Aviation Accident Summaries

Aviation Accident Summary MIA08FA141

Kennesaw, GA, USA

Aircraft #1

N484RJ

SOCATA TBM700

Analysis

During approach to runway 9, the tower controller instructed the pilot to perform an “S” turn 3 miles from the runway. The pilot initiated the “S” turn to the left, and after turning back to the right towards the runway to complete the other half of the turn, the controller advised the pilot that he did not need to finish the maneuver, and could turn onto final approach. The last recorded ground speed was 89 knots when the pilot banked the airplane sharply to the left at this time, witnesses stated that the airplane seemed to do a wing over onto its back and go straight down. Flight simulation tests revealed that while making a steep turn and not adding power, as the bank angle increased the airspeed would decrease and the airplane would enter an aerodynamic stall. Toxicology testing indicated that the pilot had been using tramadol, a prescription painkiller with potentially impairing effects. The pilot had not reported its use on his most recent application for airman medical certificate approximately 20 months prior to the accident. It is unclear what role, if any, the medication or the condition for which it might have been used played in the accident. The pilot had accumulated over 975 hours of total time in all aircraft and 44.3 hours total time in the accident airplane.

Factual Information

HISTORY OF FLIGHT On July 15, 2008, at 1457 eastern daylight time, a Socata TBM-700, N484RJ, was substantially damaged when it rolled inverted and collided with trees short of runway 9, at the Cobb County-McCollum Field (RYY), Kennesaw, Georgia. The certificated private pilot was killed. Visual meteorological conditions prevailed and an Instrument Flight Rules (IFR) flight plan was filed for the flight from Southwest Georgia Regional Airport (ABY), Albany, Georgia, to RYY. The airplane was registered to Flying Max LLC, and operated under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The flight originated from ABY at 1400 on the same day. The following was derived from a partial transcript of the communications that occurred between N484RJ and the McCollum Flight Control Facility (FCF) Air Traffic Control Tower (ATCT). At 1454:10 the pilot reported to the RYY local controller that he was inbound. At 1454:15 the tower acknowledged the call and informed the pilot that runway 9 was in use and provided him with the local weather and instructed the pilot to contact the tower when he was turning onto final approach. At 1454:23 the pilot reported turning final. At 1455:04 the controller instructed the pilot to fly across the final approach course and make an “S” turn so he could get two departures off, the pilot did not respond and at 1455:16 the controller asked the pilot if he had copied the instructions. At 1455:19 the pilot reported that he was on a four-mile final. At 1455:22 the controller again asked the pilot to make one “S” turn on final so he could get a couple of departures off. Again the pilot did not respond and at 1456:14 the pilot reported that he was on a three-mile final. At 1456:26 the controller told the pilot “one more “S” turn for me a Cessna departing you’re cleared to land.” At 1456:37 the pilot responded back “make an “S” turn.” At 1456:45 the controller told the pilot that “half an “S” turn was fine you can turn toward the runway now”. At 1456:49 the pilot acknowledged the instructions. At 1457:07 the controller attempted to contact the pilot but received no response. Witnesses at the RYY airport stated that they observed the airplane on short final for runway 9. They heard the Air Traffic Control (ATC) Tower instruct the pilot to complete an "S" turn so that he could get two airplanes off the ground. The pilot of N484RJ acknowledged the instructions and proceeded to execute the turn. Then the witnesses stated that the airplane seemed to do a wing over onto its back and go straight down. Shortly after, a “huge” fire occurred that could be seen from the ramp. PERSONNEL INFORMATION The pilot, age 66, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane, issued on December 26, 2002. He also held a third-class medical certificate, issued on December 12, 2006, with the restriction that he must wear corrective lenses. The pilot reported on his last medical application that he had accumulated 975 civilian flight hours in all aircraft. The pilot’s logbook was not recovered. Prior to the purchase of the TBM-700, the pilot owned and operated a 1997 Piper PA-46-350P, powered by a Lycoming TIO-540 SER, 310 horsepower reciprocating engine. According to his family, he operated this airplane for a couple of years before purchasing the accident airplane. Prior to the Piper PA-46, he owned and operated a 1987 Beech F33A, powered by a Continental IO-520, 285 horsepower reciprocating engine. AIRCRAFT INFORMATION The six-seat, low-wing, retractable-gear airplane was manufactured in 2005. It was powered by a Pratt & Whitney PT6A-64, 700 horsepower turbo-prop engine, and equipped with a Hartzell model HC-E4N-3, four bladed constant speed propeller. A review of the airplane’s logbooks found that the airplane’s most recent 100-hour inspection was performed on July 10, 2008. According to the inspection write-up, the total time for both the engine and airframe was 398.0 hours. Estimated total time at the time of the accident was 404.0 hours. A review of the airplane’s records found that the airplane had been purchased by the pilot on March 13, 2008, following a pre-buy inspection at a total airframe and engine time of 359.7 hours. A review of FAA certification records found that the airplane was registered by the pilot under the name of Flying Max LLC, on May 22, 2008. From the time the pilot had purchased the airplane until the date of the accident, the pilot had accumulated 44.3 total hours in the TBM-700. METEOROLOGICAL INFORMATION The nearest weather reporting station was RYY, located approximately 1.5 miles from runway 9. RYY reported the following: wind, 100 degrees at 6 knots; visibility, 10 statute miles; sky, clear; overcast, scattered 4800 feet; temperature, 30 degrees Celsius, dew point 18 degrees Celsius; altimeter setting 30.07 inches of mercury. WRECKAGE AND IMPACT INFORMATION Examination of the accident site found that the airplane had impacted into a heavily wooded city park, in a steep, nose down attitude. The airplane struck several trees and subsequently the ground, and came to an abrupt stop with no forward movement after ground contact. The airplane came to rest on a 360 degree magnetic heading, and was located 1.8 nautical miles southwest of runway 9, on a 089 degree bearing to the airport. There was a post-impact fire which consumed much of the airplane and the surrounding landscape. Examination of the wreckage found the entire airframe consumed by the post-impact fire. The only remains were a section of right wing, small pieces of left wing panels, the engine, and a portion of the engine cowling. Examination of the flap actuators found them in the landing configuration, and the landing gear was found extended. Control cable continuity could not be established due to impact forces and the post-impact fire. No airframe anomalies were noted during the on-site examination. Examination of the engine found the reduction gearbox ruptured/fractured just forward of the second stage sun and ring gear set and was leaning towards the right-hand exhaust stack at approximately a 45-degree angle. This section had completely separated from the rest of the reduction gearbox casting which remained attached to the exhaust case. There was heavy buckling evident on the exhaust case. Heavy creasing of the duct was evident between the two exhaust stacks both at the 6 and 12 o’clock positions in a counter-clockwise direction. Both exhaust stacks were damaged. The left- and right-hand exhaust stacks were twisted clockwise looking at the exhaust stack flange and also pushed rearward. The left-hand stack sustained more twisting then the right hand stack. The engine was split at the “C” flange. The compressor turbine disc looked normal; however there was evidence of light rubbing at the compressor turbine blade fir trees. The rubbing was evident along the full circumference of the disc at the fir tree location. The center hub of the compressor turbine disc also showed evidence of rubbing with the power turbine interstage baffle. This was the only damage evident to the compressor turbine disc and blade set. The remainder of the combustion chamber, small exit duct and hot section area looked normal. The power turbine assembly looked normal, however there was evidence of rubbing between the turbine interstage baffle at the centre of the baffle and more at the 12 o’clock position and it appeared that this portion of the baffle was separating from rubbing the compressor turbine disc. There was also bluing of the baffle from heat which appeared more evident at the 12 o’clock position. There was evidence of separation between the inlet case and accessory gearbox mating faces. The gapping was between the 9 and 12 o’clock position and the gapping was at its maximum approximately 0.060 inches. Three bolts were found sheared at the 11 to 12 o’clock positions. No preimpact damage to or failures of the engine were identified. All four propeller blades sustained impact damage with the trees and ground. Two of the four blades appeared to be in the power position; the other two blades were broken within the propeller hub. The propeller blades exhibited chordwise and multi-directional scratches and leading edge damage. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on July 16, 2008, by the Cobb County Office of the Medical Examiner, Marietta, Georgia. The autopsy finding reported the cause of death as sequelae of generalized trauma. Forensic toxicology was performed on specimens from the pilot by the Federal Aviation Administration Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated that there was no carbon monoxide, cyanide or ethanol detected in blood or urine. However, alfuzosin, bisoprolol, and quinine was detected in blood and urine, and 0.15 (ug/ml, ug/g) tramadol was detected in blood and urine. The pilot’s most recent application for airman medical certificate, dated 12/12/2006, noted “Yes” to “Do You Currently Use Any Medication,” and indicated the use of only bisoprolol/hydrochlorothiazide and ezetimibe/simvastatin. The application indicated “No” for all items under “Medical History,” except “High or low blood pressure.” The Medical Examiner’s report noted, in part, that the pilot’s family indicated he “… had hypertension and had arthritis …” and the pilot’s primary care provider’s office staff indicated that the pilot, “… who had his last physical in March of this year, was being treated for hypertension, benign prostate hypertrophy, and high cholesterol. He was prescribed Ziac [bisoprolol/hydrochlorothiazide] 2.5 mg, one pill per day with no other medications being prescribed. …” ADDITIONAL INFORMATION Radar data provided by the Federal Aviation Administration was overlaid onto a local area map. The radar data showed that at 14:56:09 while on a heading of 105-degrees, a ground speed of 147 knots, altitude 960 feet above ground level (AGL) the pilot began the “S” turn to the left requested by the air traffic controller. At 14:56:32, while on a heading of 065 degrees, speed 149 knots, altitude 860 feet AGL, the pilot began his turn to the right back towards the runway. At 14:57:00, which was the last radar return showed the airplane on a heading of 114-degrees, speed 89 knots, altitude 960 feet AGL, and at that time the pilot was informed by the controller that “half an “S” turn was fine you can turn toward the runway now”. This is when the witnesses stated that the airplane seemed to do a wing over onto its back and go straight down. According to the TBM-700 Pilot’s Operating Handbook, section 5, Performance, paragraph 5.5, Stall speeds, figure 5.5.1, shows that at flight idle, weight 5,512 pounds, landing gear down, flaps set for landing, the airplane’s stall speeds at 0-degrees of bank would be 57 knots indicated air speed (KIAS), 30-degrees of bank 61 KIAS, 45-degrees of bank 68 KIAS, and at 60-degrees of bank 81 KIAS. On August 5, 2008, the National Transportation Safety Board’s Investigator-in-charge, traveled to SIMCOM Orlando Lee Vista Training Center, Orlando, Florida, to conduct flight tests in a TBM-700, full motion flight simulator. The purpose of the test was to duplicate the pilot’s flight path up until the accident. Numerous approaches were attempted simulating the pilot’s flight path. The first two approaches were successful when the simulator pilot maintained 90 knots by adding power during the 45 to 60 degree left bank while intercepting the runway heading of 090 degrees. The remainder of the tests were performed by not adding power during the steep turn to runway heading. Each test resulted in the airplane stalling as the bank angle increased and the airspeed dropped. However, because the instructor pilot was aware of the imminent stall, he was able to recover the airplane before it crashed and make a successful landing.

Probable Cause and Findings

The pilot’s failure to maintain airspeed during final approach resulting in an aerodynamic stall.

 

Source: NTSB Aviation Accident Database

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