Aviation Accident Summaries

Aviation Accident Summary IAD97FA117

SMITHFIELD, RI, USA

Aircraft #1

N3286Y

Cessna 182E

Analysis

The airplane flew eight times on the same day, prior to the accident flight, taking skydivers aloft and releasing them. According to the airplane's log, the airplane was refueled 2 flights prior to the accident flight with 20 gallons of fuel. According to the owner, this was to keep the airplane within the center of gravity limits. According to witnesses and a video taken of the airplane, the pilot and five skydivers boarded the airplane and departed. The airplane reached about 300 feet agl when the engine lost power. The witnesses reported that the airplane pitched up in a nose high attitude, rolled left, and descended until ground impact about 90 degrees off runway heading. The airplane came to rest in an upright position, against the initial trees of a wooded area. The propeller was found under the right wing. One blade was bent aft 90 degrees with lengthwise scratching. The engine was test run, and no mechanical malfunction were found.

Factual Information

HISTORY OF FLIGHT On September 6, 1997, about 1700 eastern daylight time, a Cessna 182E, N3286Y, was destroyed as it impacted the terrain during a forced landing on initial climb out at North Central Airport, Smithfield, Rhode Island. The certificated commercial pilot and four skydivers were fatally injured, a fifth skydiver received serious injuries. The airplane was owned by AMAROK Inc., and operated by Boston-Providence Skydiving Center, in Lincoln, Rhode Island. Visual meteorological conditions prevailed, and no flight plan was filed for the local skydiving flight conducted under 14 CFR Part 91. The airplane's flight log indicated that it had flown eight skydiving flights earlier that day, and the owner/operator stated that the pilot had not reported any problems or malfunctions from any of the previous flights. The log showed that the airplane was fueled with 20 gallons of aviation fuel one flight prior to the accident. The owner/operator reported that the reason for 20 gallons was to keep the weight and balance within the center of gravity, which fluctuated due to the number of skydivers. The owner/operator reported that besides the pilot, there were four professional skydivers and one student on her initial jump onboard the airplane. Witness statements from people along the runway, and a pilot landing behind the airplane, indicated that the airplane reached between 200-300 feet agl, when the engine lost power. Their statements reflected that the airplane pitched into a nose high attitude, rolled left, and descended until ground impact. The accident occurred during the hours of daylight approximately 41 degrees, 55 minutes north latitude, and 71 degrees, 29 minutes west longitude. PERSONNEL INFORMATION The pilot held a commercial pilot certificate for airplane single engine land, instrument airplane, and a private pilot certificate for airplane multi-engine land. His most recent Federal Aviation Administration (FAA) medical certificate was a first class obtained August 20, 1997, with no limitations. According to the pilot's log book and FAA records, the pilot obtained his private pilot certificate on December 18, 1995, with about 90 total flight hours. His private multi-engine pilot certificate was obtained on October 16, 1996, with about 194 total flight hours, of which 22 hours were in multi-engine airplane. His single engine land instrument rating, was obtained on January 1, 1997, with about 244 total flight hours. His commercial pilot certificate, single engine land airplane, was obtained on January 20, 1997, with about 254 total flight hours. The logbook indicated that the pilot started flying company airplanes in May, 1997, when he had about 303 total flight hours, and at the time of the accident the pilot had about 553 total flight hours. AIRCRAFT INFORMATION Examination of the airplane's logbooks revealed that the airplane was modified with several Supplemental Type Certificates (STC). One STC was for the installation of a Teledyne Continental, IO-470F, 260 horsepower engine, with a header tank installed underneath the floor forward of the selector valve, and a electrically driven boost pump added on the firewall. The airplane was approved for the removal of all seats except the pilot's, and five sets of seat belts were mounted on the floor for use by skydivers. The airplane had a transparent upward sliding door installed, and a skydiving step mounted on the right main landing gear. The owner/operator of the airplane stated that "it was his understanding that he could operate the airplane utilizing the annual inspection program rather than a 100-hour program." The owner/operator reported that he changed the oil every 25 hours. The investigation did not reveal any material maintenance discrepancy in the airframe or the engine. WRECKAGE AND IMPACT INFORMATION The Investigator-In-Charge (IIC) arrived the morning after the accident and was briefed on the airframe cutting done by the rescue personnel to extract the victims. The airplane impacted the ground approximately 500 feet left of runway centerline and approximately 4,300 feet from the departure end of the runway 23, and came to rest on a 120 degrees magnetic heading. The initial impact crater measured approximately 12 inches deep, 2 feet wide and 4 feet long. About 30 feet of ground scarring was observed to extend from the initial impact crater to a tree line where the wreckage came to rest. The two bladed propeller was separated and lying underneath the right wing. One blade was bent aft 90 degrees with lengthwise scratching found on the face of the blade. The second blade showed minimal impact damage. The engine sustained damage to the propeller mounting flange, the casing was cracked, and three engine mounts were broken. The wreckage was resting on the bottom of the fuselage, with the fixed main landing gear bowed out. The nose landing gear was separated and on the right side of the wreckage. The top of the cockpit area was compressed and level with the top of the instrument panel. Both wings displayed leading edge crushing. The right wing was still attached, but lying on the ground, level with the bottom of the fuselage. The left wing was attached, but had been cut by rescue personnel, and rotated forward with the inboard leading edge resting on the pilot's seat. Fuel was observed by the IIC leaking from the left wing tank, and a strong odor of aviation fuel surrounded the wreckage. The Crash Fire and Rescue personnel stated that they had drained approximately 12 gallons of aviation fuel from the wreckage. They also reported that they experienced two explosions during their effort to extract the victims. The wreckage was taken to a hangar on the airport where a further examination began on September 8, 1997. Flight control continuity was confirmed and the flaps were in the up position. The fuel selector valve was determined to be in the "both" position. The main fuel line to the engine driven pump was detached, and a small amount of fuel was noted in the line. The gascolator was intact and was about one-third full of fuel. A FAA Inspector witnessed the preliminary examination of the engine. He reported that the fuel pump coupling was intact and free to rotate. The throttle plate was in the full open position, the throttle arm was broken, and the spark plugs were found absent of debris. Both of the magnetos produced spark when rotated, and both the fuel filter and the fuel spider bowl were clean and absent of debris. The engine crankshaft was rotated, and valve train continuity and thumb compression was obtained on all cylinders. No visible mechanical malfunctions were observed. The starter/ignition wiring from the instrument panel to the magnetos was checked for breaks and grounds, and found to be intact. The fuel boost pump switch, a three position switch, was found in the middle position or "off". TEST AND RESEARCH A family member video recorded the airplane's takeoff. A sound spectrum analysis was performed on the tape by the National Transportation Safety Board (NTSB) laboratory. The NTSB Laboratory sound analysis chart indicated that the propeller was rotating at about 2,525 rpm as it flew past the recorder. According to the manufacturer, this rpm range was in the normal climb rpm setting for the engine. A visual examination of the video tape by the IIC, revealed that the airplane had about 10 degrees of flaps extended when it taxied out for take off. When the airplane flew past the recorder, the flaps were observed to be moving towards the up position. No smoke was visible from the engine, nor was any abnormal engine sounds heard. The video tape ended abruptly after the cessation of noise from the engine. The decent of the airplane was not recorded. The engine was shipped to Mattituck Aviation, at Mattituck, Long Island, New York. On September 18, 1997, the engine was removed from its crate and assessed as capable of being tested. Its condition required a sealer to reinstall the cracked pieces on the front of the casing, and the following actions were taken in order to test run the engine: the magnetos-timed, the broken throttle arm-repaired, the control arms on the fuel control unit-repaired, and a serviceable oil sump-installed. The engine was tested on September 19, 1997. After preliminary test runs, the engine was run duplicating the sequence captured on the video. The throttle response, oil pressure and fuel flow were within the manufacturer's limits and the engine continued to run. Similar to the airplane, a header tank was placed into the test cell to determine if fuel vapor could be introduced into the main engine supply line. Clear plastic lines were used for the return lines from the engine driven fuel pump to the header tank, and from the header tank to the inlet side of the engine driven fuel pump. No bubbles nor vapors were observed in the main fuel line from the header tank to the inlet side of the engine-driven fuel pump. Vapor was seen in the clear line from the return port on the engine-driven fuel pump to the header tank. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot, on September 8, 1997, by Elizabeth A. Laposata, M.D., Chief Medical Examiner for the State of Rhode Island, Providence, Rhode Island. The toxicological testing report from the FAA toxicology Accident Research Laboratory, Oklahoma City, Oklahoma, was negative for alcohol. Ephedrine was detected in blood and liver. ADDITIONAL INFORMATION No dated weight and balance (W&B) calculations were located for the airplane. Hand written weight and balance notes were removed from the airplane. These notes indicated that the empty weight and balance of the airplane with the jump door installed was 1,712.46 pounds. They also listed an arm of 36.06 inches, and a moment of 61,756.47 inch pounds. An estimated W&B was computed by the IIC based upon information provided by the owner/operator. The information included the weights of occupants, parachutes, harnesses and clothing, and the estimated fuel onboard. The calculations revealed an estimated takeoff weight of 2,930 pounds, and an estimated center of gravity of 48.67 inches. According to the Pilot Operating Handbook, the maximum allowable takeoff weight of the airplane was 2,800 pounds. The POH also listed a center of gravity range of 38.39 to 47.32 inches, at the maximum weight. Calculations were performed by the IIC to determine the amount of fuel used during start, taxi, and takeoff. Time marks recorded on the video tape were used as the means of calculating the total amount of time the engine was run at idle and takeoff power. According to the manufacturer, the engine's estimated fuel consumption was about 1.8 quarts/minute at takeoff power, and about .08 quarts/minute at idle power. The video did not record the entire taxi and takeoff sequence, but the video camera's internal clock was continuously running and displayed in the field of view. The video included the engine start and the last 19 seconds of the takeoff and climb to when the engine lost power. The video did not include the entire takeoff roll; therefore, an estimated 30 seconds was utilized to determine fuel burn calculations at takeoff power, and 3 minutes 16 seconds was utilized for idle power calculations. Under those conditions, the engine would have consumed 1.2 quarts of fuel. The fuel header tank had a capacity of approximately 1 quart of fuel, with several ounces of fuel contained in the gascolator and the fuel line. A discrepancy was discovered with the switch on the instrument panel for the boost pump. The modification plans for the fuel injected engine installation called for a three position switch, "up" for "high" setting, "middle" for "off", and "down" for "low" setting of the boost pump. The switch on the panel energized the unit in the "down" or "low" boost pump setting only. The boost pump in the airplane was a two speed unit, and when tested, ran at both speeds. A helmet mounted video recorder carried by a instructor skydiver was found at the scene. The camera was damaged on impact and the film broke upon extraction from the camera. The film was spliced together at the NTSB Laboratory and viewed by the IIC. A summary of the film by the IIC stated "the video began as the airplane accelerated on its takeoff roll while viewing out a right side window. The view panned to the front of the airplane, none of the gauges in the field of view were readable. The film was taken to FBI to determine if their equipment was capable of enhancing each frame in order to obtain any information." The Information Resources Division of the Federal Bureau of Investigation, Washington, D. C., examined the film. No written report was done, only enhanced photographs taken from the film. No data could be extracted from the enhanced photographs. On September 23, 1997, during an interview at the hospital with the surviving skydiver, also a commercial pilot, he stated that he had difficulty remembering the accident. He remembered being on the left side of the airplane, facing aft, and positioned in front of the student skydiver, who also, was facing aft and behind the pilot. He recalled the pilot reduced the power for the en route climb setting, and shortly afterwards the engine lost power. He stated that he tried looking over his right shoulder to see what the pilot was doing. He recalled that he caught a glimpse of the intersection of the two runways, and felt the nose of the airplane rise up and wanted to push forward on the control column, and then the left wing dropped. He stated that he did not see what the pilot was doing nor did the pilot say anything. The wreckage was released to the owner/operator, Peter B. Wolfe, on September 19, 1997. Additional Persons Participating in this Accident/Incident Investigation: Ted V. Drozdz Rhode Island Airport Corporation Warwick, RI 02886 Alvan Moder Rhode Island Airport Corporation Warwick, RI 02886 Peter Wolfe Boston-Providence Skydiving Lincoln, RI 02865

Probable Cause and Findings

A loss of engine power for undetermined reason, and the pilot's failure to maintain control of the airplane.

 

Source: NTSB Aviation Accident Database

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