National Transportation Safety Board - Aircraft … Transportation Safety Board - Aircraft Accident/Incident Database Accident Rpt# WPR11FA381 08/14/2011 900 MDT Regis# N324AT Lander,

National Transportation Safety Board - Aircraft Accident/Incident Database

Accident Rpt# WPR14CA159 Regis# N43MA Missoula, MT04/04/2014 0

Acft Mk/Mdl BELL 206B III Acft Dmg: Rpt Status: Prelim Prob Caus: Pending

Regis# N43MA

Aircraft Fire:

0Fatal Ser Inj 0

Opr Name: Opr dba:

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Printed:Prepared From Official Records of the NTSB By:

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April 15, 2014

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Accident Rpt# WPR14CA160 Regis# N361CR Astoria, OR04/04/2014 0

Acft Mk/Mdl AGUSTAWESTLAND SPA AW109SP Acft Dmg: Rpt Status: Prelim Prob Caus: Pending

Regis# N361CR

Aircraft Fire:

0Fatal Ser Inj 0

Opr Name: Opr dba:

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Accident Rpt# WPR11FA381 Regis# N324AT Lander, WY08/14/2011 900 MDT

Acft Mk/Mdl BEECH A36

Eng Mk/Mdl ALLISON

Summary

The pilot was flying under visual flight rules flight following. Recorded radar data indicated that the airplane maintained a relatively straight track to the

southeast at an altitude of between 15,100 feet and 15,500 feet before descending near the area of the accident site. About 1 minute before the last recorded

radar target, the pilot checked in with the controller; the airplane's altitude was 13,200 feet. The last two radar targets indicated a descending right turn. The

airplane lost 700 feet in 21 seconds, and the last radar contact was at 12,100 feet. The controller noticed a loss of radar contact and attempted to contact the

pilot on the radio but was unable to. The accident site was located at an elevation of 11,400 feet in mountainous terrain about 1 mile west of the last radar

contact. The debris field was on a westerly heading at the bottom of a slope and extended for about 580 feet indicating controlled flight into the terrain. It could

not be determined why the pilot descended or why he did not maintain sufficient clearance from mountainous terrain. Postaccident examination of the airframe

and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Acft Dmg: DESTROYED Rpt Status: Factual Prob Caus: Pending

Apt: N/a

Acft TT 985

Acft SN E-3071

Flt Conducted Under: FAR 091

ROBERT DAWSON

Regis# N324AT

Aircraft Fire: GRD

2Fatal Ser Inj 0

Opr Name: Opr dba:

THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain

clearance from mountainous terrain.

Cause Narrative

Events

1. Enroute - Controlled flight into terr/obj (CFIT)

Findings - Cause/Factor

1. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Altitude-Not attained/maintained - C

2. Personnel issues-Action/decision-Action-Incorrect action performance-Pilot - C

3. Environmental issues-Physical environment-Terrain-Mountainous/hilly terrain-Decision related to condition

Narrative

HISTORY OF FLIGHT

On August 14, 2011, about 0900 mountain daylight time, a Beech A36, N324AT, collided with terrain near Lander, Wyoming. The pilot/owner was operating the

airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and passenger sustained fatal injuries; the airplane was

destroyed by impact forces and post crash fire. The cross-country personal flight departed Driggs, Idaho, with a planned destination of Front Range Airport,

Denver, Colorado. Visual meteorological conditions prevailed, and no flight plan had been filed.

The pilot was utilizing visual flight rules (VFR) flight following from Salt Lake City Air Route Traffic Control Center. The controller noticed a loss of radar contact,

and was unable to contact the pilot on the radio. The controller issued an alert notice (ALNOT), and a search began. The wreckage was discovered about 1530;

it was at 11,400 feet elevation in mountainous terrain in the vicinity of the last radar contact.

The National Transportation Safety Board investigator-in-charge (IIC) reviewed recorded radar data. A target with a secondary 1200 (VFR) beacon code at a

mode C reported altitude of 12,100 feet mean sea level (msl) was observed about 10 nautical miles (nm) southeast of Driggs. The target maintained a relatively

straight track to the southeast toward the accident site, except for the last two targets, which indicated a descending right turn.

About 52 miles southeast of Driggs, the target was at a mode C altitude of 15,100 feet. It switched to a secondary code of 6060, and maintained that code until

the data stopped. The target indicated a mode C altitude of 15,500 feet at 08:44:11.965, and maintained that altitude until it began a descent at 08:54:16.135.

The last transmission to Salt Lake Center was a check-in with Sector R5; this was at 08:59:23.030 at a mode C altitude of 13,200 feet.

At 09:00:01.455, the target was at 12,800 feet. The next target, about 10.6 seconds later, indicated a turn to the right, and an altitude loss of 300 feet. The next

target, which was also the last target, was 10.5 seconds later (09:00:20.555); it continued the turn to the right with an additional loss of 400 feet (final recorded

altitude of 12,100 feet). This target was less than 1 mile from the accident site, which was to the west of this target.

PERSONNEL INFORMATION

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A review of Federal Aviation Administration (FAA) airman records revealed that the 71-year-old pilot held a private pilot certificate with ratings for airplane

single-engine land and instrument airplane.

The pilot held a third-class medical certificate issued on February 28, 2011. It had the limitation that the pilot must wear corrective lenses.

No personal flight records were located for the pilot. The pilot reported on his medical application that he had a total time of 1,650 hours.

AIRCRAFT INFORMATION

The airplane was a Beech A36, serial number E-3071. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 985.3 hours at

the last annual inspection dated July 1, 2011.

According to the airplane's maintenance logbooks, the original factory piston engine had been changed on November 6, 2000, by Tradewind Turbines, Inc.

They changed it to an Allison M250-B17F/2, serial number CAE-881275, under supplement type certificate (STC) SA3523NM. Total time recorded on the

engine at the last annual inspection was 839.7 hours.

METEOROLOGICAL CONDITIONS

The closest official weather observation station was Lander (KLND), which was 20 nautical miles (nm) east of the accident site at an elevation of 5,586 feet

mean sea level (msl). An aviation routine weather report (METAR) for KLND issued at 0853 MDT stated: wind from 230 degrees at 18 knots; visibility 10 miles;

sky 11,000 feet broken; temperature 22/72 degrees Celsius/Fahrenheit; dew point 6/43 degrees Celsius/Fahrenheit; altimeter 30.14 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

Investigators examined the wreckage at the accident scene on August 25, 2011. A detailed report is part of the public docket.

The airplane and engine were highly fragmented; components at the first identified point of contact (FIPC) were scorched, but components that were scattered

throughout the debris field were not. Portions of the left and right winglets, all control surfaces, rudder, both horizontal stabilizers, both elevators, and both

ailerons were identified.

The debris path was along a magnetic bearing of 280 degrees, and further references are relative to the debris path. The debris field was about 580 feet long

and 180 feet wide, and near the bottom of a hill that sloped down to the left. The initial point of contact appeared to be upslope with the right wing contacting a

large rock. A creek ran along the bottom of the hill, and numerous parts were in the creek and its shoreline.

The FIPC was at 42 degrees 45.221 minutes north latitude 109 degrees 9.194 feet west longitude. The FIPC was an area of disturbed earth surrounded by

boulders. It contained a green lens fragment, a propeller blade fragment, right wing fragments, and paint shards that were white, blue, and dark red.

Boulders in the direction of the debris path were dislodged, and contained white scrape marks. The scrape marks along the first displaced boulder were angled

clockwise about 70 degrees.

The engine fragmented, and was a few feet past the FIPC. A nearby cluster of engine components included four stages of axial compressor wheels with

numerous blades sheared off on each wheel; the fracture surfaces were jagged and angular. The remaining blades sustained damage, and were bent opposite

the direction of rotation.

The majority of the propeller pieces were uphill from the FIPC, and near the engine pieces.

The main wreckage included portions of the empennage, fuselage, and flight control cables; these pieces were in the approximate center of the debris field. The

empennage pieces exhibited heavy leading edge crush damage.

MEDICAL AND PATHOLOGICAL INFORMATION

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A pathology consultant for Fremont County Coroner, Wyoming, completed an autopsy, and determined that the cause of death was multiple blunt force injuries.

The FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. They did not perform tests

for carbon monoxide or cyanide.

Analysis of the specimens contained no findings for ethanol in muscle or liver.

The report contained the following findings for tested drugs: atorvastatin detected in liver.

TESTS AND RESEARCH

The wreckage was examined at Beegle's Aircraft Service, Greeley, Colorado, on August 26, 2011. No evidence of preimpact mechanical malfunction was noted

during the examination. A detailed report on the examination is in the public docket.

Airframe

The right aileron up cable from the chain around the sprocket to the bellcrank, which fractured was identified. Left aileron cable operating and balance cable

continuity could not be confirmed as all components were not located. Portions of the left and right ailerons including one separated piece of right aileron with

balance weights were in place. The only aileron trim actuator was measured, which was on the left side, at 1 3/8 inch; this equated to the neutral position.

The auxiliary structure and skins were missing from the forward and aft spars for the right horizontal stabilizer. The left horizontal stabilizer had leading edge

crush damage that went aft to the forward spar.

The elevator control cables remained attached from the aft elevator bellcrank to the forward swage ball. The elevator push rods fractured at the bellcrank; were

bent, and exhibited 45-degree shear lips.

The airplane had Tradewind elevator trim actuators installed on both sides. Both the left and right actuators measured 1 1/4 inch.

Rudder control continuity was established from the aft bellcrank to the terminals at rudder forward push rods. The rudder trim actuator measured 1 inch.

The landing gear operating mechanism fractured and separated; the position of the operating arms were consistent with the gear retracted position

The left flap actuator was not located. The right flap actuator measured 2.25 inches, which equated to the retracted position.

The fuel shutoff valve was not identified

Engine

The engine data plate was not located.

The compressor front support was crushed, and exhibited rotational signatures. All four axial compressor wheels exhibited heavy rotational damage with

numerous blades fractured and separated at the wheel hubs. The remaining blades were bent opposite the direction of rotation; the fracture surfaces were

jagged and angular. The compressor impeller blades exhibited heavy scoring, and the blades bent opposite the direction of rotation from shroud contact.

The turbine to compressor coupling fractured at the spline adaptor.

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Accident Rpt# ERA12FA527 Regis# N407N Abingdon, VA08/24/2012 2230 EDT

Acft Mk/Mdl BELL 407

Eng Mk/Mdl ROLLS-ROYCE 250

Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending

Apt: N/a

Acft TT 2309

Acft SN 53077


K-VA-T & W-L AVIATION LLC

Regis# N407N

Aircraft Fire: NONE

1Fatal Ser Inj 0

Opr Name: Opr dba:

Narrative

HISTORY OF FLIGHT

On August 24, 2012, about 2230 eastern daylight time, a Bell 407 helicopter, N407N, collided into South Holston Lake during a night departure from a river

bank in Abingdon, Virginia. The airline transport pilot was fatally injured. The helicopter was substantially damaged when it impacted the water. The helicopter

was registered to and operated by K-VA-T&W-L Aviation LLC under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual night

meteorological conditions prevailed, and no flight plan was filed. The flight was originating from a private field at the time of the accident.

According to a witness, while boating on the lake across from the helicopter landing zone, he watched as the helicopter came in and landed. He recalled that

the landing light was on, and he watched as the passengers exited the helicopter. The helicopter then lifted and turned toward the lake, descended down an

embankment and made a turn over the lake. The witness said that he noticed that the landing light was not on during the departure flight. The helicopter

traveled approximately 150 yards when the bottom skids began to make the water spray on the side of the helicopter. The helicopter then nosed over and

made a loud splash. The witness waited for a short moment and then turned on his spot light and moved towards the position of the helicopter. As he moved

towards the helicopter, his boat bumped into the tail boom, which was floating away from the fuselage. He continued towards the helicopter and came upon the

helicopter floating upside down with the skids upright approximately 2 feet above the water. The witness shined his light throughout the cabin and cockpit but

did not see anyone.


The pilot, age 64, held an airline transport pilot certificate for airplane single-engine land, multi-engine land, and rotorcraft-helicopter issued May 27, 2008, and a

second-class airman medical certificate issued February 17, 2012, with limitations for corrective lenses. The pilot's logbook was not recovered for review.

According to the Federal Aviation Administration (FAA) records, the pilot reported 26,000 flight hours on his last medical.

A review of the pilot's flight schedule for that day revealed that the pilot started the passenger flights at 1500 on the day of the accident. A review of the flight

schedule times revealed that 10 passenger flights between Bristol Speedway to a private residence near South Holston Lake were made in a period of 1 hour

and 20 minutes. After the pilot returned, he was informed that the next flight would start at 2100. During the flights, the pilot hot fueled at the landing site

adjacent to the residence where he dropped off and picked up passengers. There is no record of the amount of fuel taken onboard the helicopter during the

day. According to the wife of the pilot, he was well rested the night before and there was nothing abnormal about the day. She went on to say that the pilot was

in good health.


The seven-seat, skid equipped helicopter, serial number 53077, was manufactured in 1996. It was powered by a Rolls-Royce model 250-C47B turbo-shaft

650-hp engine.

Review of copies of maintenance logbook records showed an annual inspection was completed March 20, 2012, at a recorded airframe total time of 2,339.1

hours, and an engine time of 2,091.0 hours. The Hobbs hour-meter showed 2,427.8 hours at the accident site. The engine control unit recorded an engine total

time of 2,771.06.

Video footage from a security camera captured several daytime departures by the pilot earlier that day. In all the takeoffs, the helicopter was low enough to the

surface of the lake to allow the main rotor to create a wake on the surface of the water. On the night of the accident, video footage showed the helicopter's

anti-collision lights reflecting off of the lake's surface prior to the accident.

AERODROME INFORMATION

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The intended landing site was in the backyard at the private residence of the owner of the helicopter, which is an area of turf grass. The landing site was

elevated approximately 30 feet above the lake surface. The area is unlit and not a dedicated helipad and it was used frequently by the owner for helicopter

operations.

METEOROLOGICAL INFORMATION

A review of recorded data from the Virginia Highlands Airport, Abingdon, Virginia (VJI) automated weather observation station, elevation 2,087 feet, revealed

that at 2235, conditions were wind 100 degrees at 4 knots, visibility of 10 miles, cloud conditions scattered at 11,000 feet above ground level (agl).

On the day of the accident, official sunset was at 2007, end of civil twilight was at 2033, moonset was at 1917 with an elevation more than 29 degrees below

the horizon, and moonrise would be 1519 on August 25, 2012. Moon phase was a waxing crescent with 51% of visible disk illuminated. The evening trip took

place under nighttime VFR conditions.


The fuselage of the helicopter was recovered on August 28, 2012, approximately 100 yards from the estimated location of the helicopter's original impact point

on the water. The helicopter's engine was torn from the fuselage and could not be located due to poor visibility in the water and the irregular bottom features

which rendered the search ineffective.

Examination of the cockpit area of the fuselage revealed that it had been breached during impact. The pilot and copilot's seat pans were broken away from their

respective bases and deformed. The instrument panel was dislodged from its mount and held to the fuselage by wiring. A cursory examination of the instrument

panel revealed that the landing light switch was found in the "both" position but the landing light circuit breaker was observed in the "out" position (turned off).

Examination of the fuselage exhibited evidence of main rotor contact. The top Plexiglas window and frame exhibited evidence of main rotor contact.

Examination of the flight controls revealed that all controls from the collective and cyclic to the vertical control tubes to the hydraulic actuators to the swash

plate were intact and no notable damage was observed. The forward vertical firewall exhibited rotational witness marks from the engine to transmission shaft.

Rotational witness marks were also present on the transmission shaft. The forward end of the transmission shaft remained attached to the main transmission;

the K-Flex coupling on the aft end of the transmission shaft had failed in overload and was splayed outward. The main rotor mast had fractured in overload at

its base but had not separated. Examination of the main transmission chip detector upper and lower was found clean of debris. The hydraulic reservoir was

found full of hydraulic fluid and clean of debris.

Examination of the main rotor blades revealed that all four rotor blades were fractured consistent with a sudden stoppage. The blue, red, and green pitch

change links were bent; the orange pitch change link was fractured in overload. All pitch link hardware was present, and all cotter keys were installed.

The tail boom was fractured at the aft bulkhead and the fracture surfaces were consistent with a main rotor strike. Strike marks were present on both of the top

of the vertical stabilizers above the tail boom and the bottom of the vertical stabilizers below the tail boom. The foreword-most 4 feet of the tail boom was not

recovered. The vertical fin was not damaged, and the anti-collision light remained intact. The tail boom drive shaft was fractured at the number 3 coupling.

Examination of the 90-degree gearbox revealed that the chip detector was found clean and free of debris. The 90-degree gearbox rotated with no binding or

grinding. Control continuity was confirmed from the forward fracture to the tail rotor control lever upper end. The tail rotor control lever attachment point showed

signs of impact damage and remnants of the arm bearing were located in the lower end of the tail cone. No anomalies were found with the tail rotor which would

have prevented normal operation and control.

The engine bay showed evidence of contact by the main rotor. The mounts, engine controls, fuel, oil and electrical connections were all severed from the

helicopter. The only engine components present were the Engine Control Unit (ECU), part of a throttle control arm, and a small fragment of the starter/generator

mount. All engine mounts were fractured in overload and deformed. The engine oil reservoir, oil cooler, and fan were missing.

Due to extensive impact damage, control continuity could not be established from the cockpit to the engine bay. The collective was fractured at its base. The

throttle twist grip was deformed and not movable by hand. The throttle was found in the full-open (fly) position. A piece of the throttle engine's throttle arm was

present in the engine bay, still attached to a deformed section of throttle control linkage. The airframe-mounted fuel filter was present. The outlet fuel line to the

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engine had been severed, allowing water contamination of the filter bowl. The filter bowl was opened and examined. A small amount of silt was present, from

the river bed but the filter was otherwise normal. The ECU baseplate was deformed due to impact damage.


An autopsy was performed on the pilot on August 28, 2012, by the Department of Health, Office of the Chief Medical Examiner, Roanoke, Virginia, as

authorized by the medical examiner for Washington County.

The FAA's Civil Aerospace Medical Institute performed forensic toxicology on specimens from the pilot with negative results for drugs and alcohol.

TEST AND RESEARCH

Examination of the recorded ECU data revealed that there were no engine operating exceedance prior to impact, and no accumulated engine faults were

recorded during the previous engine run. No Incident recorder (IR) data had been written to file; however, a partial Snapshot trigger dataset had been recorded.

The Snapshot trigger was caused by an Engine Torque Exceedance of 116%. Only seven sequential engine parameters were recorded in the Snapshot data.

This is consistent with destruction of the helicopter occurring almost immediately after the initial over-torque event occurred. Electrical power was lost to the

ECU before a full line of Snapshot data could be written or any IR data could be recorded.

Due to the limited amount of data recorded on the ECU, very little analysis of engine performance could be achieved. The disparity between main rotor rpm (Nr)

and power turbine speed (Np) is attributable to the rapid deceleration of the main rotor as it impacted the water. There is a 24 millisecond cycle time for the

data write; however, the Nr signal first passes through a digital converter before the Np signal. During a rapid deceleration of the main rotor, the recorded value

for Np will be lower than that recorded for Nr. The recorded Nr data was sampled a few milliseconds before the recorded Np data. The Np data was recorded

during or immediately following the main rotor strike of the water.

ADDITIONAL INFORMATION

Spatial Disorientation

According to Spatial Disorientation in Aviation (F.H. Previc and W.R. Ercoline), the otoliths (tiny organs of the inner ear), sense the acceleration of gravity and

the acceleration associated with translational motions. Because the otoliths cannot distinguish between these two types of acceleration, they can only sense a

combination of these two forces, the gravitoinertial force (GIF) vector. During coordinated, unaccelerated flight, the GIF vector is directed straight down through

the pilot's seat. When an aircraft accelerates rapidly, however, the GIF vector is displaced aft, causing a false sensation of pitching up. This misperception,

known as the somatogravic illusion, is normally dispelled when the pilot views the external horizon and/or the flight instruments. If no external horizon is visible

and the flight instruments are not continuously monitored or are not correctly interpreted, the somatogravic illusion can persist, leading to an inaccurate

understanding of aircraft orientation and direction of motion known as spatial disorientation, a condition that can lead to inappropriate pilot control inputs.

Spatial disorientation illusions are described extensively in FAA pilot training literature. For example, the 2012 Aeronautical Information Manual states, "A rapid

acceleration during takeoff can create the illusion of being in a nose up attitude." Similarly, the FAA Instrument Flying Handbook states, "A rapid acceleration,

such as experienced during takeoff, stimulates the otolith organs in the same way as tilting the head backwards. This action creates the somatogravic illusion

of being in a nose-up attitude, especially in situations without good visual references." The Manual and the Handbook warn that, "The disoriented pilot may

push the aircraft into a nose-low or dive attitude." Identical information is included in the FAA's Pilot Handbook of Aeronautical Knowledge. This particular

illusion is so well recognized that information about it is included in the FAA's private pilot, instrument rating, and airline transport pilot knowledge test guides

and the FAA practical test standards for private pilots.

According to FAA Advisory Circular AC 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long

as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further states that surface references and

the natural horizon may become obscured even though visibility may be above VFR minimums, and that an inability to perceive the natural horizon or surface

references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions.

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Accident Rpt# WPR14TA149 Regis# N497E Tehachapi, CA03/27/2014 140 PDT

Acft Mk/Mdl BELL OH 58A Acft Dmg: SUBSTANTIAL Rpt Status: Prelim Prob Caus: Pending

Apt: Tehachapi Muni TSP

Acft SN 69-16375

Flt Conducted Under: FAR PUBU

KERN COUNTY SHERIFFS

DEPARTMENT

Regis# N497E

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

Narrative

On March 27, 2014, about 0140 Pacific daylight time, a Bell OH-58A, N497E, collided with a highway near Tehachapi, California, after encountering instrument

meteorological conditions (IMC). The helicopter was registered to, and operated by, the Kern County Sheriff's Department as a public-use flight. The

commercial pilot, tactical flight officer (TFO), single passenger, and a dog were not injured. The helicopter sustained substantial damage during the accident

sequence. The cross-country flight departed Meadows Field Airport, Bakersfield, California, about 0120, with a planned destination of General William J Fox

Airfield, Lancaster, California. Marginal visual meteorological conditions prevailed at the accident site, and no flight plan had been filed.

The purpose of the flight was to transport a dog from the Sheriff Department's Canine division to urgent care in Lancaster, after it was shot while on duty, about

3 hours prior to the accident.

The pilot stated that he arrived at the air division headquarters in Bakersfield about 0100, and was briefed on the mission by the current on-duty command pilot.

They discussed the weather, and he confirmed that visual meteorological conditions (VMC) prevailed at both the departure and arrival airports. He was aware

that a weather front was moving through the area, and that he would most likely encounter IMC conditions while enroute. He planned to use Tehachapi airport

as an alternate landing site should conditions deteriorate.

At 0120, they loaded the injured dog into the rear left footwell, along with the Canine Division Chief who was seated in the rear right seat. The departure was

uneventful, but as they approached Tehachapi they encountered light rain, strong wind, and low clouds. Both the pilot and the TFO were wearing Night Vision

Goggles (NVG's) throughout the flight.

The pilot decided to proceed, and wanted to see if Sand Canyon was passable. However, once they got beyond the lights of the city, he lost visual reference

after flying into what appeared to be clouds. He reported flying at about 500 feet agl at that time, and was concerned that returning might cause them to collide

with obstacles in the area such as wind turbines. He elected to slow the helicopter and initiate a gradual descent with the hope of exiting the clouds. During the

descent he realized that the windshield had in fact fogged up, and as such, he turned on the demister. A short time later a highway suddenly came into view

and the helicopter struck the ground.

The helicopter struck the highway surface, bounced back into the air, and rotated about 180 degrees. The pilot maintained a low hover and could now see the

lights of Tehachapi ahead. The helicopter appeared to be handling normally, and was not vibrating or making any unusual sounds, so he elected to return to

Tehachapi Airport. Before landing he asked the TFO to open the door to observe the skids; they appeared intact. The TFO attempted to utilize the Forward

Looking Infrared Camera (FLIR) mounted on the nose, and rear-mounted "Nightsun" searchlight to assist with the landing, but they were both inoperative. The

helicopter then landed uneventfully.

Subsequent examination revealed that the helicopter sustained substantial damage to the belly structure, with the skids having been spread about 2 feet

beyond their normal stance. The FLIR and searchlight both sustained crush damage to their lower cowlings, and the tailskid appeared to have struck the

ground.

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Accident Rpt# CEN11FA383 Regis# N390TH Oswego, IL06/13/2011 947 CDT

Acft Mk/Mdl BOEING B-17G

Eng Mk/Mdl WRIGHT R-1820-97

Summary

The weekend before the accident, a fuel leak was identified. The fuel leak was subsequently repaired, and a final inspection the morning of the accident flight

reportedly did not reveal any evidence of a continued fuel leak. Shortly after takeoff, the flight crew noticed a faint odor in the cockpit and a small amount of

smoke near the radio room. The flight crew immediately initiated a turn with the intention of returning to the departure airport. About that time, they received a

radio call from the pilot of the accompanying airplane advising that there was a fire visible on the left wing. The accident pilot subsequently executed an

emergency landing to a corn field. Emergency crews were hampered by the muddy field conditions, and the fire ultimately consumed significant portions

airframe.

In-flight photographs showed the presence of fire on the aft lower portion of the left wing between the inboard and outboard engines. Located in the same area

of the fire were fuel tanks feeding the left-side engines. After landing, heavy fire conditions were present on the left side of the airplane, and the fire spread to

the fuselage.

A postaccident examination noted that the C-channel installed as part of the No. 1 main fuel tank repair earlier in the week was partially separated. During the

examination, the tank was filled with a small amount of water, which then leaked from the aft section of the repair area in the vicinity of the partially separated

channel. Metallurgical examination of the repair area revealed a longitudinal fatigue crack along the weld seam.

The fatigue nature of the crack was consistent with a progressive failure along the fuel tank seam that existed before the accident flight and was separate from

the damage sustained in the emergency landing and postlanding fire. The repair earlier in the week attempted to seal the leak but did not address the existing

crack itself. In fact, the length of the crack observed at the time of the repair was about one-half the length of the crack noted during the postaccident

examination, suggesting that the crack progressed rapidly during the course of the accident flight. Because the repaired fuel tank was positioned within the

open wing structure, a fuel leak of significant volume would have readily vaporized, producing a flammable fuel vapor/air mixture. Although the exact ignition

source could not be determined due to the fire damage, it is likely that the fuel vapor and liquid fuel encountered hot surfaces from nearby engine components,

which initiated the in-flight fire.


Apt: Aurora Municipal ARR

Acft TT 2579

Acft SN 44-85734


LIBERTY FOUNDATION, INC.

Regis# N390TH

Aircraft Fire: BOTH

0Fatal Ser Inj 0

Opr Name: Opr dba:

THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: An inadequate repair of the fuel

tank that allowed the fuel leak to continue, ultimately resulting in an in-flight fire.

Cause Narrative

Events

1. Initial climb - Fire/smoke (non-impact)

2. Landing - Off-field or emergency landing


1. Aircraft-Aircraft systems-Fuel system-Fuel storage-Incorrect service/maintenance - C

2. Personnel issues-Task performance-Maintenance-Repair-Maintenance personnel - C

Narrative

HISTORY OF FLIGHT

On June 13, 2011, about 0947 central daylight time, a Boeing B-17G "Flying Fortress" airplane, N390TH, experienced an in-flight fire and emergency landing

near Oswego, Illinois. One passenger sustained a minor injury. The remaining 3 flight crew members and 3 passengers were not injured. The airplane was

substantially damaged as a result of the postimpact fire. The airplane was registered to and operated by The Liberty Foundation under the provisions of 14

Code of Federal Regulations Part 91 as a repositioning flight. Visual meteorological conditions prevailed for the flight, which was not operated on a flight plan.

The flight originated from the Aurora Municipal Airport (ARR), Sugar Grove, Illinois at 0938, with an intended destination of the Indianapolis Regional Airport

(MQJ).

The airplane had been at ARR for the weekend before the accident flight as a planned stop for education/demonstration flights; however, a fuel leak had

interrupted the scheduled flights. A mechanic associated with the Foundation evaluated and repaired the fuel leak the day prior to the accident flight. According

to the mechanic, a final inspection of the repair the morning of the accident flight did not reveal any evidence of a continued fuel leak at that time and the

airplane was subsequently returned to service.

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The flight crew reported that they noticed a faint odor during initial climb after takeoff. While attempting to locate the source of the odor, the pilot noticed a small

amount of smoke near the radio room. The flight crew immediately initiated a turn with the intention of returning to ARR. About that time, they received a call

from the pilot of the accompanying airplane advising that there was a fire visible on the left wing. The third crew member onboard the B-17 subsequently

confirmed a fire behind the no. 2 engine. The pilot took control of the airplane from the co-pilot and setup for an emergency landing to a field off the left side of

the airplane. The co-pilot then shut down the no. 2 engine and discharged the fire bottles. The pilot executed an emergency landing to a corn field about 8 miles

southeast of ARR. The co-pilot noted that the airplane touched down smoothly on speed about one-third of the way down the field. The ground was firm and the

airplane came to a smooth stop.

Emergency crews were hampered by the muddy field conditions, and the fire ultimately consumed portions of the fuselage and the inboard portions of both

wings.


The pilot held an Airline Transport Pilot certificate with single and multi-engine land airplane ratings. His certificate included type ratings for B-17, B-737, B-757,

and B-767 airplanes. He was issued a first class airman medical certificate without limitations on May 17, 2011. He reported a total flight time of 14,178 hours,

with 438 hours in B-17 airplanes. His most recent regulatory checkride was completed on April 17, 2011.

The co-pilot held an Airline Transport Pilot certificate with single and multi-engine land airplane ratings. His certificate included type ratings for DC-9, B-757,

B-767, and A320 airplanes. He was issued a first class airman medical certificate with a limitation for corrective lenses on March 4, 2011. He reported a total

flight time of 15,000 hours, with 6 hours in B-17 airplanes. His most recent regulatory checkride was completed on August 26, 2010.


The accident airplane was a Boeing B-17G "Flying Fortress," serial number 44-85734. It was mid-wing monoplane design, configured with a retractable, tail

wheel landing gear. The cockpit and cabin were accessible through a door located on the right side of the fuselage just forward of the horizontal stabilizer, or

through a hatch located in the bottom of the fuselage below the cockpit. The airplane was powered by four 1,200 horsepower Wright model R-1820-97

nine-cylinder, radial engines.

Available information indicated that the accident airplane was delivered to the United States Army Air Force in 1945. In 1947, the airplane was included in a lot

of aircraft sold for scrap. However, the accident airplane was not scrapped and was subsequently sold to the United Aircraft Corporation/Pratt & Whitney

Aircraft Division for use as an engine development test bed. In 1967, the airplane was donated to the Connecticut Aviation Historical Association.

Unfortunately, in 1979, the airplane was severely damaged in a tornado. In 1999, a private individual purchased the airplane with the intention of restoring it.

During the restoration process, the airplane was sold to the Liberty Foundation. The restoration was completed in 2004 and the airplane was returned to an

airworthy condition. The FAA issued a limited special airworthiness certificate in May 2005. At the time of the accident, the airplane was being operated as a

historical demonstration/exhibition aircraft by the Liberty Foundation.

The airplane was maintained under a progressive inspection program. The program was comprised of four incremental inspection procedures designated "A",

"B", "C", and "D", which were to be conducted at 25-hour intervals, and periodic/non-routine inspection procedures as applicable. The most recent incremental

inspections were completed on: March 25, 2011, at 2,501.9 hours total time airframe (TTAF); April 21, 2011, at 2,529.6 hours TTAF; May 14, 2011, at 2,552.7

hours TTAF; and June 10, 2011, at 2,579.0 hours TTAF.

Documentation on file with the Federal Aviation Administration (FAA) revealed that a modification of the fuel system was completed during restoration of the

airplane. This modification involved removal of the outboard fuel cells, also known as "Tokyo" tanks, and related fuel lines. In addition, the fuel tank-to-fuel tank

transfer system was replaced with a fuel tank-to-engine cross-feed system. A corresponding FAA form 337, Major Repair and Alteration, dated April 26, 2005,

was on file with the airplane records.

An airplane maintenance logbook entry, dated February 24, 2011, at 2,474.7 hours TTAF, noted that the aluminum fuel tanks had been removed from the

airplane, and that the rubber fuel bladder liners were removed from the tanks. The aluminum tanks were subsequently welded to close the bladder liner

mounting relief holes and re-installed into the airplane. An operational check of the fuel tank modification did not reveal any anomalies and the airplane was

returned to service. There was no corresponding Major Repair and Alteration (FAA form 337) on file with the airplane records. The mechanic that conducted the

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work noted that the fuel bladders were degrading and occasionally clogging the fuel sumps.

The final maintenance logbook entry was dated June 13, 2011, the day of the accident. The entry noted a repair to the inboard end of the no. 1 main fuel tank.

A subsequent leak check did not reveal any anomalies and the airplane was returned to service.

The mechanic who accomplished the fuel tank repair reported that he had examined the no. 1 fuel tank the day before the accident because of a fuel leak. He

determined that the leak was due a 3-inch crack that was located in the weld bead at the bottom edge of the tank near the sump drain valve. The fuel leak was

repaired by installing 5 bolts through the fuel tank flange. An aluminum C-channel was then installed with sealant over the fuel tank flange.

METEOROLOGICAL CONDITIONS

At 0952, the ARR Automated Surface Observing System recorded weather conditions as: Wind from 060 degrees at 10 knots; 10 miles visibility; clear skies;

temperature 18 degrees Celsius; dew point 9 degrees Celsius; altimeter 30.16 inches of mercury.


The airplane came to rest on its landing gear in an agricultural field located about 8 miles southeast of ARR. Ground tracks indicated that the emergency

landing was performed toward the east; approximate course 090 degrees. There did not appear to have been any damage to the airplane as a direct result of

off-airport landing. However, the in-flight and ground fire substantially damaged the airplane.

In-flight photographs of the accident airplane showed the presence of fire on the aft lower portion of the left wing between the no. 1 (outboard) and no. 2

(inboard) engines. Also located in the same area of the fire were fuel tanks feeding the left-side engines.

In photographs taken shortly after the accident aircraft landed, heavy fire conditions were present on the left side of the aircraft with the fire spreading to the

fuselage. By the time the fire was extinguished, the inboard portion of both the left and right wings had been destroyed by fire as well as most of the fuselage.

The engines, empennage, fuselage nose, and the outboard portions of both wings remained intact.

TESTS AND RESEARCH

A postaccident examination of the no. 1 main fuel tank was conducted under the direct supervision of the NTSB investigator-in-charge. The upper, inboard end

of the fuel tank was deformed and ruptured consistent with damage sustained after the landing. However, the area repair area itself located at the center portion

of the lower, inboard seam of the tank appeared to exhibit minimal deformation. The aft portion of the repair C-channel was partially separated from the tank

seam. The remainder of the C-channel appeared to be securely bonded to the tank. The bolts installed at the time of the repair were intact and appeared to be

secure. The tank was filled with a small amount of water, which was subsequently observed to leak from the aft section of the repair area in the vicinity of the

partially separated C-channel.

Further examination of the fuel tank was conducted by the NTSB materials laboratory. A longitudinal crack, about 7.2 inches in length, was located along the

center of the weld seam. The fracture surface features were consistent with fatigue, consistent with a progressive failure at the weld seam. The sealant in the

vicinity of the aft two repair bolts was thin and the cured sealant did not conform to the inside shape of the C-channel. The sealant along the remainder of the

repair had adhered to the fuel tank and provided full coverage over the weld seam. Additionally, the cured sealant along this portion of the repair conformed to

the inside shape of the C-channel.


FAA regulations (14 CFR Part 1) define a major alteration as one that is not listed in the aircraft, aircraft engine, or propeller specifications: (1) that might

appreciably affect weight, balance, structural strength, performance, powerplant operation, flight characteristics, or other qualities affecting airworthiness; or (2)

that is not done according to accepted practices or cannot be done by elementary operations. The regulations (14 CFR Part 43) related to a major alteration

specifically include "changes to the basic design of the fuel, oil, cooling, heating, cabin pressurization, electrical, hydraulic, de-icing, or exhaust systems" as

airframe alterations.

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The FAA Major Repair and Alteration Data Approval Job Aid provides guidance to Aviation Safety Inspectors in evaluating requests for field approvals. The

document notes that a change to, or addition of, permanent fuel tanks or fuel system components, may be eligible for approval by means other than a

Supplemental Type Certificate (STC), but require FAA approved data. This data may be obtained from a Designated Engineering Representative (DER),

Organization Designation Authorization (ODA) approved engineering data or through ACO coordinated field approval.

The airplane records on file with the FAA included approvals for modification of the fuel crossfeed system and removal of outboard fuel tanks, radio room

seating, and a tail wheel modification, as well as lighting and avionics upgrades. However, the file did not include any application for, or approval of, the most

recent modification to the fuel tanks, which included removal of the fuel bladders.

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Accident Rpt# CEN13LA421 Regis# N732MD Chicago, IL07/17/2013 800 CDT

Acft Mk/Mdl CESSNA 208B

Eng Mk/Mdl P&W PT6-114A


Apt: Chicago O'hare International A KORD

Acft TT 10473

Acft SN 208B1083


MULTI-AERO INC AIR CHOICE ONE

Regis# N732MD

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

Narrative

On July 17, 2013, about 0800 central daylight time, a Cessna 208B, N732MD, was substantially damaged on the ramp at Chicago O'Hare International Airport

(KORD), Chicago, Illinois. The pilot in command, second in command, and nine passengers were not injured. The airplane was registered to and operated by

Multi-Aero Inc., doing business as Air Choice One under the provisions of 14 Code of Federal Regulations Part 135 as a scheduled domestic passenger flight.

Visual meteorological conditions prevailed for the flight, which operated on an instrument flight rules flight plan. The flight was originating at the time of the

accident.

The Director of Operations at Air Choice One reported that the pilot in command and 9 passengers were on board the airplane, and the second in command

was outside on the right side of the airplane; adjacent to the passenger door and ventral stairs. A passenger in the last row of the airplane asked the second in

command to assist her with her seatbelt, at which time the second in command climbed up the stairs into the airplane. At the same time, the gate agent

removed the tail stand from the airplane, without communicating with the flight crew.

A passenger in row 3 then stood up to hand a carry-on bag to the second in command so that it could be stowed in the cargo compartment. As the passenger

stood up and stepped towards the back of the airplane, the airplane titled backwards and the tail struck the tarmac. The pilot in command ensured that

everyone was okay and then asked passengers to move forward in the airplane in an effort to bring the nose of the airplane back down. The pilot in command,

second in command, and passengers disembarked from the airplane without further incident.

An examination of the airplane revealed substantial damage to the bulkhead in the tail section of the airplane. An examination of the airplane and remaining

systems revealed no anomalies.

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Accident Rpt# CEN13LA101 Regis# N212M Detroit Lakes, MN12/07/2012 2234 CST

Acft Mk/Mdl CESSNA 501

Eng Mk/Mdl P&W CANADA JT15D-1

Summary

While climbing on a night, instrument departure, with the autopilot most likely engaged, the airplane entered into an unusual attitude. Although both pilots

recalled a left climbing turn that transitioned into a left descending spiral, air traffic control radar information indicated a right climbing turn that transitioned into

a right descending spiral. Both pilots stated that their attention had been focused away from the attitude indicators during the time immediately before the

unusual attitude began. The pilot-in-command disconnected the autopilot and recovered the airplane by referencing the standby instruments. During the

recovery, as the pilot pulled up from the nose-low attitude, both wings sustained structural damage.

Examination of the airplane revealed that the nose radome quick release latches were not water tight and that gaps in these latches allowed precipitation to

enter the forward avionics bay. Although, avionics testing did not reveal any anomalies consistent with an uncommanded flight maneuver by the autopilot,

moisture conditions were not introduced during any of the tests. While it is possible that the moisture caused a malfunction of the avionics, it could not be

definitively determined.


Apt: N/a

Acft SN 501-0280


MAKAIRA AIRCRAFT SALES LLC

Regis# N212M

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

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Accident Rpt# CEN13FA101 Regis# N212M Detroit Lakes, MN12/07/2012 2234 CST



Summary

While climbing on a night, instrument departure, with the autopilot most likely engaged, the airplane entered into an unusual attitude. Although both pilots

recalled a left climbing turn that transitioned into a left descending spiral, air traffic control radar information indicated a right climbing turn that transitioned into

a right descending spiral. Both pilots stated that their attention had been focused away from the attitude indicators during the time immediately before the

unusual attitude began. The pilot-in-command disconnected the autopilot and recovered the airplane by referencing the standby instruments. During the

recovery, as the pilot pulled up from the nose-low attitude, both wings sustained structural damage.

Examination of the airplane revealed that the nose radome quick release latches were not water tight and that gaps in these latches allowed precipitation to

enter the forward avionics bay. Although, avionics testing did not reveal any anomalies consistent with an uncommanded flight maneuver by the autopilot,

moisture conditions were not introduced during any of the tests. While it is possible that the moisture caused a malfunction of the avionics, it could not be

definitively determined.


Apt: N/a

Acft TT 3612

Acft SN 501-0280


MAKAIRA AIRCRAFT SALES LLC

Regis# N212M

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: A loss of airplane control due to

an undetermined avionics malfunction and the pilots' inattention, which resulted in excessive airframe forces during the unusual attitude recovery. The reason

for the avionics malfunction could not be determined because postaccident testing did not reveal any anomalies that would have precluded normal operation.

Cause Narrative

Events

1. Initial climb - Inflight upset


1. Personnel issues-Task performance-Workload management-(general)-Flight crew - C

2. Aircraft-Aircraft systems-(general)-(general)-Malfunction - C

3. Personnel issues-Psychological-Attention/monitoring-Attention-Flight crew - C

4. Not determined-Not determined-(general)-(general)-Unknown/Not determined - C

Narrative

HISTORY OF FLIGHT

On December 7, 2012, about 2234 central standard time, a Cessna model 501 airplane, N212M, was substantially damaged during recovery from an unusual

attitude after departing from Detroit Lakes Airport (KDTL), Detroit Lakes, Minnesota. The two pilots and four passengers were not injured. The airplane was

registered to Makaira Aircraft Sales LLC and operated under the provisions of 14 Code of Federal Regulations Part 91 while on an instrument flight plan. Night

instrument meteorological conditions (IMC) prevailed at the flight level of the accident, which had an intended destination of Bessemer Airport (KEKY),

Bessemer, Alabama.

After takeoff from Runway 31, the pilot stated that the airplane entered IMC about 1,000 feet above ground level (AGL) and the autopilot was engaged about

3,000 feet mean sea level (MSL); 2,400 AGL. After receiving an air traffic control (ATC) clearance for a left turn on course, he rotated the heading select 'bug' to

command the autopilot to initiate a left turn. While climbing through approximately 7,000 MSL, with the autopilot still engaged, the pilot stated that the airplane

rolled to the left and transitioned rapidly into a nose down descent. Both pilots stated that their attention had been focused away from the attitude indicators

during the time immediately prior to the unusual attitude commencing.

The pilot disconnected the autopilot and attempted to recover the airplane, which he observed had entered into a nearly inverted, left turning spiral, with a steep

nose down attitude. To recover from the unusual attitude, the pilot referenced the standby attitude indicator, turn needle, and heading indicator. Both wings

were structurally damaged during recovery from the nose low attitude.

Radar track data indicated on departure from KDTL, the airplane made a climbing left turn, leveled at 6,000 feet MSL, and subsequently flew straight ahead at

6,000 feet MSL for about 30 seconds. Next, the airplane made a climbing, right turn to about 7,200 feet MSL and then transitioned into a descending spiral to

the right, with a descent rate exceeding 10,000 feet per minute. The descending spiral continued until about 3,500 feet MSL. The airplane then transitioned to a

right climbing turn through 4,800 feet MSL and subsequently began to climb with a wings level attitude. A radar study, which includes ground tracks and flight

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parameters, is located in the NTSB public docket.


The pilot, age 62, held an airline transport pilot certificate, with single-engine and multiengine land airplane ratings. He reported 10,161 total flight hours, with

810 hours in the make and model of the accident airplane. The acting copilot, age 50, held a commercial pilot certificate, with single-engine and multiengine

landing ratings. He reported 1,498 total flight hours, with 273 hours in the make and model of the accident airplane.


The accident airplane, a Cessna 501 (serial number 501-0280) was manufactured in 1977. It was registered with the Federal Aviation Administration (FAA) on a

standard airworthiness certificate and certificated for single pilot operation. The logbooks showed a total time of 3,612 hours as of December 5, 2012.


The weather observing station at KDTL, located 5 miles east of the unusual attitude location, reported the following conditions at 2213: wind 140 at 3 knots,

visibility 10 miles, broken clouds at 1,900 feet AGL, temperature minus 5 degrees Celsius, dew point minus 9 degrees Celsius, altimeter setting 30.03. The

pilots stated that light snow was occurring at the time of takeoff. Upper air soundings from Aberdeen, South Dakota and Chanhassen, Minnesota near the

accident time indicate that moderate or greater rime icing would have been likely from 2,000 feet through 14,000 feet MSL.

TESTS AND RESEARCH

Following the accident, Federal Aviation Administration (FAA) personnel examined the airplane and observed about a quarter cup of water pooled at the bottom

of the forward avionics bay, as well as openings (not water tight) in the nose radome quick release latches.

The NTSB, FAA, and an avionics technician conducted avionics testing of the airplane about ten weeks after the accident. A moderate amount of snow was

observed in the forward avionics bay, as the airplane had been parked on a ramp during several high-wind snowstorms. Previous to the accident, nose radome

quick release latches were installed utilizing Sierra Industries supplemental type certificate (STC) SA8437SW.

The avionics system was tested in accordance with Sperry maintenance manual ground test procedures. With ground power connected, the #1 and #2 attitude

systems, autopilot, and flight director system were tested, with no anomalies noted. The heading system tested normally, although the #2 heading system

exceeded the manufacturers recommended time to retract its warning flag, requiring nine minutes vice the recommended five minutes. The #1 vertical gyro, #1

vertical gyro (Ledex) switching unit (relay), autopilot computer, and flight director computer were removed from the airplane for follow on testing.

The #1 vertical gyro and vertical gyro switching unit were examined and tested by an avionics overhaul facility, with oversight by FAA personnel. The vertical

gyro became erect and operational within specified limits and gyro output signals were verified to be within manufacturer specifications. The vertical gyro case

was opened and proper bearing movement was confirmed, with no evidence of previous moisture. The vertical gyro base, which holds the electronic circuit

boards, was dissembled and inspected for evidence of moisture, with two small areas of corrosion noted. The vertical gyro was reassembled and a Precession

Test was conducted, which showed values within manufacturer specifications.

With FAA oversight, the flight director computer (Z-500, P/N 4018369-901) was examined and tested at a Honeywell facility. No corrosion or water damage was

observed on the interior or exterior of the unit. No short or blown fuses were detected during manual functional testing and the flight director passed acceptance

testing.

The autopilot computer (SPZ-200, P/N 4008519-911) was also examined and tested at the Honeywell facility. No moisture or water damage was observed on

the interior of the unit. Black spots were observed on the left and right side of the chassis and boards where the connector pins extended downward. The

substance/spots were not able to be rubbed off. The autopilot was subjected to acceptance testing, with two tests marginally out of tolerance. No short or blown

fuses were detected during simple manual functional testing.

Additional testing of the autopilot computer, which included cold temperature conditions, was conducted by an avionics overhaul facility, with oversight by FAA

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personnel. An avionics technician at the overhaul facility was familiar with previous failures of the fault isolation transformer in the SPZ-200 autopilot computer

which had produced an uncommanded roll of the autopilot. The avionics technician stated that the isolation transformer was often intermittent in operation, and

it was often difficult to recreate a failure on the bench. No anomalies with the autopilot computer were discovered during the additional testing. Moisture

conditions were not introduced during any of the tests.


The pilots estimated the time from engine start to departure at KDTL was about seven minutes. A minimum avionics warm up time is not required by the flight

manual, other than to ensure that avionics warning flags are not in view.

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Accident Rpt# CEN13TA113 Regis# N753CC Oklahoma City, OK12/21/2012 1000 CST



Summary

While on the right downwind leg, the flight crew advised the air traffic control tower controller that they would make a full stop landing. The tower controller

acknowledged, told them to extend their downwind, and stated that he would call their base turn. The controller then called out the landing traffic on final, which

was an Airbus A300-600 heavy airplane. The flight crew replied that they had the traffic in sight, and the controller cleared the flight to land behind the Airbus,

and to be cautious of wake turbulence. The flight crew observed the Airbus abeam their current position and estimated that they made their base turn about 3

miles from the runway. Before turning onto final approach, the flight crew discussed wake turbulence avoidance procedures and planned to make a steeper

approach and land beyond the Airbus's touchdown point. They also added 10 to 15 knots to the Vref speed as an additional precaution against a wake

turbulence encounter. The reported wind provided by the tower controller was 180 degrees at 4 knots. The flight crew observed tire smoke from the Airbus as it

touched down and discussed touching down beyond that touchdown point. The tower controller advised the flight crew to be prepared for a go-around if the

Airbus did not clear the runway in time, which the flight crew acknowledged. The flight crew estimated that the Airbus had turned off the runway when their

airplane was about 1,000 feet from the threshold and about 200 feet above ground level (agl). The flight crew reported having a stabilized approach to their

planned landing point. When the airplane was about 150 feet agl and established on the runway centerline, the airplane experienced an uncommanded left roll.

The heading swung to the left and the nose dropped. The crew reported that the airplane was buffeting heavily. Immediately, they set full power, and the flying

pilot used both hands on the control wheel in an attempt to roll the airplane level and recover the pitch. He managed to get the airplane nearly back to level

when the right main gear struck the ground short of the threshold and left of the runway. The airplane collided with a small drainage ditch and a dirt service

road, causing the right main gear and the nose gear to collapse.

Videos from cameras at the airport recorded the accident sequence, and the accident airplane was about 51 seconds behind the Airbus.

A wake vortex study indicated that the accident airplane encountered the Airbus's right vortex, and the airplane's direction of left roll was consistent with the

counter-clockwise rotation of the right vortex.


Apt: Will Rogers World OKC

Acft TT 13506

Acft SN 550-0109


UNITED STATES CUSTOMS SERVICE

Regis# N753CC

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The flight crew's decision to fly

close behind a heavy airplane, which did not ensure there was adequate distance and time in order to avoid a wake turbulence encounter with the preceding

heavy airplane's wake vortex, which resulted in a loss of airplane control during final approach.

Cause Narrative

Events

1. Approach-VFR pattern final - Aircraft wake turb encounter

2. Uncontrolled descent - Collision with terr/obj (non-CFIT)


1. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Flight crew - C

2. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-(general)-Not attained/maintained - C

3. Environmental issues-Conditions/weather/phenomena-Turbulence-Wake turbulence-Contributed to outcome - C

Narrative

HISTORY OF FLIGHT

On December 21, 2012, about 1000 central standard time, a Cessna 550 Citation airplane, N753CC, impacted terrain while on approach to runway 17L at the

Will Rogers World Airport (OKC), near Oklahoma City, Oklahoma. The pilot was uninjured and the copilot sustained minor injuries. The airplane sustained

substantial wing and fuselage damage. The airplane was registered to and operated by the United States Customs Service under the provisions of 14 Code of

Federal Regulations (CFR) Part 91 as a public use flight. Day visual flight rules (VFR) conditions prevailed for the flight. The local flight originated from OKC

about 0920.

According to the operator's report, the purpose of the flight was a local VFR training flight. The crew consisted of two flight instructor pilots; one who was current

and qualified in the airplane and the second pilot who was qualified but out of currency. This was to be a training flight for the pilot under instruction (PUI) to

reset his currencies so he could attend re-current training. The PUI had recently returned from a 12-month military deployment and had not flown for more than

a year.

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The crew's preflight activities were described as routine. They attended the morning crew briefing, checked weather and notices to airmen, completed their

pre-mission paperwork, and completed the preflight of the airplane together. The weather was forecast to be VFR conditions throughout the day.

The airplane departed OKC on runway 17L, VFR westbound and climbed to 12,500 feet above mean sea level (msl). The flight instructor was the pilot not flying

(PNF) and sat in the left seat; the PUI was the pilot flying (PF) from the right seat. The PF completed a series of normal stalls and steep turns, then requested

vectors back to OKC for a practice instrument landing system (ILS) approach on runway 17L followed by pattern work. The PF flew the practice ILS, and then

made two touch-and-go landings. The PNF described PF's performance up to this point as being above average for someone who had not flown in a year and

his approach and landings were described as excellent.

While on the right downwind leg, the crew advised the air traffic control (ATC) tower that they would make a full stop landing. ATC acknowledged, told them to

extend their downwind leg, and stated that the controller would call their base turn. The controller then called out the landing traffic that was currently on final

approach, which was an Airbus A300-600 heavy. The flight crew replied back that they had the traffic in sight, and the controller cleared the flight to land,

number two behind the preceding Airbus, and advised to have caution for wake turbulence. The crew observed their position was abeam the Airbus and

estimated that they made the base turn about three miles from the runway. While making the turn, the flight crew discussed wake turbulence avoidance

procedures and planned to make a steeper approach and land beyond the Airbus's touchdown point. The PF added 10 to 15 knots to the Vref speed as a

precaution. The reported winds provided by the tower controller were 180 degrees at 4 knots. The crew observed tire smoke from the Airbus as it touched down

near the 1,500-foot runway markings. The flight crew discussed touching down at the 2,000-foot markings and continued. The Airbus continued on the runway,

and the tower advised the Citation flight crew to be prepared for a go- around, should the Airbus not clear the runway in time, which the flight crew

acknowledged. The flight crew estimated that the Airbus turned off the runway on taxiway F when they were about 1,000 feet from the threshold and about 200

feet above ground level (agl). The flight crew reported having a stabilized approach, and elected to continue while maintaining their planned landing point. When

landing was assured, the PF reduced the power levers.

The operator indicated that when the airplane was approximately 150 feet agl, established on runway centerline, it had an uncommanded left roll to 60 degrees

of bank or beyond. The heading swung to the left to about 130 degrees and the nose dropped. The flight crew reported that the airplane was buffeting heavily

and that they momentarily lost sight of the horizon. Immediately, the PNF set full power and the PF used both hands on the control wheel in an attempt to roll

the airplane level and recover the pitch. The PF managed to get the airplane nearly back to level when the right main landing gear struck the ground short of the

threshold and left of the runway. Less than 50 feet after the right main landing gear had touched down, the airplane collided with a small drainage ditch and a

dirt service road, causing the right main and the nose gear to collapse. The airplane skidded across a grassy area, across a taxiway, and before it came to rest

it "ground looped" to the right in the infield between the taxiway and runway. A small ground fire had begun in the grassy area beyond the taxiway. The flight

crew checked each other and immediately evacuated the airplane through the main cabin door. Upon exiting, they observed fuel pouring out of a hole in the left

wing and elected to get a safe distance away from the airplane. The PNF had no injuries; the PF was taken to the hospital and treated for back pain.

The pilot flying an Air Force T-1 Jayhawk airplane, which was trailing the accident airplane, saw the accident sequence. He indicated that he had begun timing

for wake turbulence as soon as the Airbus crossed the runway threshold and never visually acquired the Citation other than on the airplane's traffic collision

avoidance system (TCAS). Based on TCAS, the Citation was about 3 miles in front of the T-1 and about 900 feet below the T-1's altitude. When the T-1 was

about 4 miles from the threshold of the runway, the tower controller advised the Citation to expect a go-around. Shortly after this call, he visually acquired the

Citation that was on short final as the wings rolled "nearly vertical," allowing the sun to be reflected in a "wing flash". He saw that the Citation subsequently

impacted terrain short and slightly left of the runway striking right wing first. It then cart wheeled and stopped upright on a northwesterly heading. He also saw

smoke, dust and debris, and flames/sparks upon impact. The T-1 was about three to four miles out on final at this point and was "coming up on (or shortly

past)"the flight's two minute interval time for wake turbulence. The pilot estimated that the Citation was about a minute or less behind the Airbus and was on a

low final based on the T-1's TCAS indications. The Airbus was just turning off the runway as the Citation was approaching about a 1/2 to 1/4 mile final at 100 to

200 feet when it encountered the wake. The T-1 pilot stated that, after the crash, the T-1's crew began a go-around and were subsequently given ATC

instructions to go-around. On the go-around, the pilot noticed the Citation's airframe was still intact and he did not notice any post-impact fire.

Video cameras at the airport recorded the accident sequence. A video showed the accident airplane following approximately 51 seconds behind an Airbus

airplane landing on the same runway. The video showed the accident airplane rolled left to about a bank angle of 60 degrees and a heading of approximately

140 degrees before recovering to a right-wing-low, nose-down attitude and impacting terrain. The right wing fuel tank ruptured, the airplane skidded along grass,

crossed an airport perimeter road, crossed taxiway hotel, and came to rest upright near a parking lot along the east side of runway 17.

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Pilot Not Flying

The 49-year old pilot, who was seated in the left seat, held a Federal Aviation Administration (FAA) airline transport pilot certificate with a multiengine land

rating with commercial pilot privileges for single engine land airplanes. He held a Cessna 500 type rating and a certified flight instructor rating with single-engine,

multiengine, and instrument airplane ratings. According to the operator's report, the pilot had accumulated 5,097 hours of total flight time and 420 hours of flight

time in the same make and model as the accident airplane. The pilot held a second-class medical certificate with a limitation for corrective lenses.

Pilot Flying

The 41-year old co-pilot, who was seated in the right seat, held a FAA airline transport pilot certificate with a multiengine land rating with commercial pilot

privileges for single engine land airplanes and rotorcraft and instrument helicopters. He held Cessna 500 and Beechcraft 200 type ratings and a certified flight

instructor rating with single-engine, multiengine, and instrument airplane ratings. According to the operator's report, the pilot had accumulated 357 hours of flight

time in the same make and model as the accident airplane. The pilot held a second-class medical certificate without limitations.


N753CC, a Cessna model 550 (Citation), with serial number 550-0109, was a twin-engine, turbojet airplane. The airplane was configured to seat four

occupants. The transport category airplane was powered with two Pratt & Whitney Canada JT-15D-4 turbofan engines, serial numbers PCE-71690 and

PCE-70313, each capable of producing 2,500 pounds of thrust. The operator reported that the airplane was maintained under an annual inspection program and

its most recent continuous airworthiness inspection was completed on April 23, 2012, when the airplane accumulated 13,506 hours of total time.


A National Transportation Safety Board (NTSB) senior meteorologist produced a meteorology group chairman's report for the investigation. His report indicated

that a surface analysis chart for 0900 on December 21, 2012, depicted a col or neutral zone centered over Oklahoma with a weak pressure gradient over the

area, with resulting light winds. No boundaries were identified over the area to result in any significant low-level wind shear or shifting wind surrounding the

period.

The station models depicted light southerly wind with no significant weather depicted over the area. The regional radar mosaic did not depict any meteorological

echoes over the region and the convective outlook indicated no organized thunderstorms were expected across the area.

A constant pressure charts for 0600 on December 21, 2012, indicated that Oklahoma was located behind or west of an upper level trough with general

convergence aloft and subsiding motion over the region. The station model over Oklahoma City depicted warm low-level conditions with a freezing level above

8,000 feet.

At 0952, the recorded weather at OKC was: Wind 190 degrees at 7 knots; visibility 10 statute miles; sky condition scattered clouds 25,000 feet; temperature 4

degrees C; dew point -8 degrees C; altimeter 30.36 inches of mercury. No wind gusts were noted and no significant variations in the wind field were noted

surrounding this period.

The 0600 upper air sounding from Norman, Oklahoma depicted a defined surface based temperature inversion to approximately 1,166 feet agl with another

inversion above. The atmosphere was stable and dry and did not support any significant cloud growth.

Satellite imagery did not depict any significant clouds or boundaries surrounding the period.

Weather radar in the Norman, Oklahoma, area was operating in the clear air mode during the period and depicted no meteorological echoes or boundaries over

the area during the period. It did depict false echoes associated with ground clutter from a strong inversion.

The terminal aerodrome forecast for OKC predicted light southerly wind over the airport at nine knots with no significant weather surrounding the period. No

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significant icing, low-level turbulence, low-level wind shear, or icing conditions were expected over the area and no advisories were current. The meteorologist's

report is appended to the docket associated with this investigation.

AIDS TO NAVIGATION

The published inbound course for OKC's instrument landing system (ILS) runway 17L approach was 175 degrees magnetic, with the published straight in

decision altitude of 1,486 feet msl, with a height above touchdown of 200 agl. The glide slope intercept altitude at the HANGS intersection was 2,800 feet. The

distance between HANGS and the touchdown zone was 4.6 nm. The runway's threshold elevation was 1,286 feet. The OKC ILS RWY 17L approach plate is

appended to the docket associated with this investigation.

AIRPORT INFORMATION

OKC, located approximately nine miles southwest of downtown Oklahoma City, Oklahoma, was a certificated airport under 14 CFR Part 139. It was owned by

The City of Oklahoma City, Oklahoma (City). The Oklahoma City Airport Trust, a public trust whose sole beneficiary is the City, leases, operates, manages,

and holds title to airport property in trust for the City. OKC's field elevation was 1,295 feet above mean sea level. Its class C airspace had continuous air traffic

control services. The airport supported aircraft rescue and firefighting index C requirements.

OKC had 4 runways: runway 17L/35R - 9,802 feet by 150 feet, concrete/grooved; runway 17R/35L - 9,800 feet by 150 feet, concrete/grooved; runway 13/31 -

7,800 feet by 150 feet, asphalt/concrete/grooved; runway 18/36 - 3,078 feet by 75 feet, asphalt.

Runway 17L was marked as a precision approach runway and had high intensity runway edge lights. It was not serviced by any visual approach path system.

The runway had MALSR (medium intensity approach lighting system with runway alignment indicator lights) approach lighting and centerline lighting.

FLIGHT RECORDERS

The airplane was equipped with an enhanced ground proximity warning system (EGPWS) that provided aural and visual alerts and warnings to prevent

controlled flight into terrain and for low altitude windshear conditions. The accident airplane's model was a Honeywell MK VIII EGPWS with serial number 0967.

The accident model VIII took inputs from airplane sensors and systems such as, the air data inertial reference unit, weather radar, GPS, and radio altimeter to

calculate projected position and potential collision with nearby terrain. Audio alerts messages will sound over the flight deck speakers and visual warnings will

appear on the electronic flight indication system to the flight crew if a potential collision is detected.

An EGPWS is designed to protect against seven different scenarios categorized by modes. Mode 1 is excessive descent rate, Mode 2 is excessive closure to

terrain, Mode 3 is altitude loss after takeoff, Mode 4 is unsafe terrain clearance, Mode 5 is excessive deviation below glideslope, Mode 6 is advisory callouts,

and Mode 7 is windshear protection. Each mode has soft and hard limit alert criteria with the hard limit requiring more urgent attention by the crew.

The accident model is designed to record events triggered by exceeding the hard and soft limits set by the device. Once a limit has been exceeded, a new

event will be recorded at one sample per second that includes 20 seconds before and 10 seconds after the exceedence. The EGPWS parameters are sampled

one time per second, but the actual time of occurrence can be anywhere within the second. Each record is identified by the unit's operating time, the mode that

was exceeded, and a unique flight number from the device. A status log is also recorded that contains each landing and takeoff.


A FAA inspector along with a safety investigator from Cessna examined the wreckage after it was recovered to a ramp area at OKC. The left wing tip exhibited

abrasions on its lower surface and was bent upward. The left wing leading edge exhibited an impact dent about three feet outboard of the fuselage similar in

shape to the nose landing gear tire. The left trailing edge flap was extended. The right lower fuselage nose area exhibited impact witness marks and the nose

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section was buckled upward. The right wing leading edge was punctured about one foot outboard of the fuselage. The outboard right wing section was bent

upward and its fuel tank was compromised. The right wingtip lower surface exhibited abrasion damage and was bent upward. The right aileron was bent upward

near its mid-span. The right flap trailing edge upper skin separated from the airplane. The right horizontal stabilizer leading edge was dented mid-span. The right

elevator trailing edge exhibited impact damage. The aileron trim tab was near neutral. The elevator trim tab was near neutral. The rudder trim tab was deflected

to the left. The speed brakes were retracted. The nose and right main landing gear separated from the airplane. The right engine fan exhibited foreign object

debris witness marks on its blades. The aft fuselage was twisted and its skin was wrinkled near the engines. The airplane was outfitted with four cabin seats,

which remained attached to the seat tracks. The pilot and copilot seat's three-point safety restraint systems were intact. The area around the rudder pedals was

pushed upward and rearward. The left and right altimeters' Kollsman window indicated an altimeter setting of 30.36. The flap and landing gear controls were in

the extended position and brake anti-skid was on. The flap position indicator was near the extended position. The elevator trim indicator was near neutral. The

on-scene examination and subsequent disassembly of the airplane did not reveal any preimpact anomalies that would have precluded normal operations.


The toxicological samples from the PNF were collected and tested. The results were negative for the tests performed.

TESTS AND RESEARCH

The EGPWS download was performed by its manufacturer with oversight by NTSB staff. The downloaded files were sent to a vehicle recorder specialist in the

NTSB Vehicle Recorder Laboratory for subsequent analysis. According to the vehicle recorder specialist's factual report, the total operating time of the device

was 494:44:55. Each power cycle was tagged with a sequential flight leg number. The accident event was identified as flight number 1420 with a bank angle

and terrain clearance exceedance at the recorded operating times of 494:20:21 and 494:20:28, respectively.

Correlation of the EGPWS data from unit operating time to central standard time was established using ATC radar data. The radar data was overlaid against

the EGPWS data in Google Earth. The location at ATC time of 11:59:03 was aligned with the similar EGPWS location at 494:20:01 EGPWS Operating Time.

Accordingly, 478:20:58 was subtracted from EGPWS operating time to convert to local time.

The accident flight's recorded EGPWS data was plotted. A plot contained basic airplane parameters such as airplane attitudes, airspeed, altitude, and system

discrete conditions. It showed the bank angle exceedance occurs at 11:59:23, with a roll to the left of 59.1 degrees. The terrain clearance exceedance occurs

at 11:59:30, with a GPS altitude of 1,326 feet. The vehicle recorder specialist's EGWPS factual report is appended to the docket associated with this

investigation.

A NTSB senior transportation safety specialist produced an ATC specialist's report. The report included ATC radar data and ATC audio recordings from the

OKC airport traffic control tower and its terminal radar approach control. The recorded data was consistent with the accident flight crew's report. The ATC

specialist's report is appended to the docket associated with this investigation.

A NTSB aircraft performance national resource specialist produced an aircraft performance wake vortex study. This study included data from OKC airport

surveillance radar, EPGWS data, the NASA Langley Aircraft Vortex Spacing System Predictor Algorithm (APA), meteorological information, and aerodynamic

considerations. The study's calculated results indicated that the location of the Airbus' right vortex after one minute supports an encounter with the accident

airplane, and it direction of roll (to the left) is consistent with the counter-clockwise rotation of the right vortex (as viewed from behind). The study is appended

to the docket associated with this investigation.

ADDITIONAL DATA/INFORMATION

The instructor pilot in the T-1 reported that the ATC tower told the crew they were behind a heavy Airbus and were number two for the runway. The instructor

stated that his student pilot requested a 360-degree turn to build spacing, which was granted as requested. Following the 360-degree turn, the tower cleared the

flight for the visual straight in approach. The tower indicated that the flight was now number three for the runway behind the Airbus airplane and cleared the

Citation behind the Airbus.

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According to the operator, the agency's flight training included wake turbulence training. However, following the accident, the operator increased the structure of

their wake turbulence training, in part, to include:

�Developing new wake turbulence procedures to be incorporated into

their Office of Air and Marine's (OAM) Air Operations Handbook (AOH)

�Developing new wake turbulence training procedures to be

incorporated into OAM's Aircrew Standardization Manuals (ASM)

�Incorporating two new slides outlining new wake turbulence

procedures into our training materials, which are discussed during

training

�Posting a front page Quarterly Special Emphasis Item banner on wake

turbulence in the Opstar web portal

�Produced a Quarterly Special Emphasis Item, which is required to be

completed and documented in pilots' training folders

�Developed a Wake Turbulence awareness video that will be

disseminated to all OAM personnel via OAM's website and OpSTAR

�Delivering human factors training and crew resource management

training to all instructor pilots at the National Air Training Center by a

FAA contractor

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Accident Rpt# WPR12LA341 Regis# N5038F Cody, WY07/31/2012 920 MDT

Acft Mk/Mdl FAIRCHILD HILLER FH-1100

Eng Mk/Mdl ALLISON 250-C18

Summary

The pilot reported that while in cruise flight, the rear of the helicopter suddenly began to vibrate. He performed an autorotation to a field, and the helicopter

landed hard. The tailboom and main transmission mounts were substantially damaged. The pilot reported that a tail rotor driveshaft coupling had split in half,

which resulted in a loss of tail rotor drive. Postaccident examination of the tail rotor driveshaft coupling revealed that the coupling failure was initiated by fatigue

cracking. A complete history of the part was not available; therefore, the total time in service of the part could not be determined.


Apt: N/a

Acft TT 2250

Acft SN 186


HARRISON TIMOTHY BRUCE ECLIPSE HELICOPTER SERVICES

Regis# N5038F

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The failure of a tail rotor

driveshaft coupling due to fatigue.

Cause Narrative

Events

1. Enroute-cruise - Flight control sys malf/fail

2. Autorotation - Hard landing


1. Aircraft-Aircraft systems-Flight control system-(general)-Failure - C

2. Aircraft-Aircraft systems-Flight control system-(general)-Fatigue/wear/corrosion - C

3. Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Yaw control-Attain/maintain not possible

Narrative

On July 31, 2012, about 0920 mountain daylight time, a Fairchild Hiller FH-1100 helicopter, N5038F, was substantially damaged following the failure of its tail

rotor drive shaft and subsequent autorotation to a hard landing near Cody, Wyoming. The commercial pilot and his three passengers were not injured. The

helicopter was being operated by the pilot, doing business as Eclipse Helicopter Services, Cody, under the provisions of 14 Code of Federal Regulations Part

91. No flight plan had been filed for the local personal flight, which had originated about 1 hour before the accident. Visual meteorological conditions prevailed at

the time of the accident.

The pilot reported that while in cruise flight, there was a sudden onset of a vibration coming from the rear of the helicopter. He performed an autorotation to a

field straight ahead. During the landing sequence, the helicopter spun to the right 180 degrees. The landing skids, tail boom, and main transmission mounts

were bent. The pilot reported that a tail rotor driveshaft coupling, identified as a Bendix 19E101-1D coupling, had split in half, which resulted in a loss of tail

rotor drive.

Postaccident examination of the tail rotor driveshaft coupling by the National Transportation Safety Board's Materials Laboratory in Washington, D.C., revealed

that it failed due to fatigue cracking. A complete history of the part was not available; therefore, the total time in service of the part could not be determined.

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Accident Rpt# ANC13FA004 Regis# N27PH Willow, AK10/15/2012 1557 AKD

Acft Mk/Mdl GRUMMAN AIRCRAFT ENG CORP C-1A

Eng Mk/Mdl WRIGHT R-1820 SER

Summary

The airline transport-rated pilot was on the first leg of a flight to deliver fuel to a remote mining site. About 30 minutes after departure, a primary radar track,

thought to be that of the accident airplane, showed the airplane make a 180-degree turn back toward the point of departure. Two witnesses described hearing

the airplane pass overhead, and both said that "the airplane did not sound right." One witness stated that the airplane flew directly overhead of his location

under a low ceiling and was going very slow.

The airplane was severely damaged by a postimpact fire and explosion. A review of on-scene photographs by an NTSB fire and explosives investigator

determined that there was no evidence of an in-flight fire.

Analysis of weather in the area around the time of the accident showed that although the ceiling was low, the weather did not play a significant role in the

accident.

An NTSB on-scene examination of the airframe revealed no preaccident mechanical anomalies that would have precluded normal operation. However, due to

the disposition of the wreckage, a detailed examination of the engines could not be accomplished on-scene. The wreckage was not recovered from the accident

site. The circumstances leading up to the accident could not be determined.


Apt: N/a

Acft SN 136791


FUEL SERVICES, LLC

Regis# N27PH

Aircraft Fire: GRD

1Fatal Ser Inj 0

Opr Name: Opr dba:

THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's loss of control of the

airplane for reasons that could not be determined because the wreckage was not recovered from the accident site.

Cause Narrative

Events

1. Enroute - Unknown or undetermined



1. Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C

2. Not determined-Not determined-(general)-(general)-Unknown/Not determined - C

Narrative

HISTORY OF FLIGHT

On October 15, 2012, about 1557 Alaska daylight time, a twin-engine Grumman C-1A "Trader" airplane, N27PH, was destroyed when it collided with

tree-covered terrain and incurred a postcrash fire and explosion about 19 miles west of Willow, Alaska. The airline transport rated pilot, who was the only

occupant, was fatally injured. The airplane was registered to Fuel Services, LLC, Anchorage, Alaska, and was being operated as a 14 CFR Part 91 visual flight

rules (VFR) cross-country fuel transport flight when the accident occurred. Marginal visual meteorological conditions were reported at the airplane's point of

departure. The accident flight originated from the Wasilla Airport, Wasilla, Alaska, about 1520, en route to the Nixon Fork Mine, about 28 miles northeast of

McGrath, Alaska.

According to the co-owner of the airplane, the purpose of the flight was to transport approximately 900 gallons of diesel fuel to a company owned tank that

supplies fuel for a mining operation.

When the airplane did not arrive at its destination, the co-owner of the airplane reported it overdue to the Federal Aviation Administration (FAA) at 1757. After

being notified of the overdue airplane, personnel from the 11th Air Force's Rescue Coordination Center initiated a search for the missing airplane along its

supposed route of flight. On the morning of October 16, an Air National Guard C-130 Hercules was able to locate the wreckage. Rescue personnel aboard a

HH-60G helicopter were able to reach the site later that morning, and confirmed the pilot was deceased.

Two witnesses reported seeing the airplane fly over their locations. The first witness saw the airplane as it was flying northwest at an altitude that he estimated

at 3,000 to 4,000 feet under an overcast layer. He stated that the airplane did not sound "normal," but he did not notice anything unusual, like smoke, trailing

the airplane.

The second witness stated that he saw the airplane fly over his cabin headed southeast at an estimated altitude of 300 to 400 feet. He stated that the airplane

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sounded like it was "struggling," but he could not see anything abnormal about the airplanes appearance.

Primary radar data taken from the Anchorage Terminal Radar Approach Control Facility (TRACON), shows an unidentified aircraft, believed to be the accident

airplane, depart the Wasilla airport about 1522. After departure, the track proceeded to the Northwest with cruising groundspeeds of between 180 and 193

knots. No altitude or transponder code data was transmitted by the airplane. Around 1343 the radar track changed direction and proceeded to the southeast.

Groundspeeds after the track changed direction started at 143 knots, and gradually decreased to a low of 117 knots about 5 minutes before the accident. The

last radar plot for the airplane was at 1556:47, approximately 5.5 nautical miles from the accident site, and showed a heading of 088 degrees, and a

groundspeed of 175 knots.


The pilot, age 62, held an Airline Transport Pilot Certificate with airplane multiengine land, airplane multiengine sea, airplane single engine land, airplane single

engine sea, and rotorcraft-helicopter ratings. His most recent first-class medical was issued on February 7, 2012, with the limitation that he must have glasses

available for near vision.

No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from a review of the airmen

Federal Aviation Administration (FAA) records on file in the Airman and Medical Records Center located in Oklahoma City. On the pilot's application for medical

certificate, dated February 7, 2012, he indicated that his total aeronautical experience was about 25,000 hours, of which 200 were in the previous 6 months.


The airplane was a surplus United States Navy, high-wing, twin-engine, transport airplane manufactured by the Grumman Aerospace Corporation in 1957. It

was powered by two Wright R-1820-82WA Cyclone, nine cylinder radial piston engines, each capable of producing 1,525 horsepower.

No logbooks or other maintenance records were located, and according to the owner were onboard the airplane at the time of the accident, and destroyed by

the postcrash fire.


The closest weather reporting station to the accident site is the Skwentna Airport, Skwentna, Alaska, about 22 miles west. About 63 minutes before the

accident, at 1452, a weather observation was reporting, in part: Wind, 350 degrees (true) at 10 knots, gusting to 18 knots; visibility, 15 statute miles; sky

condition, scattered at 1,500 feet, 3,000 feet overcast; temperature, 30 degrees F; dew point, 23 degrees F; altimeter, 29.11 inches Hg.

There were two witness reports that included weather conditions from their viewpoint. The first, near Willow, reported that there was an overcast layer about

5,000 feet agl, with no precipitation. The second, about 14 miles northwest of the accident site, reported an overcast ceiling between 600 and 1000 feet, with

occasional snow showers. He said that the airplane was flying below the ceiling, going in, and out of some of the low clouds.

See the NTSB Meteorology Report in the public docket for this accident for more detailed weather information.

COMMUNICATIONS

No communications were noted with the accident airplane


The airplane impacted in tree covered terrain on an approximate heading of 125 degrees. Portions of the fragmented airplane were scattered along a debris

path oriented along a magnetic heading of 130 degrees, and measured about 240 feet from the point of initial impact to the furthest piece of wreckage. The

initial point of impact was noted to be a birch tree, approximately 60 feet from the first point of ground impact.

The first point of ground impact was noted to be the left wing tip. The left wing tip structure was found buried approximately 1 foot under the ground. An impact

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scar, consistent with the left wing leading edge, extended from the initial ground impact point. Fragments of the left wing were found adjacent to the ground

scar. From the first point of impact to the first ground scar, it could be surmised that the angle of impact was approximately 60 degrees nose down.

A postimpact fire and explosion destroyed most of the airplane's structure.

There was an impact crater of size and shape consistent with the left engine and propeller. A second impact crater consistent with the fuselage was adjacent to

the first crater. The second crater contained the empennage, the left engine and propeller, and left engine nacelle. A tree adjacent to the second crater on the

southwest edge had significant scraping and marks, as well as two pieces of embedded metal which looked like it came from a propeller. The marks were

consistent with contact from the right engine propeller and the empennage.

The empennage remained mostly intact, and came to rest upside down on the edge of the second impact crater. The horizontal stabilizer was mostly

undamaged. The vertical stabilizer sustained fire damage consistent with the postimpact fire. No anomalies were noted with either the pitch or rudder trim

systems.

Just adjacent to the second crater on the north edge, were the right engine propeller, and the remains of the cockpit and forward fuselage.

A second area of severely burned wreckage was located approximately 15 feet forward of the second impact crater on an approximate 125 degree heading.

Amongst the charred wreckage were the remains of the fuselage, a large section of the right wing and engine nacelle, the right engine, and various other pieces

of burned wreckage.

The left engine, located in the first impact crater, was partially buried. No anomalies were noted to the visible portion of the exterior of the engine case. The

exhaust tubes had malleable bending and folding, producing sharp creases that were not cracked or broken along the creases. The left propeller remained

attached to the engine. All three blades were bent aft and exhibited a slight amount of torsional S-bending. The left propeller hub also showed rotational scoring.

The right engine, located in the second area of wreckage, sustained severe thermal damage during the postaccident fire. The exhaust tubes showed no signs of

ductile folding. The right propeller separated from the engine at the crankshaft. All three blades showed leading edge gouging, chord wise scratching, and

torsional S-bending.


A postmortem examination of the pilot was done under the authority of the Alaska State Medical Examiner, Anchorage, Alaska, on October 17, 2012. The

examination revealed that the cause of death for the pilot was attributed to blunt force injuries.

A toxicological examination by the FAA's Civil Aeromedical Institute (CAMI) on January 9, 2013 was negative for any carbon monoxide, alcohol, or drugs.

FIRE

A review of the on-scene photos by an NTSB fire and explosives investigator revealed that there was no evidence of an in-flight fire.

ORGANIZATIONAL AND MANAGEMENT INFORMATION

The company was set up to transport fuel to support mining operations at various locations throughout Alaska. Since the operator leased the fuel farms that

they delivered fuel to, it was not required for them to operate as a FAR Part 135 carrier.


About 3 months prior to the accident, the airplane was involved in a gear up landing, which required inspection of the engine, and replacement of the engine

propellers for both engines. The operator told the NTSB IIC that the inspections were satisfactory, but could not provide documentation to support.

A more detailed examination of the airframe and engines was not possible because the wreckage was never recovered from the accident site.

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The operator did not fill out the required NTSB Pilot/Operator accident reporting form 6120.1.

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Accident Rpt# WPR13CA406 Regis# N519PA Kalalau, HI09/12/2013 1350 HST

Acft Mk/Mdl HUGHES 369D

Eng Mk/Mdl ALLISON 250-C20B


Apt: N/a

Acft TT 5261

Acft SN 370097D


AIRBORNE AVIATION INC

Regis# N519PA

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

Narrative

The pilot reported that the purpose of the flight was to drop off crew members and pick up secured bundles of trash from a remote landing zone. He had landed

at this landing zone several times throughout the day. After an uneventful landing, the helicopter started to shake abruptly. The pilot maintained control of the

helicopter until the shaking stopped and he could shut down the engine. A witness reported that a tarp from a nearby trash bundle had flown up into the main

rotor blades; subsequently, one of the main rotor blades departed the helicopter and sustained substantial damage. There were no mechanical failures or

malfunctions with the airframe or engine that would have precluded normal operations.

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Accident Rpt# CEN13LA366 Regis# N112EM Cincinnati, OH06/18/2013 1125 EDT

Acft Mk/Mdl ISRAEL AIRCRAFT INDUSTRIES 1124

Eng Mk/Mdl GARRETT TFE 731 SER


Apt: Cincinnati Municipal Airport KLUK

Acft TT 7522

Acft SN 336


E MICAH AVIATION INC

Regis# N112EM

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

Narrative

On June 18, 2013, about 1125 eastern daylight time, an Israel Aircraft Industries (IAI) 1124 airplane, N112EM, was substantially damaged following a landing

gear collapse at Cincinnati Municipal Airport (KLUK), Cincinnati, Ohio. The flight instructor, pilot, and pilot-rated passenger did not report any injuries. The

airplane was registered to and operated by E. Micah Aviation Incorporated under the provisions of 14 Code of Federal Regulations Part 91 as an instructional

flight. Day visual meteorological conditions prevailed and no flight plan was filed. The local flight departed KLUK about 1045.

According to the cockpit voice recorder (CVR), the pilot and flight instructor briefed an instrument landing system (ILS) approach to runway 21L at KLUK. The

flight instructor requested two ILS approaches from air traffic control (ATC) and was given missed approach instructions. After contacting the KLUK control

tower, the flight instructor requested and received clearance for the "option", which permits a touch-and-go, low approach, missed approach, stop-and-go, or full

stop landing.

The flight instructor verbally coached the student throughout the instrument approach, flare and landing. Although the student had flown more than 3,600 total

flight hours, he was attempting his first landing in this airplane type and had not landed a high-performance or turbine powered airplane in several years.

As the pilot was flaring the airplane to land, the CVR recorded a steady tone with the frequency of the 'trim movement' buzzer, which continued 8.5 seconds.

Immediately after the airplane touched down, the flight instructor stated "no, no, no, we're not stopping". As the flight instructor was making this statement, at

1125:00, a half-second rumbling sound was recorded and the trim movement buzzer tone stopped. One second later, the student stated "okay, my bad". A half

second later, at 1125:01.5, the CVR recorded a steady tone with the frequency of the gear warning horn, which continued until the end of the recording. At

1125:03, a 'thunk' sound was recorded, followed by a scraping noise. At 1125:07, the scraping noise restarted and continued for about 20 seconds. The

background sound and scraping noise decreased in intensity over the 20 second period, similar to the airplane decelerating.

The airplane came to a stop near the end of runway 21L with the left landing gear collapsed outward, since the IAI 1124 landing gear normally retracts outward.

The airplane was hoisted up by airport personnel for recovery. While being raised, the left landing gear dropped, by gravity force alone, from a retracted position

to a 'down and locked' position. No damage was observed to the left landing gear or its brace assemblies. Scrape damage consistent with runway contact was

observed on the underside of the right wing, near the wingtip. Substantial damage had occurred to structural areas of the fuselage.

The flight instructor stated that the airplane never lifted off the ground during the touch-and-go sequence and thought a mechanical failure of the landing gear

had occurred. The pilot was unsure of the sequence of events and stated that the flight instructor seemed to be rushing the touch-and-go sequence, as he

perceived that ample runway and time existed to accelerate further prior to takeoff rotation. Neither the flight instructor nor pilot recalled moving the landing gear

handle during the touch-and-go sequence.

A pilot-rated passenger, who was seated aft of the pilot and flight instructor, stated that the landing was normal. When he heard the flight instructor's command

to continue with a touch-and-go, he leaned back in his seat and no longer had a view into the cockpit area. The passenger observed the airplane become

airborne for one or two seconds. While airborne, the airplane banked to the right and the right wing tip contacted the runway. The airplane subsequently yawed

left and the left landing gear collapsed as the airplane contacted the runway. The passenger did not notice if the landing gear selector handle was moved during

the touch-and-go sequence.

A maintenance worker located at the departure end of the runway observed the airplane land normally, followed by a bank to the right and strike of the right

wingtip. He then noticed the airplane yaw to the left and the left landing gear collapsed.

Federal Aviation Administration (FAA) personnel examined and tested the landing gear. The landing gear hydraulically retracted 'outward' into the strut and

wheel well, under the wing. The gear was locked in the 'up' position by means of a lock assembly located in each wheel well. In the 'down' position, the gear

was locked and braced by side and jury brace assemblies.

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The airplane was placed on jacks and the landing gear was cycled several times, with no anomalies noted. No damage was observed to the landing gear or

brace assemblies. The FAA conducted a second test of the landing gear to examine adjustment criteria called out in the IAI 1124 maintenance manual. The

landing gear was again cycled several times, with no anomalies noted. The clearance was checked between the piston plunger end of the landing gear unlock

cylinder and unlock tang on back of the upper jury brace. This measurement was correct, which ensured that the piston travel was correct.

A review of manufacturer records and NTSB accident data did not reveal any similar landing gear incidents or accidents for IAI 1124 aircraft. The manufacturer

stated that jury and/or side brace damage would be evident if the landing gear was down and locked during a collapse sequence.

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Accident Rpt# WPR12TA436 Regis# N911BL Las Vegas, NV09/24/2012 1600 PDT

Acft Mk/Mdl MCDONNELL DOUGLAS HELI CO 369FF

Eng Mk/Mdl ALLISON 250-C30


Apt: North Las Vegas Airport VGT

Acft TT 20200

Acft SN 0601FF


LAS VEGAS METROPOLITAN POLICE

DEPARTMENT

Regis# N911BL

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

Narrative

On September 24, 2012, about 1600 Pacific daylight time, a McDonnell Douglas 369FF helicopter, N911BL, sustained substantial damage during a hard

landing following a practice autorotation at North Las Vegas Airport, Las Vegas, Nevada. The two pilots, who both held flight instructor certificates, sustained

minor injuries. The helicopter was registered to the Las Vegas Metropolitan Police Department, and the flight was a public aircraft operation. Visual

meteorological conditions prevailed for the local training flight, which had originated from North Las Vegas Airport approximately 30 minutes before the accident.

A flight plan had not been filed.

The pilot-in-command (PIC)/pilot-giving-instruction stated that he and the pilot receiving instruction were alternately practicing autorotations. He decided to

demonstrate a 270-degree autorotation to the touchdown point on taxiway Zulu. He began the maneuver on a 180-degree heading, 800 feet above the ground

and an airspeed of 85 knots. As he crossed his intended touchdown point, he rolled the throttle back to begin the autorotation. He thought the wind was about

180 to 230 degrees at 15 knots gusting to 26 knots. He entered a left turn. While in the turn, he reported that because of a tailwind he increased his bank angle

to maintain his ground reference to the touchdown point. The pilot receiving instruction reported that moments later, the helicopter was in a high rate of descent

and its airspeed was decreasing. The helicopter impacted terrain in a tail low attitude. Subsequently the tail boom separated from the fuselage, the helicopter

rolled onto its right side, and the right landing skid support structure folded under the fuselage.

At 1605, the reported wind at North Las Vegas Airport, elevation 2,205 feet, was 270 degrees at 13 knots gusting to 22 knots. The calculated density altitude,

using the barometric pressure of 29.77 inches of mercury, was 5,116 feet.

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Accident Rpt# WPR12FA332 Regis# N146SL Henderson, NV07/28/2012 832 PDT

Acft Mk/Mdl PIAGGIO P180

Eng Mk/Mdl P&W PT6A SER

Summary

The twin-engine airplane departed 23 minutes behind schedule to pick up passengers at an intermediate airport. During the takeoff roll, the left elevator

departed the airplane and was found off the side of the runway 3 days later. The crew arrived at the intermediate airport and quickly boarded the two waiting

passengers.Theydid not perform an adequate preflight inspection and departed about 5 minutes behind schedule. The airplane arrived at the destination airport

about 10 minutes behind schedule.

Upon postflight examination by the crew, the left elevator was observed missing from the tail's horizontal stabilizer. An examination of the attachmentnuts on

the hinges of the right elevatorfound that they were finger tight.Examination of the hinge fittings onthe left elevator andhorizontal stabilizer revealed no

mechanical damage or deformation to any of the components. Review of airplane maintenance records showed that an airworthiness directive (AD) had been

complied with 54 days earlier, which involved both elevators being removed and then reinstalled.

Materials laboratory examination of one of the right elevator attachment hardware bolt-nut combinations revealed that the self-locking nut exhibited run-on

torque values well below the acceptable minimum torque. Based on the fingertight condition of the right elevator attachment hardware and the lack of any

mechanical damage to the hinge fittings of the left elevator and stabilizer hingestructure, it is likely that all four sets of attachment hardware for both elevators

were not properly torqued during the AD maintenance 54 days earlier. Additionally, 26 days before the event, a phase inspection was completed during which

the elevator should have been visually inspected and functionally checked. The airplane had flown 158.9 hours with loose elevator attachment hardware before

the two sets of bolts on the left elevator had completely worked their way out of the hinges, and the elevator departed the airplane.

The cockpit voice recorder revealed that the flight crew had experienced unusual pitch control responses during each of the departures and landings.The flight

crew could have identified the missing elevator during a preflight inspection at the intermediate airport, yet they decided to continue the flight despite the pitch

control problems experienced during the takeoffs and landing.


Apt: Henderson Executive Airport KHND

Acft TT 8352

Acft SN 1091

Flt Conducted Under: FAR 091K

AVANTAIR INC

Regis# N146SL

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The failure of maintenance

personnel to properly torque the elevator attachment hardware in accordance with the maintenance manual, which led to the detachment of the elevator.

Contributing to the accident were maintenance personnel's failure to identify the loose attachment hardware during a scheduled inspection, the flight crew's

decision to continue the flight after identifying a flight control problem, and the flight crew's failure to perform an adequate preflight inspection at the intermediate

airport.

Cause Narrative

Events

1. Takeoff - Flight control sys malf/fail


1. Personnel issues-Task performance-Maintenance-Scheduled/routine maintenance-Maintenance personnel - C

2. Aircraft-Aircraft systems-Flight control system-Elevator control system-Incorrect service/maintenance - C

3. Personnel issues-Task performance-Inspection-Preflight inspection-Flight crew - F

4. Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Flight crew - F

5. Personnel issues-Task performance-Inspection-Scheduled/routine inspection-Maintenance personnel - F

Narrative

HISTORY OF THE FLIGHT

On July 28, 2012, at 0832 Pacific daylight time, a Piaggio P180, N146SL, arrived at Henderson Executive Airport, Henderson, Nevada, missing its left elevator.

The airplane was operated by Avantair under Title 14 Code of Federal Regulation, Part 135. The two crew, both airline transport pilots, and two passengers

were unhurt, and the airplane was substantially damaged. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been

filed. The flight originated from San Diego, California, about 0735.

According to the Aventair trip sheet, the planned schedule for the Piaggio P180 crew was to depart Camarillo, California, at 0552, arrive at San Diego at 0642,

then depart San Diego at 0730, and arrive at Henderson at 0822. The crew arrived at Camarillo at 0500, preflighted the airplane, and took off at 0615. The

Piaggio P180 arrived at San Diego at 0715. The Captain went to the fixed base operator (FBO) to sign for services then did a walk around on one side of the

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airplane. The First Officer met the two passengers, loaded the baggage, and stayed with the passengers who were upset about the delay. The First Officer

stated that he did not perform the required walk around prior to departing San Diego, and that, per the Aventair general operating manual, both pilots are

required to do an airplane walk around on every leg. The airplane departed San Diego at 0735 (5 minutes behind schedule), and arrived at Henderson

Executive Airport at 0832 (10 minutes behind schedule). When the crew performed a post flight walk around, they noticed that the left elevator was not present

on the tail. The crew reported that they had a non-eventful departure and flight from San Diego, and that the captain noticed that more back pressure on the

flight controls was required for a normal landing upon arrival at Henderson.

On July 31, 2012, at 1720, personnel at the Camarillo Airport located an airplane flight control surface lying in the grass off the north side of runway 8 near the

intersection of taxiway C. The flight control surface was identified by personnel at the Avantair fixed base operator (FBO) as an elevator from a Piaggio P180.

An FAA inspector collected the elevator from airport personnel, and delivered it to the NTSB investigator-in-charge (IIC) on August 1, 2012.


The 10-seat, twin turboprop, business airplane, serial number 1091, was manufactured in 2004. It was powered by two Pratt & Whitney PT6A-66 850-hp

engines, and equipped with two Hartzell HC-E5N-3A controllable pitch propellers. The airplane was in a continuous airworthiness program utilizing the

manufacturer's inspection criteria. Review of the airplane maintenance records show that the total airframe time was 8,351.9 hours when it landed at

Henderson. The most recent maintenance inspection was a 150-hour "A" inspection completed on July 2, 2012, at total aircraft time (TAT) of 8,269.4 hrs. The

"A" phase inspects the engines, propellers, flight controls, and landing gear. Part of the inspection includes a visual inspection and functional check of the

elevator.

The most recent maintenance was performed on July 27, 2012, at TAT 8,350.3 hours. The crew had repositioned the airplane from Van Nuys, California, to

Camarillo, in order to have the right main landing gear door rod assembly and the navigation lights repaired.

Airplane maintenance records show that on June 4, 2012, TAT 8,191.5 hours, Avantair complied with airworthiness directive AD 2010-23-01, which required the

left and right elevators be removed, the elevator hinges be inspected for corrosion between the elevator hinge fittings (metal) and the horizontal stabilizer

(carbon fiber), and replaced if necessary. The elevators were then reinstalled.

Examination of the hinge fittings by the NTSB IIC of the left horizontal stabilizer and the corresponding hinge fitting on the left elevator revealed no damage,

deformation, or witness marks. The two sets of bolts, nuts, and straight bushings that attached the left elevator to the horizontal stabilizer were not located.

The airframe and powerplant (A&P) mechanic who removed the right elevator reported that the self-locking nuts on the right elevator were loose, and could be

loosened and removed with his fingertips. The mechanic took photos to document the loose nuts before he removed the elevator.


The Captain, age 31, held an Airline Transport Pilot certificate with ratings for multiengine land and instrument airplane, and held a first-class medical certificate

issued April 16, 2012, with no limitations. The pilot reported in the NTSB Pilot Accident Report Form 6120.1 that he had 5,037 hours of total flight time.

The First Officer, age 34, held an Airline Transport Pilot certificate with multiengine land and instrument airplane ratings, and held a first-class medical

certificate with no limitations issued on April 11, 2012. He reported in the NTSB Pilot Accident Report Form 6120.1 that he had 5,624 hours of total flight time.

FLIGHT RECORDERS

The airplane was equipped with an L-3/Fairchild FA2100-1010 cockpit voice recorder (CVR), which records 30 minutes of digital audio stored in solid-state

memory modules. The CVR was removed, and sent to the NTSB's Audio Laboratory for readout. The CVR contained 30 minutes of excellent quality recording

from the captain's and first officer's audio panels, and 30 minutes of good quality recording from the cockpit area microphone (CAM). A CVR Group was not

convened. The recording was audited by the NTSB's Vehicle Recorder Laboratory, and a summary report prepared. The Cockpit Voice Recorder Specialist

Factual Report is located in the official docket of this investigation.

The majority of the conversation between the Captain and First Officer between 0815 and 0825 pertained to airplane operations. At 0825, air traffic control

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(ATC) cleared the airplane for a visual approach to runway 17R at Henderson. At 0829, the crew lowered the landing gear, and performed landing checks. One

minute later, the CAM starts recording a rattling sound that continues all the way to touchdown. At 0831:24, an automated voice announced "five hundred

above, sink rate, sink rate." The Captain replied "correcting". At 0831:53, the Captain said "ha ha," the First Officer replies "crazy isn't it?" and the Captain said

"yeh, its really bad at the end there." As the crew taxied the airplane, they continued to discuss the unusual feel of the airplane in the flare and landing. The

First Officer said he had the same unusual feel landing in San Diego.

After the airplane engines were shut down and the passengers disembarked, the CAM recorded a 2 1/2-minute cell phone call made by the Captain. The

Captain described to the person on the other end of the phone that he and the First Officer were not getting normal elevator control at rotation and landing, and

that he had no real control during the landing flare. He described the takeoff out of San Diego where he had the control yoke all the way back at rotation speed

of 106 kts, but the airplane didn't rotate until 120 kts. On the departure out of Camarillo the First Officer said the controls felt strange, and he saw him pull the

yoke all the way back. The Captain also said that at that point they were in a hurry, and that was why he hadn't called in the problem after departing Camarillo.

The Captain then noted that that he had not experienced the unusual control response yesterday when departing out of Van Nuys.

TESTS & RESEARCH

The left elevator command lever with attached fractured torque tube and the two sets of right elevator attachment hardware were examined by the NTSB

Materials Laboratory. On the attachment fittings, the elevator rotates about bushings that are held in place by two ¬-28 bolts, washers, and self-locking nuts. In

order to measure the wear on the in service elevator attachment hardware, new OEM (exemplar) attachment hardware was also tested in the same manor. The

complete Materials Laboratory Factual report is located in the official docket of this investigation.

The left elevator torque tube remained bolted to the left elevator bellcrank. The attachment fitting was observed to be fractured through a flange where it

transitioned out of a cylindrical section. The top part of the flange was bent in the outboard direction, and the lower part of the flange was bent in the inboard

direction. Using a stereomicroscope, the fracture surfaces were examined, and were found to have a smeared appearance. The deformation and fracture

features were consistent with an overstress failure caused by downward bending of the left elevator about the attachment fitting.

The attachment hardware of the right elevator (2 bolts & 2 self locking nuts) were examined for thread wear and functionality. The running torque of the right

attachment fitting self-locking nuts was measured using a calibrated torque wrench with 0.1 in-lbs precision. A stack of washers was placed over each right

attachment fitting bolt shank such that three bolt threads were exposed when the nut was turned onto the bolt and tightened to a wrenching torque of 115 in-lbs

in accordance with the P180 maintenance manual (Piaggio, 1991) and MS21043 (NASC, 2003). The wrenching torque was measured using a calibrated torque

wrench with 1 in-lbs precision. The running torque was measured while turning the nut onto the bolt (on-running torque) and while turning the nut off of the bolt

(off-running torque). For the first bolt/nut combination, the on- and off-running torque was 1.2 in-lbs and 1.5 in-lbs, respectively. For the second bolt/nut

combination, the on- and off-running torque was 8.5 in-lbs and 9.0 in-lbs, respectively. According to the P180 maintenance manual, self-locking nuts should be

discarded when the running torque (called breakaway torque in the manual) falls below 3.5 in-lbs for ¬-28 nuts.

The change in running torque and breakaway torque with sequential torque cycles was measured using exemplar hardware. Two A286 bolts were used in

conjunction with silver-plated self-locking nuts and gray-anodized aluminum washers. The A286 bolts, nuts, and washers were the same material types as the

accident attachment hardware. The results for the A286 bolts show an on-running torque between 6.1 and 7.0 in-lbs, and off-running torque between 6.8 and

8.8 in-lbs.


On August 7, 2012, Avantair initiated a fleet wide inspection of all their Piggio P180 airplanes. The focus of the action was to inspect and replace as necessary

all elevator mounting hardware. The Executive Vice President of Avantair confirmed on December 6, 2012, that as a precaution, all elevator self-locking nuts

had been replaced with new hardware for their fleet of P180's.

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Accident Rpt# ERA12FA409 Regis# N508GT Morgantown, WV06/22/2012 1001 EDT

Acft Mk/Mdl RAYTHEON AIRCRAFT COMPANY C90GT

Eng Mk/Mdl PRATT & WHITNEY CANADA PT6A-135A


Apt: Morgantown Municipal Airport MGW

Acft TT 1439

Acft SN LJ-1775


OZ GAS AVIATION LLC

Regis# N508GT

Aircraft Fire: BOTH

1Fatal Ser Inj 0

Opr Name: Opr dba:

Narrative

HISTORY OF FLIGHT

On June 22, 2012, at 1001 eastern daylight time a Raytheon Aircraft Company, C90GT, N508GT, operated by Oz Gas Aviation LLC, was substantially

damaged when it struck a communications tower near Morgantown, West Virginia. The certificated airline transport pilot was fatally injured. No flight plan had

been filed for the positioning flight from Nemacolin Airport (PA88), Farmington, Pennsylvania, to Morgantown Municipal Airport (MGW), Morgantown, West

Virginia conducted under Title14 Code of Federal Regulations (CFR) Part 91.

At 0924 on the morning of the accident, the airplane departed from Rigrtona Airport (13PA), Tidioute, Pennsylvania for PA88 with the pilot and three

passengers onboard. The airplane landed on runway 23 at PA88 at 0944. The pilot then parked the airplane; shutdown both engines, and deplaned the three

passengers. He advised them that he would be back on the following day to pick them up. After the passengers got on a shuttle bus for the Nemacolin

Woodlands Resort, the pilot started the engines. He idled for approximately 2 minutes, and then back taxied on runway 23 for takeoff. At 0957, he departed

from runway 23 for the approximately 19 nautical mile positioning flight to MGW, where he was going to refuel and spend the night.

After departure from PA88, the airplane climbed to 3,100 feet above mean sea level (msl) on an approximately direct heading for MGW. The pilot then

contacted Clarksburg Approach Control and was given a discrete code of 0130. When the airplane was approximately nine miles east of the Morgantown

airport, the air traffic controller advised the pilot that he had "radar contact" with him. The airplane then descended to 3,000 feet, and approximately one minute

later struck the communications tower on an approximate magnetic heading of 240 degrees.

HISTORY OF FLIGHT

On June 22, 2012, at 1001 eastern daylight time a Raytheon Aircraft Company, C90GT, N508GT, operated by Oz Gas Aviation LLC, was substantially

damaged when it struck a communications tower near Morgantown, West Virginia. The certificated airline transport pilot was fatally injured. No flight plan had

been filed for the positioning flight from Nemacolin Airport (PA88), Farmington, Pennsylvania, to Morgantown Municipal Airport (MGW), Morgantown, West

Virginia conducted under Title14 Code of Federal Regulations (CFR) Part 91.

At 0924 on the morning of the accident, the airplane departed from Rigrtona Airport (13PA), Tidioute, Pennsylvania for PA88 with the pilot and three

passengers onboard. The airplane landed on runway 23 at PA88 at 0944. The pilot then parked the airplane; shutdown both engines, and deplaned the three

passengers. He advised them that he would be back on the following day to pick them up. After the passengers got on a shuttle bus for the Nemacolin

Woodlands Resort, the pilot started the engines. He idled for approximately 2 minutes, and then back taxied on runway 23 for takeoff. At 0957, he departed

from runway 23 for the approximately 19 nautical mile positioning flight to MGW, where he was going to refuel and spend the night.

After departure from PA88, the airplane climbed to 3,100 feet above mean sea level (msl) on an approximately direct heading for MGW. The pilot then

contacted Clarksburg Approach Control and was given a discrete code of 0130. When the airplane was approximately nine miles east of the Morgantown

airport, the air traffic controller advised the pilot that he had "radar contact" with him. The airplane then descended to 3,000 feet, and approximately one minute

later struck the communications tower on an approximate magnetic heading of 240 degrees.

According to a witness who was cutting timber across the road from where the accident occurred; the weather was cloudy with lighting and thunder, and it had

just started "sprinkling". He then heard a loud "bang", turned, and observed the airplane descending upside down, and then impact. About 20 minutes later it

stopped "sprinkling". He advised that he could still see the top of the tower when it was "sprinkling".


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The pilot was self-employed and flew and managed the airplane for Oz Gas Aviation LLC. He also flew for a training organization that provided ground and flight

instruction in customer's airplanes.

According to Federal Aviation Administration (FAA) records, the pilot held an airline transport pilot certificate with ratings for airplane single-engine land and

airplane multi-engine land, and type ratings for the CE-500, DA-10, IA-JET, LR-JET, N-265, and CE-525S. He also held commercial privileges for

rotorcraft-helicopter, and instrument helicopter, and a flight instructor certificate with ratings for airplane single-engine, airplane multi-engine,

rotorcraft-helicopter, instrument airplane, and instrument helicopter.

He held a special issuance FAA second-class medical certificate which was issued on August 1, 2011 and was not valid for any class of certificate after August

31, 2012. Review of FAA and pilot records revealed that the pilot had reported to the FAA during the application of his special issuance medical certificate that

he had accrued 22,000 total hours of flight experience, 150 hours of which were in the previous 6 months. He had completed C90GT initial training on February

4, 2008, and C90GT recurrent training on February 9, 2009. No other records of training, or record of completion of an FAA flight review within the two years

preceding the accident were discovered during the course of the investigation.


The accident aircraft was a low wing, pressurized, twin engine airplane, of conventional metal construction equipped with retractable landing gear. It was

powered by two Pratt & Whitney Canada PT6A-135A turbopropeller engines capable of producing 550 shaft horsepower, each equipped with a Hartzell

4-bladed, fully reversing, constant speed propeller. It could cruise at 270 knots true airspeed and could operate at altitudes up to 30,000 feet. Its range with full

fuel was 1,068 nautical miles.

According to FAA and maintenance records, the airplane was manufactured in 2006. The airplane's most recent phase inspection was completed on May 11,

2011. At the time of the inspection the airplane had accrued 1,305 hours of operation.

At the time of the accident the airplane had accrued 1439.2 hours of operation and was overdue for its next phase inspection.


Destination Weather

The reported weather at MGW at 0953, included: winds 220 degrees at 5 knots, 9 miles visibility, a few clouds at 1,700 feet, temperature 24 degrees C, dew

point 20 degrees C, and an altimeter setting of 29.95 inches of mercury.

There were clouds around 1,500 to 2,000 feet above ground level (agl) with a slight reduction in visibility due to haze. With the haze that was present there was

likely more reduced visibility in the horizontal direction than the vertical direction and though 9 miles visibility was reported, it was likely slightly less than that,

looking up or down at an angle, but nothing below 7 miles visibility. The clouds would have likely been most prominent near the mountainous terrain given the

weather in the Mid-Atlantic region, and mountain and valley breeze circulations present during the morning hours.

Accident Area

From 0900 to 1100, there was an increase in mid- level clouds as satellite images of the area taken at 0945, 1045, and 1145 showed an increase in cloud

cover, indicating that the pilot would have had reduced visibility and possibly instrument meteorological conditions from clouds at 1,500 to 3,000 feet agl.

A witness statement also indicated that light rain and thunder was present at the time of the accident, and review of a photograph taken of the communications

tower at 1130, revealed the presence of cumulus clouds in close proximity to the top of the communications tower.

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FLIGHT RECORDERS

Per federal regulation, because the aircraft was certificated to be operated by one pilot, it was not required to be equipped with a cockpit voice recorder (CVR).

The aircraft, however, was equipped with a solid-state CVR that recorded the last 30 minutes of aircraft operation; this was accomplished by recording over the

oldest audio data. When a CVR is deactivated or removed from the airplane, it retains only the most recent 30 minutes of CVR operation. This model CVR, the

L-3/Fairchild FA2100-1010, recorded 30 minutes of digital audio, which was stored in solid-state memory modules. Four channels of audio information were

retained: one channel for each flight crew and one channel for the cockpit area microphone (CAM).

The CVR had sustained only minor physical damage. The audio information was extracted from the recorder normally, without difficulty.

The recording consisted of two channels of audio information. One of the channels contained audio information from the pilot's audio panel. The quality of this

channel was good. One channel contained audio information from the CAM. The quality of this channel was also good. The third and fourth channel did not

contain audio, nor was it required by regulation to do so. The quality of these channels was unknown.

The following is a summary of the recorded audio information:

At 9:24:28.7, recording started.

At 9:25:00.3, the airplane was in a VFR climb to 8,000 feet msl, destined for PA88 talking to Cleveland Air Route Traffic Control Center (ARTCC).

At 9:26:48.4, the pilot can be heard talking to a male passenger about the destination.

At 9:27:28.9, the pilot advises Cleveland ARTCC that he was descending to 6,000 feet msl.

At 9:27:51.5, unintelligible background conversation of passenger can be heard during most of the flight.

At 9:28:09.6, the pilot contacted the Johnstown approach controller.

At 9:38:29.8, the pilot advised Johnstown approach that he was descending to 4,500 feet.

At 9:40:38.2, Johnstown approach advised the pilot that that the airport was at 12 o'clock and 10 miles. Pilot advised the airport was in sight and canceled flight

following.

At 9:40:57.8, the pilot made a radio call to Nemacolin traffic that he was landing on runway 23.

At 9:43:14.8, the sound of a radio altimeter aural call of "five hundred feet" was recorded.

At 9:43:21.8, a passenger makes a comment to the pilot that "he didn't hear any terrain warning alert" pilot's response was that he "turned it off".

At 9:44:00.0, the sound of touchdown was recorded.

At 9:45:01.5, the engines were shutdown.

At 9:45:13.0, electrical power was removed from the CVR.

At 9:50:58.5, recording started again.

At 9:51:04.1, sound of first engine start was recorded.

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At 9:51:47.3, sound of second engine start was recorded.

At 9:55:25.3, the pilot made a radio call to Nemacolin traffic that he was back taxiing on runway 23 for takeoff.

At 9:57:07.1, sound of increasing engine noise was recorded.

At 9:57:29.1, sound similar to a gear retract motor was recorded.

At 9:57:48.5, sound of altitude alert was recorded.

At 9:58:35.7, the pilot attempted to contact Morgantown approach.

At 9:59:01.8, the pilot contacted Morgantown again.

At 9:59:06.9, Clarksburg approach answered.

At 9:59:11.5, the pilot reported his position as 14 miles to the northeast landing Morgantown.

At 9:59:58.2, Clarksburg approach reported that he had radar contact nine miles east of the Morgantown airport at 3,100 instructed pilot to maintain VFR and to

expect runway 18 and advise you have the Morgantown weather.

At 10:00:20.5, sound of altitude alert tone was recorded.

At 10:00:27.7, sound of Morgantown automated weather broadcast starts and continues until the end of the recording.

At 10:01:00.1, sound of first impact was recorded.

At 10:01:01.9, recording ended.


Examination of the Accident Site

Examination of the accident site revealed that the airplane made first contact with the antenna with the spinner for the right engine's propeller. The right wing

then broke apart, and impacted .1 miles from the communications tower where portions of the fragmented wing were then consumed by a post impact fire.

The left horizontal stabilizer separated from its mounting location, and impacted in the woods adjacent to the communications tower.

The left engine separated from its mounting location and impacted approximately .2 miles from the communications tower. The fuselage and left wing impacted

inverted approximately .3 miles from the communications tower.

The right engine impacted .5 mile from the communications tower.

In all, hundreds of pieces of the airplane were spread over the area with the majority of the pieces situated along a .5 mile wide wreckage path which started at

the communications tower site and continued to the right engine on a 244 degree magnetic heading.

Examination of the Communications Tower

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Examination of the communications tower revealed that it was located approximately 7.9 nautical miles northeast of MGW, and it was the highest obstruction in

the area.

The antenna site was approximately 2,596 feet above mean sea level. The tower's overall height above ground level was approximately 493 feet, and the

tower's overall height above mean sea level was approximately 3,089 feet.

It was marked and lighted in accordance with Federal Communications Commission requirements under Title 47 CFR Part 17, Paragraphs 1, 3, 4, 13, and 21.

The airplane struck the communications tower's antenna which then separated in to three large sections which fell from the top of the tower, along with multiple

smaller fragments and debris.

One section which included the beacon light and digital antenna fell through the roof of the broadcasting building which contained the equipment for operation of

the communications tower and was adjacent to the antenna site.

The other two sections fell to the ground, coming to rest approximately 244 feet southwest of the base of the tower structure with the end of one portion buried

in the ground.

Examination of the antenna revealed that the antenna exhibited deformation, impact damage, and black scuff marks.

Examination of the history of the communications tower also revealed that it had also been struck previously by an aircraft approximately 9 years before, when

on May 21, 2003, when a Piper PA-28-180 being operated on a visual flight rules (VFR) cross country flight (NYC03FA113), struck the top guy wire of the

communications tower, mid-span between the top of the tower, and its ground anchor. As the airplane fell to the ground it struck a 12,000 volt power line. A

postcrash fire resulted. The pilot who was fatally injured in the accident had received a weather briefing which included ceilings between 1,300 feet and 1,500

feet, and mountain obscurement. Power company personnel who responded to the power outage reported that the top of the mountain was obscured in fog.

Examination of the Wreckage

Examination of the wreckage revealed no evidence of any preimpact malfunctions or failures of the flight controls, engines, or airplane that would have

precluded normal operation.

With the exception of the aft fuselage, vertical stabilizer, and left wing, the rest of the airplane had been fragmented with the majority of the pieces displaying

crush, compression, and impact damage.

The left engine displayed impact and buckling damage to the gas generator case. The exhaust duct displayed torsional bending. The compressor turbine vane,

shroud, and power turbine vane baffle displayed circumferential wear. The propeller pitch lever was in feather (fail safe mode), and the propeller pitch lever

cable was fractured.

The right engine displayed compression, buckling, and distortion damage of the exhaust duct and gas generator case. The propeller shaft was sheared. The

compressor stator vanes were bent and displaced, and the power turbine blades were fractured.


An autopsy was performed on the pilot by the State of West Virginia, Office of the Chief Medical Examiner. Cause of death was catastrophic injuries.

Toxicological testing of the pilot was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens were

negative for carbon monoxide, cyanide, basic, acidic, and neutral drugs, with the exception of:

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- Amlodipine, which is a prescription medicine, calcium channel blocker used to treat high blood pressure and angina, and was detected in Urine and Liver.

- Glucose, which is a blood sugar, is indicative of diabetes, and was detected in Urine, but not detected in Vitreous.

- Pioglitazone, which is an oral antidiabetic agent that acts primarily by increasing uptake of glucose by peripheral organs and decreasing glucose production by

the liver. It is used in the management of type 2 diabetes mellitus, and was detected in Urine and Liver.

- Salicylate, which is an over the counter analgesic used in the treatment of mild pain, and was detected in Urine.

Review of FAA records revealed that the pilot had a history of coronary artery disease with a stent, diabetes treated with oral and injectable medications, high

blood pressure treated with medication, and a history of stroke with no residual neurological symptoms.

No other significant issues were identified on his last physical examination by an airman medical examiner (AME). The pilot had no recent changes in his

cardiac history. He had not significantly modified his medications since his physical examination, and had no recent changes in his vision.

Review of toxicological testing revealed that all medications detected during the testing, had previously been reported to his AME by the pilot.

TESTS AND RESEARCH

Charting and Obstructions

Review of the airplane's route of flight revealed that the pilot had selected a direct route of flight which brought him into proximity of rising terrain and

obstructions within a Designated Mountainous Area (DMA), at his selected cruise altitude of 3,100 feet msl.

Review of the Cincinnati Sectional Aeronautical Chart revealed that the quadrangle bounded by the ticked lines of latitude and longitude surrounding the

accident site contained a maximum elevation figure (MEF) of 3,500 feet. The MEF was based on information concerning the highest known feature in the

quadrangle, including terrain and obstructions (trees, towers, antennas, etc.).

Review of the L29 instrument flight rules (IFR) Enroute Low Altitude Chart revealed that the quadrangle bounded by the ticked lines of latitude and longitude

surrounding the accident site contained an Off Route Clearance Obstruction Altitude (ORCOA) of 7,100 feet msl. The OROCA represented the highest possible

elevation including both terrain and other vertical obstructions (towers, trees, etc.) bounded by the ticked lines of latitude and longitude. The OROCA was

determined just as the MEF was on the Cincinnati Sectional Aeronautical Chart except that it provided a 2,000 foot vertical buffer inside the DMA. Unlike the

MEF, The OROCA was also determined by analyzing a 4 nautical mile area around the quadrangle for obstructions. This would provide a chart user the same

lateral clearance an airway would provide should a line of intended flight follow a ticked line of latitude or longitude.

Onboard Aeronautical Charts

During the examination of the wreckage a search for aeronautical charts was conducted. The search of the wreckage revealed that the airplane did have

multiple aeronautical charts onboard, however further examination revealed that they were approximately 2 years out of date. However, despite the age, these

charts depicted the tower hazard.

During this search two tablet computers were discovered in the wreckage which were functionally capable of supporting applications for electronic flight bags,

flight planning and filing, aviation weather depiction, and electronic flight charts. Examination of the tablets revealed that they had sustained significant impact

damage and it could not be determined if either tablet was in operation and being used by the pilot at the time of the accident. Attempts to recover data that

may have been stored in the tablets non-volatile memory also were unsuccessful.

A search of electronic flight planning and flight support providers revealed that the pilot however, had a current subscription with a flight planning and flight

support provider, and had downloaded the most current revision of the provider's software. During the download the pilot had the option of downloading

sectional aeronautical charts, terminal area charts, IFR enroute low altitude charts, and IFR enroute high altitude charts. However, it could not be determined

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what charts the pilot may have downloaded, as the provider's system did not track that information.

Enhanced Ground Proximity Warning System

The airplane was equipped with a Bendix/King KMH880, traffic advisory and multi hazard awareness system which provided an enhanced ground proximity

warning system (EGPWS) function which provided terrain display, terrain alerting and warning, and obstacle alerting and warning to the pilot.

The system used data from an internal global positioning system (GPS) receiver, a proprietary world-wide terrain database, obstacle database, and runway

database, as well as uncorrected pressure inputs from the airplane's transponder, and outside air temperature probe.

The KMH880 pilots guide outlined the basic requirements for system operation and recommended procedures for its use. The terrain database, runway

database, and alerting/warning functionality were contained in the EGPWS computer and required no pilot action for system operation.

Outputs generated by the system were:

ú Terrain/Obstacle Display

ú Voice Alerts/Warnings/Callouts

ú Visual Alerts/Warnings

During normal flight operations, the system would remain essentially silent, using GPS, altitude, and temperature data in combination with database information

to provide the pilot with a display of the airplane's position relative to the surrounding terrain and known obstacles, thereby providing situational awareness for

the pilot.

Should an airplane fly into danger where a conflict with terrain or a known obstacle was imminent, the system would provide both visual and aural alerts and

warnings to the pilot. The system would also provide alerts and warnings for excessive rates of descent and inadvertent descents or altitude loss after take-off.

According to the KMH880 Pilot's Guide, prior to flight the system should be tested for proper operation. Normally, this is done by the pilot during the "BEFORE

TAKE-OFF" check. All aircraft power and systems should be up and running, and the EGPWS "Not Available" annunciator lamp should be off.

Terrain Inhibit Switch

A "Terrain Inhibit" switch was required as part of the EGPWS system. When engaged by the pilot, the switch would inhibit all "visual and aural alerts and

warnings" associated with the EGPWS system. Also an external annunciator lamp would be illuminated and a status message would be displayed indicating

"Warnings Inhibited".

According to the EGPWS pilot's guide, the purpose of the "Terrain Inhibit" switch was to allow aircraft to operate without nuisance or unwanted warnings at

airports that are not in the system database such as private airports or those with runways shorter than 2,000 feet. Additionally, there may be some visual flight

rules (VFR) only airports where unique terrain features are in close proximity to the runway, and the "Terrain Inhibit" switch may be used when operating in

good VFR conditions. However, the pilot's guide cautioned that the "Terrain Inhibit" switch should "NOT" be engaged for normal operations.

Review of EGPWS Stored Data

The EGPWS maintained a flight log which was representative of flights since the unit was first installed and powered up. It was activated every takeoff. Memory

size limited the amount of stored information. Terrain inhibit data was available for flights 878 through 1261. Data for alerts was available for flights 605 through

1261. As part of this investigation, this data was downloaded from the EGPWS.

Review of the data downloaded from the EGPWS revealed that the database was the one originally delivered with the unit; it had never been updated, and was

out of date.

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Further review revealed that flight 1261 was the accident flight. The airport from which the aircraft departed prior to the accident was listed in the EGPWS data

base as PA88. The accident flight was the only flight out of PA88 in the more than 375 flights that were stored in the unit's data base.

According to the stored data, the terrain inhibit was turned on 20 seconds prior to landing at PA88 and remained on for takeoff on flight 1261. Approximately

three minutes after takeoff from PA88 with the terrain inhibit switch still on, the EGPWS calculated an obstacle alert for terrain, however the alert was not

annunciated with the terrain inhibit switch on. This was the last data stored on the unit.

Review of previous flights also revealed that the airplane routinely flew into 13PA and it was not included in the EGPWS data base. The stored data indicated

that terrain inhibit was routinely selected when the airplane was flying into this airport, usually after a terrain alert caused by landing at an airport that was not in

the database. Terrain inhibit would then be deselected after departure.

Air Traffic Control Voice and Radar Data

Review of air traffic control (ATC) voice and radar data, revealed that the airplane was first detected by radar on a 1200 transponder code at 0958:55, 3 miles

southwest of PA88 while it was climbing out. The pilot contacted Clarksburg approach at 0959:22 to obtain radar services. After controller acknowledgement of

his call, at 0959:31 the pilot stated, "uh Clarksburg uh 508GT's 14 miles to the uh northeast landing Morgantown". After obtaining the airplane's type from the

pilot, at 0959:53 the controller issued transponder code 0130 and the pilot acknowledged. The airplane's transponder code changed from 1200 to 0130 at

1000:06 while the airplane was continuing straight ahead at an indicated altitude of about 3,000 feet msl. and a ground speed of approximately 217 knots. At

1000:19, the controller transmitted, "King Air 508GT you're radar contact niner miles east of Morgantown Airport, 3,100, maintain VFR, expect runway 18,

advise when you have the weather." At 1000:28, the pilot responded, "uh roger we're getting it." The airplane was approximately 3.8 nautical miles (62 seconds)

northeast of the antenna.

Between 1001:05 and 1001:32, the controller was engaged in a discussion with Mystic 42, a C-130 executing a practice approach at Elkins-Randolph County

Airport (EKN), Elkins, West Virginia. According to recorded radar data, N508GT struck the communications tower at 1001:12. At 1001:37, the controller made

the first of several unsuccessful attempts to contact the pilot and transfer communications to Morgantown Tower. There was no further contact with the

airplane.

FAA Order 7110.65

The pilot was operating under visual flight rules (VFR) and had requested radar service from Clarksburg approach control. The controller identified the airplane

and verified the observed and reported altitude as correct. At the time that the airplane was identified, it was about 3.8 miles from the communications tower,

the trajectory was below the top of the tower, and the tower's location was depicted on the controller's radar map as an obstruction to flight.

Review of FAA Order 7110.65, "Air Traffic Control," Revealed that it provides direction to controllers on the services to be provided when a VFR aircraft

requests radar advisories. Chapter 7, Section 6 of the order states in part:

7-6-1. APPLICATION

a. Basic radar services for VFR aircraft must include:

1. Safety Alerts.

2. Traffic Advisories.

3. Limited radar vectoring when requested by the pilot.

4. Sequencing at locations where procedures have been established for this purpose and/or when covered by a letter of agreement.

Chapter 2 of the order defines duty priorities and procedures to be followed in the provision of safety alerts:

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2-1-2. DUTY PRIORITY

a. Give first priority to separating aircraft and issuing safety alerts as required in this order. Good judgment must be used in prioritizing all other provisions of

this order based on the requirements of the situation at hand.

2-1-6. SAFETY ALERT

Issue a safety alert to an aircraft if you are aware the aircraft is in a position/altitude which, in your judgment, places it in unsafe proximity to terrain,

obstructions, or other aircraft. Once the pilot informs you action is being taken to resolve the situation, you may discontinue the issuance of further alerts. Do

not assume that because someone else has responsibility for the aircraft that the unsafe situation has been observed and the safety alert issued; inform the

appropriate controller.

NOTE-

1. The issuance of a safety alert is the first priority (see para 2-1-2, Duty Priority) once the controller observes and recognizes a situation of unsafe aircraft

proximity to terrain, obstacles, or other aircraft. Conditions such as workload, traffic volume, the quality/limitations of the radar system, and the available lead

time to react are factors in determining whether it is reasonable for the controller to observe and recognize such situations. While a controller cannot see

immediately the development of every situation where a safety alert must be issued, the controller must remain vigilant for such situations and issue a safety

alert when the situation is recognized.

a. Terrain/Obstruction Alert. Immediately issue/initiate an alert to an aircraft if you are aware the aircraft is at an altitude which, in your judgment, places it in

unsafe proximity to terrain/obstructions. Issue the alert as follows:

"LOW ALTITUDE ALERT (call sign), CHECK YOUR ALTITUDE IMMEDIATELY. THE (as appropriate) MEA/MVA/MOCA/MIA IN YOUR AREA IS (altitude)."

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Accident Rpt# CEN12FA001 Regis# N266CY Philip, SD10/01/2011 1255

Acft Mk/Mdl ROBINSON HELICOPTER CO R66

Eng Mk/Mdl ROLLS-ROYC RR300

Summary

The helicopter was on a cross-country flight when it experienced a separation of the main rotor mast 8 inches below the teeter bolt, and the main rotor blade

assembly separated from the flying helicopter. Subsequently, the helicopter impacted terrain and a postimpact fire ensued. Examination of the mast revealed

fracture features consistent with overload failure and mechanical damage indicative of mast bumping. An examination of the airframe, engine, and remaining

systems revealed no preimpact anomalies. The reason for the mast bumping event could not be determined due to the amount of thermal damage to the

wreckage.


Apt: N/a

Acft TT 120

Acft SN 0010


P P & J LLC

Regis# N266CY

Aircraft Fire: GRD

1Fatal Ser Inj 0

Opr Name: Opr dba:

THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The in-flight separation of the

main rotor mast following a mast bumping event. The reason for the mast bumping event could not be determined due to postaccident damage.

Cause Narrative

Events

1. Enroute-cruise - Unknown or undetermined

2. Enroute-cruise - Aircraft structural failure

3. Uncontrolled descent - Part(s) separation from AC



1. Aircraft-Aircraft propeller/rotor-Main rotor system-Main rotor head system-Damaged/degraded - C

2. Aircraft-Aircraft propeller/rotor-Main rotor system-Main rotor head system-Failure - C

Narrative

HISTORY OF FLIGHT

On October 1, 2011, about 1255 mountain daylight time, a Robinson Helicopter, R66, N266CY, was destroyed during an in-flight breakup while in cruise flight

near Philip, South Dakota. The private pilot, the sole occupant, was fatally injured. The helicopter was registered to and operated by P.P. and J. LLC., of

Gillette, Wyoming. Visual meteorological conditions prevailed and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The

cross-country flight originated from the Gillette-Campbell County Airport (GCC), around 1105 and was en route to the Winner Regional Airport (ICR), in Winner,

South Dakota.

A friend of the pilot was at GCC when the pilot was preparing for the flight. The friend reported that the pilot appeared to be in good health and was excited

about the flight. He further reported that the pilot had "topped off" the helicopter with fuel before departure. Approximately an hour and a half later the pilot

called the friend during the flight. The pilot reported that he was between Wall, South Dakota, and Philip, South Dakota, and inquired if the Philip Airport (PHP),

had jet fuel available. The friend called the pilot back a few minutes later to report that PHP did not have jet fuel. The friend stated that the pilot did not report

any anomalies with the helicopter during either conversation.

An eyewitness located approximately 2 miles northwest of the accident site, observed the helicopter flying from west to east, along a river, approximately 1,000

feet above ground level (AGL). The eyewitness reported that he heard nothing abnormal as the helicopter flew past him. He then observed the helicopter make

a turn to the left before it flew out of view behind trees. About 20-30 seconds later, he heard a noise that he described as sounding like an "exploding propane

tank."


The pilot, aged 64, held a private pilot certificate with airplane single and multi-engine land, rotorcraft helicopter, and instrument airplane. He was issued a

third-class medical on November 3, 2009, with the limitation of "Must have available glasses for near vision."

The pilot's flight logbooks were not recovered during the course of the investigation. On an aircraft insurance application dated February 4, 2011, the pilot

estimated having logged 3,600 hours of total flight time with 60 hours in the last 90 days. Of that time, 210 hours had been in helicopters and 22 hours had

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been in the Robinson R66. The pilot also indicated that his last biannual flight review had taken place on May 5, 2010.

The NTSB investigator-in-charge (IIC), contacted the two flight instructors who instructed the accident pilot. The first instructor reported that he had provided

instruction to the accident pilot once or twice for an estimated total of 2 hours in the R66. The second instructor reported that he had instructed the accident

pilot for 1 flight in the R66. Both instructors stated that they did not provide a signoff for the accident pilot in the R66; however, a signoff was not required.

Although the Federal Aviation Administration (FAA) had issued SFAR 73-2, Special Training and Experience Requirements for the Robinson R-22 and the

R-44, the R66 was excluded.

HELICOPTER INFORMATION

The 2011-model Robinson Helicopter Co R66, serial number 0010, was registered with the Federal Aviation Administration standard airworthiness certificate for

normal operations. The helicopter was powered by a turbo-shaft Rolls-Royce RR300 engine, serial number (SN) RRE200013, which drove the two-blade main

rotor.

According to the airframe and engine logbooks, the helicopter's most recent 100-hour inspection was completed on June 6, 2011, with an airframe and engine

total time of 82.6 hours.


At 1255, the automated weather observing system at PHP, located 3 nautical miles northeast from the site of the accident, reported wind from 150 degrees at 6

knots, 10 miles visibility, clear of clouds, temperature 84 degrees Fahrenheit, dew point 39 degrees Fahrenheit, and a barometric pressure setting of 30.00

inches of Mercury.


The helicopter wreckage and debris came to rest on rolling ranch land and was spread out over an area approximately 1,520 feet long by 600 feet wide. The

main rotor head, with attached blades, came to rest 513 feet from the main wreckage. The main wreckage consisted of the fuselage, engine, and tail rotor

assembly.

The airframe was severely damaged by fire and impact forces. A few pieces of airframe and numerous pieces of Plexiglas were located away from the main

wreckage and were not fire damaged. Two portions of the right forward door frame exhibited scoring and deformation similar to the shape of the main rotor

blade leading edge. The right front seat bottom had a lateral cut/impact mark near the forward edge and was detached from the helicopter. The controls and

tunnel structure exhibited what appeared to be a cut/gash in a vertical line, from the right side, approximately 5 inches forward of the collective pivot. A section

of the door frame from the left door exhibited large curved dents, one with paint smearing, on the inside surfaces.

The cabin area was nearly consumed by a post-crash fire. All removable controls were found installed. The engine fuel control was found in the full "ON"

position. The collective was in a full up position, based on the friction slider. The airframe fuel cutoff valve was extended ¬ inch from its full down position. The

remains of what appeared to be a steel shot bag were found beneath the cabin remains.

The forward 1.5 bays of tailcone were consumed by fire. The remainder of the tailcone was intact aftward to the last bay, which was separated at the forward

end. The empennage had separated from the tail cone and sustained light fire damaged. The small horizontal stabilizer at the base of vertical stabilizer was

damaged on left side. The tail rotor visual guard separated from aircraft and fractured in 4 places.

Both skid toes and both forward struts separated from the skids. Both rear struts remained attached to skids. The forward cross tube was straight in the

horizontal plane and bent forward at the left end in the longitudinal plane and burned through at left side. The rear cross tube destroyed was by fire. The left

rear strut exhibited a deep dent on the upper end inboard side.

The fuel system was mostly destroyed by fire. The fuel vent tubes had been consumed and only one rollover vent fitting could be located. Investigators were

able to blow air through this vent in the upright and inverted positions. The fuel bladder was consumed by fire. The finger screen was recovered and was clear

of any debris. The D205-21 fuel hose was found intact, connected to the F670-1 valve.

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All rod ends for the main rotor flight controls were accounted for and secure to their mounting device, other than at components that were destroyed by fire. The

disconnects in the push/pull tubes were consistent with overload and or thermal damage. The servo to swashplate push/pull tubes were bowed. All rod ends for

the tail rotor flight controls were accounted for and secure to their mounting device, other than at bellcranks that were destroyed by fire. The disconnects in the

push/pull tubes were consistent with overload and or thermal damage.

The sprag clutch was subjected to fire and did not rotate. The engine output flex coupling was intact but bent. The F642-1 engine to main rotor gearbox

driveshaft was separated at both ends at the yoke weld. The main rotor gearbox input coupling was intact. The main rotor gearbox exhibited thermal damage

and had two holes in the case. The output shaft could only be rotated a few degrees. The main rotor gearbox oil filter was not located. In addition, the gearbox

rubber mounts were consumed by fire.

The main rotor had separated approximately 8 inches below the teeter bolt. The main rotor hub was intact and both blade roots remained attached to it via the

coning bolts. Both droops stops were in place. Both elastomeric teeter stops were split horizontally through the middle. The droop stop "tusk" for main rotor

blade SN 0049 appeared straight while the "tusk" for blade SN 0067 was bent down approximately 10 degrees. There were small arc shaped scores on the

main rotor hub just inboard of both rotor blade pitch change housings.

Main rotor blade SN 0067 was found intact with an upward and aftward bend approximately 108 inches from the coning bolt. The lower surface of the blade had

a pattern of scratches centered on the bend area and compression buckling of the trailing edge. Main rotor blade SN 0049 was bent downward and afteward,

and the skins and honeycomb were separated from the spar over the span between 72 inches and 180 inches from the coning bolt. The spar was fractured

approximately 141 inches and 174 inches from the coning bolt. The most outboard portion of spar remained attached to the skins and honeycomb. A swap

sample was taken from a piece of the separated rotor blade skin and honeycomb and was sent to the Smithsonian National Museum of Natural History for DNA

and Microscopic analysis.

The engine driveshaft was disconnected at both ends at the flex coupling flanges and compressed at both ends. The edges of the shaft at the disconnects were

angular and jagged. Both flex plates were bent slightly. The forward tail rotor driveshaft was disconnected at the intermediate flex coupling flange and

compressed at both ends. The edges of the shaft at the disconnect were angular and jagged. Both flex plates were bent slightly. The aft tail rotor driveshaft was

disconnected approximately 4 inches aft of the flex coupling. The edges of the forward section of the shaft at the disconnect were angular and jagged. The

edges of the aft section of the shaft at the disconnect appeared melted. The driveshaft hanger bearing was damaged by fire. The damper linkage was exposed

to fire and did not rotate. The aft flex plate was bent and one arm of the tail rotor gearbox flange was disconnected, and one of the flexplate arms was torn. The

edges of the disconnect were angular and jagged.

The tail rotor gearbox contained oil and was free to rotate, but rotation was limited by the bent input yoke contacting the input cartridge hardware. The output

shaft and hub were intact. The slider bearing was free to rotate but rotation was limited as described above. Both tail rotor blades were damaged by fire and

were bent to the left. One tail rotor blade was bent approximately 30 degrees to the left, and the other tail rotor blade was bent approximately 90 degrees to the

left with a separated trailing edge.

The engine was found disconnected from the aircraft structure. The compressor front support, engine air inlet, and the first stage compressor were free of

visible damage. The compressor left-hand compressor scroll arm flange was bent inward. The N1 and N2 rotor system were bound. The power turbine

governor, fuel pump and filter assembly, and the accessory gearbox were consumed in the post-crash fire. The N1 and N2 coupling shafts were fractured at the

turbine portion of the shaft and were sent to the NTSB materials lab for examination. No anomalies were noted to the P/T- 4 turbine wheel as viewed through

the exhaust collector. The gas producer fuel control unit was damaged by fire at the mounting base. Control linkage rigging was found in the closed position.

The exhaust collector received crushing deformation during the accident sequence. The right air guide tube was unremarkable. The left air guide received

crushing deformation during the accident sequence. The fuel cutoff arm on the fuel control unit was in the closed position. The throttle arm on the fuel control

unit was in the idle position.

The Rolls-Royce RR300 Engine Monitoring Unit (EMU) was removed and sent to the National Transportation Safety Board's (NTSB) vehicle recorder laboratory

for an attempted data extraction.


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The Clinical Laboratory of the Black Hills, located in Rapid City, South Dakota, performed an autopsy on the pilot on October 3, 2011. The autopsy concluded

that the cause of death was due to "blunt trauma injuries" and the report listed the specific injuries.

The FAA, Toxicology Accident Research Laboratory, located in Oklahoma City, Oklahoma, conducted toxicological testing on the specimens that were

submitted. Carbon monoxide and cyanide tests were not performed. Tests for ethanol were negative. Losartan, a blood pressure medication, was detected in

the liver.

TESTS AND RESEARCH

The main rotor mast, hub, and gear box assemblies were sent to the NTSB Material Laboratory in Washington, DC, for further examination. The inboard end of

each main rotor blade was attached to the hub. The enclosure for the gear box assembly and the mast were made from non-ferrous metal. The enclosure for

the gear box and other nonferrous pieces in the general area of the gear box showed sagging deformation features consistent with heat damage from exposure

to fire. The wall portion of the gear box in certain areas exhibited globule-like features consistent with re-solidified metal. The mast in the area of the fracture

exhibited severe bending deformation. The cover for the mast in the area between the hub and gear box also showed evidence of bending deformation and

contained a longitudinal fracture in the wall. Portable binocular microscope examination of the ferrous pieces such as the main structural tubes, attachment

points for the control surfaces (clevis bolts) and non-ferrous pieces revealed the fracture faces were on slant plane relative to their longitudinal axes and

contained dimpled features consistent with overstress separation. The noted signatures were consistent with a mast bump event.

The Rolls-Royce RR300 Engine Monitoring Unit (EMU) was examined at the NTSB vehicle recorder laboratory. The EMU records the engine's gas temperature,

torque, N1, and N2 speeds. Due to the extreme heat and fire damage, no data was recovered from the device.

A teardown examination of the engine was conducted, under the oversight of the NTSB investigator-in-charge (IIC), at Roll-Royce Corporation in Indianapolis,

Indiana. The examination revealed the compressor backplate assembly stationary seals, and the impeller rotating seals, exhibited 360 degree rotational

scoring. In addition, the P/T-4 nozzle exhibited localized rub area on both the P/T-3 and P/T-4 blade tracks. The inspection of the engine did not reveal any pre

impact failures or conditions that would prevent the engine from normal operation.

The engine's N1 and N2 coupling adapters were sent to the NTSB Materials Laboratory for further examination. The N1 coupling adapter contained an internal

spline at each end. A circumferential fracture split the part into two pieces. The smaller piece contained a longitudinal fracture. The circumferential and

longitudinal fractures intersected the internal spline portion at one end of the shaft. The N2 coupling adapter contained only a circumferential fracture. The

pieces were ultrasonic cleaned and examination of the fracture faces revealed that they were on a slant plate relative to their longitudinal axes and contained

dimpled features consistent with overstress separation.

On February 21, 2012, Robinson Helicopter Company released, R66 Service Bulletin SB-03. This service bulletin addressed the possibility of machining burrs

being present in certain helicopter hydraulic servos. NTSB investigators removed and examined the three hydraulic control servos from the accident helicopter

at Robinson Helicopter Company on November 1, 2012. The examination did not reveal any preimpact anomalies.

Multiple swab samples were taken from the wreckage and sent to the Smithsonian National Museum of Natural History for DNA and Microscopic analysis. All

samples were negative for bird remains.

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Accident Rpt# ERA12FA023 Regis# N37SV Hollywood, FL10/12/2011 1334 EDT

Acft Mk/Mdl SOCATA TBM 700

Eng Mk/Mdl P&W PT6A-66D

Summary

In anticipation of the maintenance test flight, a about 72 gallons of fuel was added to the left fuel tank to balance the fuel load. During the preflight, the pilot

noted that the left tank had 105 gallons and that the right tank had 108 gallons. Because of the fuel level indications, the pilot did not visually inspect the tanks;

��even if he had done so the wing dihedral would have prevented him from seeing the fuel level. About 20 minutes after takeoff, the pilot received the first

annunciation of "Fuel Low R," which lasted for about 10 seconds then went out. This indicates the fuel quantity is less than or equal to 9 gallons of usable fuel

in the right tank. The pilot attributed this to a malfunction of the low fuel level sensor, since the fuel gauge showed about 98 gallons of fuel. He instructed the

right front seat occupant (the mechanic) to make a note so the sensor would be replaced after the flight. Shortly thereafter, the amber "Fuel Unbalance"

��illuminated, and indicated that the right fuel quantity was greater than the left; as a result the pilot switched the fuel selector to the right tank. He then initiated a

descent to 10,000 feet to perform system checks, and after levelling off at that altitude for about 15 minutes, received a second "Fuel Low R" annunciation; he

verified that the fuel selector automatically switched to the left tank and noted that the message went out after about 10 seconds. Either before or during a

descent to 4,000 feet, the second "Fuel Unbalance" annunciation occurred. The right tank again depicted a greater quantity of fuel, so the pilot again switched

the fuel selector to the right tank. The flight continued to a nearby airport, where the pilot terminated an instrument approach with a low approach. The flight

��then proceeded to the destination airport and entered the traffic pattern on a left downwind leg.. While on the downwind leg, the pilot received the third "Fuel

Unbalance" annunciation and at this time the left fuel gauge indicated 55 gallons while the right fuel gauge indicated 74 gallons. Because he intended to land

within a few minutes, the pilot manually selected the fullest (right) tank, then turned to base then final. While at 800 feet on final approach, the red warning

message "Fuel Press" illuminated and the engine lost all power. Attempts to restore engine power were unsuccessful. Unable to reach the airport, the pilot

landed on a nearby turnpike. Both fuel tanks were breached, and fuel leakage, likely from the left fuel tank, was noted at the site. Inspection of the fuel outlet

filter on the engine and the fuel sequencer reservoir considered an airframe item revealed both contained minimal fuel consistent with fuel starvation from the

��right fuel tank that actually did not contain an adequate supply of fuel. Postaccident operational testing of the engine revealed no evidence of preimpact failure

or malfunction that would have resulted in the loss of power. Examination and testing of the right fuel gauge harness revealed that a high impedance shielded

cable was not correctly soldered to the shielding braid when the airplane was manufactured, which resulted in erroneous high readings of the fuel quantity in the

��right tank. Several opportunities existed to detect the fuel quantity errors in the right tank during the airplane's 600-hour and annual inspection, which was

signed off the day before. Several times during the inspection, electrical power was applied and different fuel quantities for the right tank were displayed, yet

nothing was done to determine the reason for the different fuel indications. For example, 41 gallons was displayed, yet 70 gallons was drained; the fuel was

returned to the tank after maintenance, yet the gauge showed 51 gallons, and after a post-maintenance run was performed, the gauge showed over 140 gallons

even though it hadn't been fueled. Maintenance personnel incorrectly attributed the difference to fuel migration. Further, the pilot had the opportunity to

�terminate the test flight after multiple conflicting indications from the right tank, yet he continued the test flight, which resulted in fuel starvation.


Apt: North Perry Airport HWO

Acft TT 593

Acft SN 441


SOCATA NORTH AMERICA, INC.

Regis# N37SV

Aircraft Fire: NONE

0Fatal Ser Inj 0

Opr Name: Opr dba:

THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to terminate

the flight after observing multiple conflicting errors associated with the inaccurate right fuel quantity indication. Contributing to the accident were the total loss of

engine power due to fuel starvation from the right tank, the inadequate manufacturing of the right fuel gauge electrical harness, and failure of maintenance

personnel to recognize and evaluate the reason for the changing fuel level in the right fuel tank.

Cause Narrative

Events

1. Approach-VFR pattern final - Loss of engine power (total)

2. Emergency descent - Off-field or emergency landing

3. Landing-flare/touchdown - Hard landing

4. Landing-flare/touchdown - Collision with terr/obj (non-CFIT)


1. Personnel issues-Action/decision-Info processing/decision-Understanding/comprehension-Pilot - C

2. Personnel issues-Task performance-Use of equip/info-Use of available resources-Pilot - C

3. Aircraft-Aircraft systems-Fuel system-Fuel indication system-Malfunction - C

4. Aircraft-Fluids/misc hardware-Fluids-Fuel-Fluid level - F

5. Organizational issues-Development-Manufacture/production-Equipment manufacture-Manufacturer - F

6. Personnel issues-Action/decision-Info processing/decision-Understanding/comprehension-Maintenance personnel - F

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Narrative

HISTORY OF FLIGHT

On October 12, 2011, about 1334 eastern daylight time, a Socata TBM 700, N37SV, registered to SV Leasing Company of Florida, operated by SOCATA North

America, Inc., sustained substantial damage during a forced landing on a highway near Hollywood, Florida, following total loss of engine power. Visual

meteorological conditions prevailed at the time and an instrument flight rules (IFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91

maintenance test flight from North Perry Airport (HWO), Hollywood, Florida. The airline transport pilot and pilot-rated other crewmember sustained minor

injuries; there were no ground injuries. The flight originated from HWO about 1216.

The purpose of the flight was a maintenance test flight following a 600 hour and annual inspection.

According to the right front seat occupant, in anticipation of the flight, he checked the fuel load by applying electrical power and noted the G1000 indicated the

left fuel tank had approximately 36 gallons while the right fuel tank had approximately 108 gallons. In an effort to balance the fuel load with the indication of the

right fuel tank, he added 72.4 gallons of fuel to the left fuel tank. At the start of the data recorded by the G1000 for the accident flight, the recorded capacity in

the left fuel tank was approximately 105 gallons while the amount in the right fuel tank was approximately 108 gallons.

The PIC reported that because of the fuel load on-board, he could not see the level of fuel in the tanks; therefore, he did not visually check the fuel tanks. By

cockpit indication, the left tank had approximately 105 gallons and the right tank had approximately 108 gallons. The flight departed HWO, but he could not

recall the fuel selector position beneath the thrust lever quadrant. He further stated that the fuel selector switch on the overhead panel was in the "auto"

position.

After takeoff, the flight climbed to flight level (FL) 280, and levelled off at that altitude about 20 minutes after takeoff. While at that altitude they received a "Fuel

Low R" amber warning CAS message on the G1000. He checked the right fuel gauge which indicated 98 gallons, and confirmed that the fuel selector

automatically switched to the left tank. After about 10 seconds the amber warning CAS message went out. He attributed the annunciation to be associated with

a failure or malfunction of the sensor, and told the mechanic to write this issue down so it could be replaced after the flight. The flight continued and they

received an amber warning CAS message, "Fuel Unbalance" which the right fuel tank had more fuel so he switched the fuel selector to supply fuel from the

right tank to the engine. The G1000 indicates they remained at that altitude for approximately 8 minutes.

He then initiated a quick descent to 10,000 feet mean sea level (msl) and during the descent accelerated to Vmo to test the aural warning horn. They

descended to and maintained 10,000 feet msl for about 15 minutes and at an unknown time, they received an amber warning CAS message "Fuel Low R."

Once again he checked the right fuel gauge which indicated it had 92 gallons and confirmed that the fuel tank selector automatically switched to the left tank.

After about 10 seconds the CAS message went out. Either just before or during descent to 4,000 feet, they received an amber CAS message "Fuel

Unbalance." Because the right fuel gauge indicated the fullest tank was the right tank, he switched the fuel selector to supply fuel to the engine from the right

tank.

The flight proceeded to the Opa-Locka Executive Airport, where he executed an ILS approach which terminated with a low approach. The pilot cancelled the

IFR clearance and proceeded VFR towards HWO. While in contact with the HWO air traffic control tower, the flight was cleared to join the left downwind for

runway 27L. Upon entering the downwind leg they received another amber CAS message "Fuel Unbalance" and at this time the left fuel gauge indicated 55

gallons while the right fuel gauge indicated 74 gallons. Because he intended on landing within a few minutes, he put the fuel selector to the manual position and

switched to the fullest (right) tank.

Established on final approach to runway 27L at HWO with the gear down, flaps set to landing, and minimum speed requested by air traffic for separation (85

knots indicated airspeed). When the flight was at 800 feet, the red warning CAS message "Fuel Press" illuminated and the right seat occupant with his

permission moved the auxiliary fuel boost pump switch from "Auto" to "On" while he, PIC manually moved the fuel selector to the left tank. In an effort to

restore engine power he pushed the power lever and used the manual over-ride but with no change. Assured that the engine had quit, he put the condition lever

to cutoff, the starter switch on, and then the condition lever to "Hi-Idle" attempting to perform an airstart. At 1332:42, a flightcrew member of the airplane

advised the HWO ATCT, ".just lost the engine"; however, the controller did not reply.

The PIC stated that he looked to his left and noticed a clear area on part of the turnpike, so he banked left, and in anticipation of the forced landing, placed the

power lever to idle, the condition lever to cutoff, the fuel tank selector to off, and put the electrical gang bar down to secure the airplane's electrical system. He

elected to retract the landing gear in an effort to shorten the landing distance. The right front seat occupant reported that the airplane was landed in a southerly

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direction in the northbound lanes of the Florida Turnpike. There were no ground injuries.


The airplane was manufactured in 2008, by EADS Socata as model TBM 700, and was designated serial number 441. At the time of the accident, it was

powered by a 850 horsepower Pratt & Whitney Canada PT6A-66D engine and equipped with a Hartzell HC-E4N-3/E9083 propeller with reverse capability.

The airplane's fuel system consists of a 150.5 gallon capacity wet wing fuel tank in each wing, with a resulting total usable capacity of 292 gallons. Fuel gauging

is a capacitance type with 3 probes installed in each wing, and a low fuel sensor installed in each wing inboard of the inboard fuel probe, which provides a low

level CAS messages when the fuel quantity remaining in the concerned tank is under about 9 U.S. gallons. The fuel probes are capacitors connected in parallel

via electrical harness to the fuel amplifier (FCU) which in turn is connected electrically to the G1000 in the cockpit for display for the fuel tank readings.

Review of the maintenance records revealed an entry on August 4, 2010, indicating, "Troubleshoot right fuel quantity, found pin B at P61 connector loose,

removed and replaced pin B at P61 connected as required, performed an operational check of right fuel quantity, system operates normal." The airplane total

time at that time was recorded to be 451.1 hours. There was no other record of repair of the right fuel harness.

On September 29, 2011, the airplane was flown to HWO for compliance with an annual/600-Hour inspection. A pre-inspection engine run-up was performed and

according to a fuel timeline provided by the maintenance facility, the reading for the fuel level in the right fuel tank at the completion of the run was recorded by

the G1000 to be 41 gallons. On October 4, 2011, due to fuel leaking from 2 panels of the right wing, it was drained of fuel. A total of about 70 gallons of fuel

were drained from the right fuel tank. The same day, electrical power was applied for about 43 seconds and during this time the right fuel quantity at the

beginning and ending of the power-up was recorded to be approximately 11 gallons, though there was no remaining fuel in the fuel tank. The leaking panels

were removed, repaired, and reinstalled. On October 5th, the fuel drained from the right tank were placed back into the right wing, and a post maintenance

run-up was performed using only fuel from the right fuel tank. This was done in an effort to balance the fuel load. The G1000 recorded that at the completion of

the engine run, the right fuel tank contained 51 gallons. The G1000 indicated power application 2 days later indicating the right fuel tank had approximately 143

gallons, despite the fact that it had not been fueled. Five days later, on October 12, 2011, the G1000 indicated power application for less than 30 seconds

which indicated the right fuel tank had 107 gallons of fuel, while the left fuel tank had 35.5 gallons of fuel. No maintenance was done to evaluate the reason for

the changing right fuel quantity.

Further review of the maintenance records revealed that the airplane was last inspected in accordance with a 600 hour inspection and annual inspection which

was signed off as being completed the day before. The airplane total time at that time was recorded to be 593.4, while the airplane total time at the time of the

accident was 595.2 hours.

FLIGHT RECORDERS

The airplane was equipped with a Garmin G1000 Integrated Flight Deck, which is a collection of multiple avionics units which include flight displays. Each

display has two SD card slots. The SD memory card was removed from the MFD and sent to the NTSB Vehicle Recorder Division for readout.

According to the NTSB Factual Report, the data was extracted normally and contained 59 log files. The event flight was recorded and contained approximately

1 hour and 38 minutes of data; the calculated sample time interval was 1.055 seconds per data record. A review of the recorded data with respect to the fuel

level revealed that beginning about 1218, or about 2 minutes after takeoff until 1229, during which time the airplane was at FL190 and climbing to FL280, the

fuel level indication for the left steadily decreased consistent with supplying fuel to the engine, while the fuel level indication for right varied with increases

noted. The left fuel level remained steady from about 1229 until about 1245, indicative of fuel being provided from the right fuel tank. From about 1245 until

about 1324, a steady decrease of the left fuel quantity was noted, while during the same period the right fuel quantity indication showed a general decline. At

the end of the recorded data, the left fuel quantity was approximately 62 gallons, while the right fuel quantity was approximately 60 gallons. A copy of the report

and data is contained in the NTSB public docket.


The NTSB did not immediately respond to the accident site; however, the NTSB did view the airplane during the recovery process. The approximate location of

where the airplane came to rest was reported to be 25 degrees 59.845 minutes North latitude and 080 degrees 13.312 minutes West longitude, or

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approximately 4,338 feet and 94 degrees from the approach end of runway 27L (intended runway). The airplane was recovered for further examination.

According to the recovery crew, fuel leakage was noted at the accident site; however, it was not determined what tank(s) the fuel leaked from, nor the amount

of fuel leaked.

The airplane was formally inspected by NTSB on October 17 and 18, 2011. Also in attendance were representatives of the FAA, technical advisor from

Daher-Socata, and Pratt & Whitney Canada. As first viewed, both wings and the horizontal stabilizer were removed. The fuselage was fractured

circumferentially at frame 8.

Examination of the cockpit revealed the auxiliary fuel boost pump switch was in the "Auto" position, the manual fuel tank selector was in the "Off" position, and

the fuel selector switch on the overhead panel was in the "Manual" position.

Testing of the airplane's fuel quantity indicating system was performed using the aircraft's battery for electrical power. The right wing which was empty of fuel

was electrically connected while the wing was inverted. With the aircraft's battery power applied, the G1000 displayed red X's for fuel quantity for both sides.

The G1000 indicated that the fuel used was 88 gallons, and the fuel remaining was 123 gallons. The left wing which was empty of fuel was then electrically

connected in an upright position and with the aircraft's battery power applied, the G1000 displayed 108 gallons in the left wing on initial power up. The gallons

decreased steadily over the next 10 minutes to 29 gallons when the test was terminated. The left and right wings were electrically connected in an upright

position, and with aircraft's battery power applied, the G1000 displayed 33 gallons for the left fuel tank and the right fuel tank indicated red X's. With battery

power applied and fuel selector switch on overhead panel in auto position, the G1000 displayed changing of the fuel selector position. The fuel sequencer was

not in bypass; approximately 2 ounces of fuel were drained from the fuel sequence reservoir, which contained slight aluminum particles on the screen. With

battery power applied, a fuel supply plumbed to the left wing root, and the fuel selector positioned to the left tank, fuel flow noted at the firewall fitting and no

suction was noted at the right wing root fitting. With battery power applied, a fuel supply plumbed to the right wing root, and the fuel selector positioned to the

right tank, fuel flow noted at the firewall fitting and no suction was noted at the left wing root fitting. The fuel amplifier was retained for further examination.

Examination of the left wing following fuel system testing revealed the fuel tank was breached, but there were no obstructions inside the fuel tank. The fuel tank

outlet finger screen had a little fuzz material present. Both flapper valves were installed and noted to operate normally. The low fuel sensor, fuel probes, and

electrical harnesses pertaining to fuel were noted to be installed correctly. The low fuel sensor, inner fuel probe, intermediate fuel probe, outer fuel probe, main

fuel tank electrical harness, intermediate strap electrical harness, high and low fuel vent valves, and fuel check valve were removed for further examination.

Examination of the right wing following fuel system testing revealed the fuel tank was breached, but there were no obstructions inside the fuel tank. The fuel

tank outlet finger screen had some debris. Both flapper valves were installed and operate normally. The low fuel sensor, fuel probes, and electrical harnesses

pertaining to fuel were noted to be installed correctly. The low fuel sensor, inner fuel probe, intermediate fuel probe, outer fuel probe, main fuel tank electrical

harness, intermediate strap electrical harness, high and low fuel vent valves, and fuel check valve were removed for further examination.

Cursory examination of the engine and propeller revealed all four propeller blades were bent aft. Rotation of the propeller by hand resulted in expected rotation

of the power turbine assembly, while rotation of the compressor assembly resulted in expected rotation of all the Accessory Gearbox (AGB) drives.

Examination of the fuel filter revealed the level of residual fuel in the bowl measured 0.400 inch. The propeller was removed from the engine which was

removed from the airframe and shipped to Pratt & Whitney Engine Services (PWES) facility for engine operational testing.

Prior to operational testing of the engine with FAA oversight, borescope examination of it revealed no discrepancies. The engine was placed in a test cell as

received and with FAA oversight, the engine was started and operated at various power settings for over 2.5 hours. Four parameters exceeded the Overhaul

Manual tolerances for a zero time engine , but when the repair limits that factor in the engine's operating time were used, the only parameter out of tolerance

was the inter turbine temperature (ITT), which can be adjusted with a trim class change. A copy of the report from the engine manufacturer is contained in the

NTSB public docket.

TEST AND RESEARCH

According to the maintenance manual, a low level test, and indicator calibration on aircraft are not due until 1,500 hours and/or 4 years; therefore, these special

inspection items were not performed during the last 600-Hour/Annual inspection.

According to section 3.8 of the Pilot's Operating Handbook (POH), in the event of annunciation of "Fuel Low R" as reported by the pilot occurring twice, the

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emergency procedures specify to check the corresponding gauge, check that the other tank has been automatically selected, and if not, place the fuel selector

switch to manual and manually select the opposite tank of the indication. Section 3.8 of the POH also indicates that with respect to the red warning CAS

message "Fuel Press" on, a fuel pressure drop at the high pressure engine pump inlet. The corrective action indicates to check the remaining fuel, move the

fuel selector to the opposite tank, check the fuel pressure indication, and place the "Aux BP" fuel switch to the auto position.

The POH also indicates that the fuel selector automatically changes in-flight every 10 minutes, and the maximum dissymmetry is 15 U.S. gallons. When the

first low level CAS message occurs, the sequencer immediately selects the other tank. The selected tank will operate until the second low level CAS message

occurs. When both low level CAS messages are visible, the sequencer changes tanks every 1 minute 15 seconds. There are no procedures specified in the

POH to deal with multiple conflicting fuel level annunciations from the same fuel tank.

Testing of the 3 capacitance fuel probes from each wing, the low fuel sensor from each wing, the fuel amplifier (FCU), the fuel check valves from each wing, the

left fuel gauge harness and intermediate strap, the right fuel gauge harness and right intermediate strap were performed at the respective manufacturer's facility

with oversight from personnel of Bureau d'Enquetes et d'Analyses (BEA), Bourget, France. The results of the examinations revealed no evidence of preimpact

failure or malfunction.

Examination of the right fuel gauge harness, part number (P/N) T700G921201000100, serial number (S/N) 0110740 was performed at the manufacturer's

facility BEA oversight, who also performed X-ray testing of the harness. An electrical continuity check revealed a discrepancy of pin B of the P60 and P61

harnesses. During the testing resistance values of several thousand Ohms were noted; however, during movement of the harness, the resistance value

increased to more than 1 Million Ohms. Both harnesses were examined with an x-ray machine, the results of which were compared with the left harness, as

well as to an exemplar harness. It was noted that the High Impedance shielded cable near the P60 connector appeared to be outside of the solder joint. The

shielded wire on the P60 and P61 sides is a copper nickelled (kapton type) with a self-soldering sleeve adapted to this technology. A complete disassembly of

the P60 harness was then performed which revealed that when the self-soldering sleeve was cut, the shielded HI wire was not correctly soldered to the

shielding braid near the P60 connector during manufacturing; it was not complete. Testing of an exemplar harness duplicating the improper solder connection of

the right harness was performed on an exemplar airplane with no fuel. During the testing, the right fuel quantity depicted the maximum value.

Personnel from the BEA reported that during research, starting with airplane serial number 434, new kapton type electrical wires were utilized for some of the

fuel gauge harnesses. And although the manufacturing instructions were clear, one mistake was identified in the manufacturing process.

ADDITIONAL DATA/INFORMATION

Post-Accident Corrective Actions

As a result of the initial finding of the investigation and the result of a second airplane with erroneous fuel indication issue, in October 2011, a representative of

the airplane manufacturer sent an e-mail to all owners, operators, and network owners of TBM 700 and TBM 850 (market name for TBM 700) airplanes

equipped with Garmin G1000 Integrated Flight Deck. The e-mail advised of 2 instances in which erroneous fuel indication occurred. The e-mail asked that

before the next flight, document the quantity of fuel in each tank, and then fill each tank noting the amount. If a discrepancy exists, contact a maintenance

center to correct the discrepancy. The issue involving the other airplane was attributed to be from an intermediate fuel probe.

Additionally, in March 2013, the airplane manufacturer developed technical note (TN) 70-014, titled Fuel Gauge Harness. This made it mandatory to replace the

shielded cable on TBM 700 airplanes equipped with modification (MOD) MOD70-0176-00, affected airplanes were S/N's 434 through 440, and 442 through 450.

The airplane manufacturer also changed their quality control procedure for fuel gauge harnesses for production airplanes, and implemented a specific box used

for manufacturing fuel gauge harnesses.

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Documents

National Transportation Safety Board - Aircraft … Transportation Safety Board - Aircraft Accident/Incident Database Accident Rpt# WPR11FA381 08/14/2011 900 MDT Regis# N324AT Lander,