total loss of engine power for reasons that could not be determined during postaccident examination of the airplane and engine. Also causal to the accident was the pilot's decision to attempt to reach the farthest runway and land into the wind instead of conducting a crosswind or downwind landing at a closer runway following the loss of engine power.”

     

    Lessons

    This is an example of the need for rapid decision making. There was not a lot of time to ponder the decision, but a few seconds could be spent on analysis. It seems obvious that the pilot had a strong bias toward landing into the wind regardless of circumstances. That bias was evident in his initial response to the controller that he would land into the wind. Once he made that decision, confirmation bias apparently set in and he did not do further analysis of the situation. He most likely could have reached a runway crosswind runway, Runway 34.

    Rapid analysis requires us to draw on our training and experience to help us make a good decision. We do not know how long it had been since the pilot had been presented with a simulated engine-out situation. Recurrent training can help us make better rapid decisions. Had this pilot participated in recent recurrent training that included power loss scenarios, it seems likely that he would have known to head for the nearest runway and the recommended procedure for this airplane, including best glide speed and the need to leave the flaps and landing gear retracted.

     

  • Piper PA28-140 Deficient Maintenance

    CEN17FA139
    Stonewall, TX March 25, 2017
    Fatal: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    Analysis The airplane owner and a mechanic completed the airplane's annual inspection the morning of the accident. The mechanic did no work but returned the airplane to service with an endorsement that the annual inspection/airworthiness requirements had been met based on his determination that the engine runup was satisfactory. The airplane departed but returned to the airport shortly after the departure. During the return, a witness said that the airplane was "way too high," and its approach was "pretty steep." The airplane touched down about halfway down the short-grass runway and was "going way too fast." The airplane overran the end of the runway and into a pond where it became submerged. Postaccident examination of the runway revealed the presence of skid marks from the airplane main landing gear wheels along the last 300 ft of the runway.

    The propeller exhibited rotational signatures but with some loss of torque. Postaccident examination of the airplane revealed numerous unairworthy maintenance items and/or lack of maintenance to the engine and accessories; further the engine and various accessories surpassed their manufacturers' recommended time for overhaul/replacement. The exhaust manifold was blocked with internal fractured pieces that would have resulted in power loss. The condition of these pieces was consistent with a failure that had been preexisting. The induction hose to the carburetor was the wrong part for the installation. The hose was collapsed and would have restricted airflow into the carburetor resulting in power loss. Both magnetos were no longer serviceable and would have produced minimal ignition. The engine timing was not set to the engine manufacturer's specification. Had the mechanic conducted a proper annual inspection, he would have identified many of the issues found during the airplane's postaccident examination.

    Based on the evidence, the pilot likely returned to the airport due to a loss of engine power. It could not be determined which of the many discrepancies led to the loss of engine power. Further, the pilot did not attain a power-off approach glideslope that would have led to a proper touchdown point near the approach end of the runway.

     

    Probable Cause

    The National Transportation Safety Board determines the probable cause(s) of this accident to be:
    The pilot's failure to attain a proper touchdown point following a loss of engine power and his inability to stop the airplane on the short, soft runway. Contributing to the accident was the inadequate maintenance of the airplane by the owner and the mechanic and the improper annual inspection by the mechanic.

     

    Lessons

    Unfortunately, this is a much more common practice than we would like to think. I have been personally aware of pilots who knew somebody who held an IA rating on his/her mechanic certificate who would provide a sign-off to an annual inspection without actually checking the airplane. We all know that quality aircraft maintenance is expensive. But what price do we put on our own well being and the well being of our family and passengers? If the money for quality maintenance is not available, it is time to reconsider aircraft ownership. There are some excellent flying clubs available and an aircraft partnership may provide a solution.

    NTSB Photo (White rectangle is protecting identity of recovery personnel)

     

    Click here to see the entire NTSB report

  • Beech Bonanza Wake Turbulence

    WPR16FA172
    Sparks, NV August 30, 2016
    Fatal: 2

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    NTSB Analysis

    The 73-year-old commercial pilot was on the fourth and final leg of a 950-mile round trip same day flight. As the airplane neared the airport, the pilot was told by the air traffic controller to

    expect runway 25 for landing. After the controller informed him of a delay for that runway, the

    pilot stated that he could accept runway 16L; the pilot was told to proceed for runway landing,

    but the runway was not specified, an instruction which he acknowledged. Shortly after

    establishing contact with the tower controller, who instructed the pilot to continue for runway

    25, the pilot reported that the airplane was on a downwind leg for landing on runway 16L. The

    controller acknowledged and, rather than correcting the pilot, instructed him to continue

    inbound for 16L. At the time, runway 16R was being used for landing by two Boeing 757 (B757)

    airplanes in sequence, separated from each other by about 7 miles. The controller advised the

    accident pilot that a B757 was on a 9-mile final for runway 16R and cautioned him about wake

    turbulence, then cleared the accident airplane to land. Shortly thereafter, the pilot reported

    that he had "the airliner" in sight. At this time, one of the B757s was on a short final approach

    for 16R, about 4.5 miles ahead of and below the accident airplane. The other B757, which was

    the potential conflict, was about 5 miles away from the accident airplane at its 2-to-3-o'clock

    position. Given that the pilot's attention was likely focused toward the runway during this

    portion of the approach, it is likely that he misidentified the ATC-reported traffic as the B757

    on short final, which landed soon after and likely resulted in the pilot relaxing his vigilance in

    looking for traffic. Shortly thereafter, the controller issued an all-aircraft advisory that the wind

    was from 250° at 17 knots with gusts to 20 knots. Although these wind conditions met or

    exceeded the airplane's maximum demonstrated crosswind capability for a landing on 16L, and

    the airplane was still well-positioned to revert to an approach to runway 25, the pilot continued

    toward 16L.

    About 70 seconds after the pilot reported sighting the traffic, just after turning the airplane

    onto the base leg of the traffic pattern, the B757 passed about 1 mile ahead of and about 100 ft

    below the accident airplane. The investigation was unable to determine whether the pilot saw

    that B757, or if he did, whether he was cognizant of the potential for a wake vortex encounter

    and the flight path alterations necessary to avoid such an encounter. The pilot made no radio

    communications or flight path adjustments to indicate that he saw the B757 or tried to avoid its

    wake.

    According to witnesses, the airplane's flightpath appeared normal as it approached the runway

    for landing. When the airplane was on about a 1/2-mile final approach, at an altitude of less

    than 200 ft above ground level, it suddenly rolled and descended to the ground. Ground scars

    and debris distribution was consistent with a near-vertical descent and impact. Examination of

    the wreckage did not reveal any evidence of pre-impact mechanical deficiencies or

    malfunctions that would have precluded normal operation. A wake vortex analysis study

    revealed that the airplane most likely encountered the wake vortices that were generated by a

    B757 landing on the parallel, upwind runway. The vortices were of sufficient size and strength

    to radically upset the airplane at an altitude too low to recover.

    Had the controller informed the pilot that there were two B757s on final approach for 16R, it is

    likely that the pilot's traffic situational awareness would have been more complete. The pilot

    likely would have altered his traffic scan or questioned ATC further to ensure that he had

    identified the correct B757. The pilot's radio communications did not indicate any doubt about

    whether he had properly identified his traffic, and in postaccident interviews, the controller

    stated that he was certain that the pilot had correctly identified it. Had either the controller or

    the pilot specified the location of the traffic once the pilot reported it in sight, that information

    would have significantly improved the likelihood of detecting the pilot's identification error.

    The safety of the approach sequence was dependent on assured separation of the airplane from

    the B757 and its wake. In this case, because both airplanes were being controlled by ATC in a

    radar environment, aircraft and wake turbulence (vortex) separation was the responsibility of

    the controller until explicitly transferred to the accident pilot. Although ATC requirements to

    apply pilot-based visual separation had been satisfied and it was the controller's intent to have

    the accident pilot maintain visual separation from the B757, the controller relinquished his

    separation responsibility without explicitly transferring that responsibility to the accident pilot.

    As a result, no separation services were being provided by the controller. The accident pilot's

    likely misidentification of his traffic, the controller's lack of awareness of that apparent error,

    and the controller's failure to monitor, detect, or intervene in a situation conducive to a wake

    vortex encounter enabled the accident to occur.

    At the time of the accident, the pilot had been awake about 14.5 hours and had flown about 8.5

    hours that day. Given the pilot's experience level, it is unlikely that he was not aware of the

    effect of either the extreme landing crosswinds or wake vortex behaviors and hazards, but for

    reasons that could not be not determined during the investigation, the pilot nevertheless

    continued his approach to land on 16L. Investigators were also unable to determine the effect

    of the pilot's long duty day on his mental acuity or explain the reasons behind several of his

    actions and decisions, including his vague communications with ATC regarding the landing

    runway, his decision to forego landing on a runway more favorable to the wind conditions, and

    his misidentification of the conflicting traffic.

     

    NTSB Probable Cause

    The pilot's selection of a landing runway which, given the wind and traffic conditions, was

    susceptible to high crosswinds and the translation of wake turbulence across its approach path,

    and the controller's and pilot's failure to ensure separation from the B757 and its wake, which

    resulted in a low-altitude encounter with wake vortices that the pilot was unable to recover

    from.

     

    Lessons

    Wake turbulence is sneaky. It is there and it is a very real hazard but it is invisible. Any pilot who routinely flies into air carrier airports has heard the warning, "caution wake turbulence" many times. Those who have never had an encounter with wake turbulence and have lived to tell about it tend to become complacent. Whether or not complacency played a role in this accident, we will never know. The pilot did acknowledge seeing one large airliner landing and apparently mistook that airplane for the airplane that posed the real threat. Was he confident that the threat had passed or did complacency prevent him from questioning whether that was airplane in question? In any case, he did not have the necessary situational awareness. Maintaining situational awareness when landing at a busy airport with large airplanes is not easy. In this case, the pilot was most likely to suffering from some fatigue which is detrimental to good situational awareness.

    We can learn from this that wake turbulence is a very real threat and we must never allow ourselves to be complacent about it. I was once rolled 360 degrees at altitude by the wake of a B-52. On another occasion, I was rolled 45 degrees or more in the traffic pattern by the wake of a large airplane. Obviously, I was able to recover in both instances, but either of them could have ended badly for me. For more information, view my YouTube video, "Wake Turbulence Essentials."

    Another lesson is that we need to avoid fatigue when we fly. This pilot was on the final and fourth leg of a 950 mile round trip same day flight. That is a lot of flying for one day for a single pilot. Fatigue has an adverse effect on many of our abilities, including the ability to maintain situational awareness. The only remedy for fatigue is sleep. Coffee and other products can help mask it which might actually increase the danger.

  • Cessna 182 - Propeller Accident

    ERA18LA199
    Cleveland, TN July 26, 2028
    Fatal: 1

    Accidents discussed in this section are presented in the hope that pilots can learn from the misfortune of others and perhaps avoid an accident. It is easy to read an accident report and dismiss the cause as carelessness or as a dumb mistake. But let's remember that the accident pilot did not get up in the morning and say, "Gee, I think I'll go have an accident today." Nearly all pilots believe that they are safe. Honest introspection frequently reveals that on some occasion, we might have traveled down that same accident path.

    Analysis

    After completing a personal flight with his wife, the private pilot secured the engine by placing the mixture control in the idle cut-off position. Based on physical evidence observed after the accident, he likely moved the ignition switch toward the off position and removed the key. The pilot's wife indicated that, after they performed local errands and returned to the airport, the pilot was performing his preflight inspection of the airplane with the ignition key in his pocket. Although airport security video did not capture the accident sequence and the pilot's wife, who was by the airplane's right cabin door, did not see her husband move the propeller, she heard the propeller move and the engine starting or trying to start. The pilot likely slightly moved the propeller and the engine briefly started; the propeller then rotated and fatally injured the pilot. The engine did not sustain operation, and the propeller ceased rotating.

    Postaccident examination of the 42-year-old ignition switch revealed that it appeared to be in the off position when observed visually from the pilot's seat, but its actual selected position was more toward the right magneto position. The switch and key were determined to be slightly misaligned with the instrument panel placard markings. On- and off-airframe operational testing of the ignition switch in the as-found position revealed the right magneto was hot, or not grounded. In addition, examination of the cut surfaces of the key notches revealed relatively smooth and reflective surface features consistent with a worn surface on the flank of the notch adjacent to the key retention ridge and on the tip end of the shank opposite the notched side. Examination of the key cylinder revealed an area with a smooth and reflective surface consistent with wear on the lower side of the key slot. The location and shape of the worn area was consistent with wear contact with the tip of the key as it was inserted and removed. The key could be removed from the switch in any of the five positions due to the wear of the switch's internal components, contrary to its intended function that would retain the key in any position except the off position. Although the switch manufacturer tested all new switches to ensure this functionality when new, that test is not specified to be performed at any time as part of any inspection or checklist by the switch manufacturer, airframe manufacturer, or Title 14 Code of Federal Regulations Part 43 Appendix D.

    Although the mechanic who performed the last annual inspection reported the key-to-switch integrity was satisfactory with no discrepancies, the worn condition of the ignition switch likely existed at the time of the annual inspection, which was about 31 flight hours before the accident flight (excluding the pilot's previous flight the day of the accident). Additionally, during the annual inspection when the mechanic installed the ignition switch after repairs, he failed to properly align the switch positions with the marks on the instrument panel placard.

     

    Probable Cause

    The National Transportation Safety Board determines the probable cause(s) of this accident to be: The undetected wear of the ignition switch and key, which allowed removal of the key from an intermediate position and subsequently led to an unintended engine start-up. Contributing to the undetected wear of the 42-year-old ignition switch was the lack of guidance by the switch manufacturer and airframe manufacturer for procedures to detect lack of integrity between the ignition key and switch.

     

    Lessons

    First, never trust a propeller! Avoid crossing the plane of the propeller whenever possible. When it is necessary to handle or cross the propeller plane, do so with the expectation the engine will start. Be spring-loaded to retreat. Other problems, such as a disconnected P-lead, can also allow the ignition system to be energized. When it comes to propellers, treat them like sleeping vicious animals ready to attack without warning.

    Personally, it terrifies me when I go to an aviation event in which people, including children, are walking around the parked airplanes unaware of the propeller danger. I seen kids holding onto a propeller while having their picture taken. I always feel that I must say something and it is not always well-received, but I would rather take the rebuff from the offended mom or dad than to live with the knowledge that I failed to act and that a tragedy occurred.

    FAA Digital Photo: View of the Ignition Switch Position as First Observed.