Aviation Accident Summaries

Aviation Accident Summary ERA10LA277

Wakefield, VA, USA

Aircraft #1

N91HR

RUTTER HERBERT G LONG EZ

Analysis

Acquaintances of the pilot indicated that his intended destination was an airport located about 200 miles to the south of his departure airport. A witness reported that he observed the airplane approach, and after completing the first legs of a traffic pattern, it over flew the turn onto the final approach path. The airplane then executed a left 360 degree turn about 700 feet above ground level. After the turn, the airplane was again past the extended runway centerline. The airplane continued the left turn for several seconds, and then followed with a sharp turn to the right. The airplane impacted terrain about 250 feet prior to the runway threshold; ground scars indicated that it struck in a right wing down attitude. At the time of the accident, the wind velocity was about 4 knots and the sky was clear of clouds. The majority of the witness observations were corroborated by global positioning system (GPS) data that was recovered from a unit in the airplane. Examination of the GPS data, the airplane, and the engine did not reveal any evidence of preimpact mechanical failures. No definitive reasons for the pilot's decision to land at the accident airport, or his difficulties in aligning with the runway, were discovered. The pilot's most recent Federal Aviation Administration third-class medical certificate expired about 22 months prior to the accident. Shortly thereafter, the FAA withdrew the pilot's eligibility for medical certification, and his eligibility for medical certification was never re-established. Neurological evaluations, family member observations, and autopsy findings were consistent with the pilot experiencing progressive cognitive decline due to Alzheimer’s disease.

Factual Information

HISTORY OF FLIGHT On May 21, 2010, about 1500 Eastern Daylight Time (EDT), an experimental amateur-built Long EZ, N91HR, was substantially damaged during an attempted landing at Wakefield Municipal Airport (AKQ), Wakefield, Virginia. The certificated private pilot was fatally injured. The flight was operated under the provisions of 14 Code of Federal Regulations Part 91. The flight originated from Altoona-Blair County Airport (AOO), Altoona, Pennsylvania with a reported intended destination of Suffolk Executive Airport (SFQ), Suffolk, Virginia. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight. A pilot who landed at AKQ about 10 minutes earlier, was fueling his airplane when he witnessed the accident. He estimated that the wind was from the east, blowing "directly across" the runway, at a speed of about 8 knots. He saw the accident airplane approach from the northwest, and make a mid-field left turn to track along the runway to the northeast, at traffic pattern altitude. When the airplane crossed the threshold of runway 2, it flew a "teardrop" pattern by first turning to the right, and then making a continuous turn to the left to become established on the final leg for runway 20. The witness stated that "the winds appeared to cause the plane to overshoot its turn to final," northwest of the runway centerline. When the airplane was about 3/4 of a mile from the threshold of runway 20, and about 700 feet above ground level (agl), the airplane began a left 360 degree turn, apparently in an attempt to conduct another approach. After that turn was completed, the airplane was again northwest of the extended centerline of runway 20, and the airplane initially continued around to the left, which caused the witness to believe that the pilot would conduct another full circle, and another approach. When the airplane was "a little closer" to the threshold than it was when the previous approach was abandoned, and at an altitude of about 500 feet agl, the witness observed it bank sharply to the right, in what appeared to him to be a third attempt to align with the runway. The witness perceived it to be "a skidding turn in a nose high attitude" with a noticeable sink rate. He observed the airplane’s nose “drop" as the airplane continued to roll to the right. The right wingtip and nose struck the ground first, in an open field adjacent to airport property. The airplane then “cartwheeled” across a road and onto airport property, near the approach end of runway 20. PERSONNEL INFORMATION Federal Aviation Administration (FAA) records indicated that the pilot held a private pilot certificate, with an airplane single-engine land rating, and a repairman certificate for the accident airplane. On his July 2006 application for an FAA medical certificate, the pilot reported that he had 3,600 total hours of flight experience, including 50 hours in the 6 months prior to July 2006. No further records of the pilot's experience in the accident airplane make and model, or of his most recent flight review, were able to be located. The daughter of the pilot, who resided in Europe, reported that her father flew the accident airplane “several times a week” up until the day of the accident. AIRCRAFT INFORMATION The Long EZ was a canard-equipped kit-built airplane of composite construction. The configuration also featured two-place tandem seating, tricycle-style landing gear with a retractable nose gear, and a pusher propeller. According to FAA records, the airplane was built by the pilot, and was issued an airworthiness certificate in 1995. It was equipped with a Lycoming O-235 series engine, and a two-blade, fixed-pitch wood propeller. In addition to the normal flight and navigation instruments, the airplane was equipped with an autopilot. No maintenance records for the airplane were able to be located. METEOROLOGICAL INFORMATION The AKQ 1454 automated weather observation included variable direction winds at 4 knots, visibility 10 miles, clear skies, temperature 28 degrees C, dew point 8 degrees C, and an altimeter setting of 30.13 inches of mercury. According to the National Oceanic and Atmospheric Association, on the day and time of the accident, the elevation of the sun was 56 degrees above the horizon, and the sun's azimuth was 243 degrees true. The 1500 automated weather observation at the pilot's supposed intended destination, SFQ, included winds from 120 degrees at 9 knots, visibility 10 miles, clear skies, and a temperature of 28 degrees C. AIRPORT INFORMATION Accident Location: Wakefield Municipal Airport (AKQ) FAA records indicated that AKQ was a public-use airport. The elevation of AKQ was 113 feet above mean sea level (msl), and it was equipped with a single asphalt runway, which measured 3,337 feet long by 75 feet wide. The alignment of runway 20 was 197 degrees true, 203 magnetic. Published FAA information indicated that a left-hand traffic pattern was to be used for runway 20. Visual slope indication information was provided by panels on the left side of runway 20; the panels were configured to indicate a 3 degree glide path. The airport was not equipped with an air traffic control tower, but it was equipped with a designated Unicom/common traffic advisory frequency. Pilot's Reported Destination: Suffolk Executive Airport (SFQ) FAA records indicated that SFQ was a public-use airport, located about 25 miles southeast of AKQ. The elevation of SFQ was 72 feet msl. SFQ was equipped with two runways; 4/22, which measured 5,009 feet long by 100 feet wide, and 7/25, which measured 4,706 feet long by 100 feet wide. The airport was not equipped with an air traffic control tower. WRECKAGE AND IMPACT INFORMATION According to information provided by the FAA inspector who responded to the accident site, the debris path was approximately 150 feet long, and was oriented along a magnetic heading of approximately 220 degrees. The airplane first contacted a cornfield across a road from the threshold of runway 20, and then struck an earthen berm between the cornfield and the road. Fragments of the right wingtip and the canopy transparency were the earliest components in the debris field. Dislodged earth and other airplane fragments were distributed across the road. A metal post in the wire mesh fence that separated the road from the airport was bent in the airplane's direction of travel, and the majority of the airplane debris came to rest on airport property, in the grassy area just west of the taxiway at the approach end of the runway. The right wing was fracture-separated from the fuselage. The left wing remained attached to the fuselage, and that section came to rest in an approximately upright position, facing back along the debris path. All flight control surfaces remained attached to their respective airfoils. The flight control actuation mechanisms consisted of push-pull rods and cables, and the only control system anomalies were collocated with fracture locations in the airplane. The fuselage nose section was fracture-separated from the main body at approximately the front seat (pilot's) station. The canopy frame was fracture-separated from the fuselage, and the canopy transparency was fractured into multiple segments. Numerous small airplane fragments, as well as paper items from the airplane, were scattered in the vicinity of the main wreckage. The propeller remained attached to the engine, and the engine remained attached to the engine mount, but the engine mount had separated from the fuselage. The propeller, engine and engine mount were found under the main fuselage segment, and only remained attached to the fuselage by cables and hoses. One propeller blade was fracture-separated from the hub. The airplane was equipped with two integral fuel tanks, one in each wing. Each fuel tank was placarded with a capacity of 24 gallons. The right tank was breached, and no fuel was observed in the tank remains. A small area of blighted grass was found near the right tank. The left tank was intact, and approximately 12 gallons of blue aviation gasoline were drained from that tank. The fuel appeared clear, and no water was observed in it. The carburetor inlet line was disconnected from the carburetor on scene, and fuel was observed in the carburetor bowl. The fuel selector valve was completely separated from the airplane, and was found set to the right tank. The cockpit mixture control was found in the full rich position, and the throttle was found in the idle position. The Hobbs-brand hour meter was separated from the airplane, but remained intact, and registered 132.9 hours. Two handheld global positioning system (GPS) units were recovered from the wreckage. One was a dedicated aviation unit, a Garmin GPSMap 196. The other was a generic non-aviation unit, a Garmin NUVI. The units were retained for data download by the National Transportation Safety Board (NTSB). MEDICAL AND PATHOLOGICAL INFORMATION According to documents provided by the FAA Civil Aerospace Medical Institute (CAMI), the pilot's most recent FAA third-class medical certificate was issued in July 2006, and was initially scheduled to be valid for 2 years. However, shortly thereafter, the FAA requested that the pilot provide certain additional documentation to substantiate his medical fitness, and in September 2008, for at least two unrelated reasons, including suspected dementia, the FAA withdrew the pilot's eligibility for medical certification. The pilot's eligibility for medical certification was not re-established prior to the accident. The FAA CAMI conducted toxicological testing on specimens from the pilot. The results were negative for carbon monoxide, cyanide and ethanol. Acetaminophen was detected in the blood. An autopsy was performed by the Department of Health, Office of the Chief Medical Examiner in Richmond, Virginia. The autopsy report noted microscopic findings of “Widespread neurofibrillary tangles associated with plaques of varying morphology” in the brain and indicated “the density of neurofibrillary tangles and plaques within the brain are consistent with those observed in this setting of dementia.” The autopsy report also noted congestive cardiomegaly, hepatomegaly, hepatosteatosis, and chronic pancreatitis. The report of the examination of the heart noted “The mitral valve exhibits marked senile valvular redundancy and annular calcification,” with no other valvular abnormalities, and “minimal atherosclerosis” of the coronary arteries. The autopsy report stated that the cause of death was “blunt force injuries of torso and lower extremities.” ADDITIONAL INFORMATION Global Positioning System (GPS) Flight Track Information The two recovered handheld GPS units were sent to the NTSB Vehicle Recorders Laboratory for download of the data. Data was successfully recovered from the GPSMap 196, and one dataset was determined to be from the accident flight. It was therefore decided not to attempt data recovery from the NUVI non-aviation GPS unit. Correlation of the GPS data with the known time of the accident indicated that GPS dataset time base was Universal Coordinated Time (UTC), which was 4 hours later than the local EDT time. All time references in the paragraphs below are expressed as EDT. The GPS data indicated that the accident flight began at AOO about 1306. During the first 8 minutes of flight, the airplane climbed steadily to about 4,700 feet GPS altitude, and for the next 20 minutes the altitude then varied between 4,700 and 3,800 feet, before the airplane began a second steady climb to about 5,500 feet. For the first 40 minutes of the flight, the ground track was approximately due south, but with local deviations to the east and west. About 1346, when the airplane was about 4 miles northwest of Front Royal, Virginia, the airplane turned about 20 degrees to the east, and the ground track varied less than 4 degrees for the next 93 miles, until about 1432. At that point, the airplane was 7 miles west-southwest of Richmond, Virginia, and the groundtrack turned another 20 degrees to the east. The airplane maintained that groundtrack of about 140 degrees until about 1453, when it was about 0.5 miles north-northwest of the AKQ runway 20 threshold. The GPS data indicated that the airplane then flew approximately parallel to runway 20, with an offset of approximately 1,200 feet to the west northwest, which placed the airport off the pilot's left side. Just beyond the end of the runway, the airplane made a 180 degree turn to the left, which positioned it on an approximate downwind leg for runway 20, offset about 4,600 feet from the runway. The airplane descended from approximately 1,500 feet to 1,100 feet during that segment. The airplane then turned left to approximate a base leg, but continued around to the left to describe an oval that was centered about 4500' north-northeast of the 20 threshold. The major axis of the oval was perpendicular to the runway, and measured about 3,500 feet. The minor axis measured about 2,700 feet, and the oval was completed in about 1 minute. The completion of the oval coincided with the last of the GPS data. The final recorded GPS data point was recorded at 1456:39. It indicated an airplane ground track of 185 degrees true, a groundspeed of 103 mph, and a GPS altitude of 671 feet. Pilot's Planned Activities The annual Virginia Regional Festival of Flight, which was a local fly-in and exhibition that included aerial and static displays, was scheduled to take place at SFQ on May 22 and 23, 2010. The operations manager for the Festival of Flight reported that the SFQ airspace remained open throughout the entire period, with the exception of a restriction at noon on May 22 for a military flyby. The Festival operations manager also reported that they did not require or take arrival or parking reservations for individual airplanes at the Festival, so no records of the pilot's reported intent to attend the Festival were available. The pilot's daughter, who was living in Europe when the accident occurred, provided a receipt that indicated that the airplane was fueled in Pennsylvania on the morning of the accident flight. She stated that her father had been trying to sell the airplane for the past few years, and that he intended to fly the airplane to SFQ, in order to try to sell it at the Festival. Also according to the daughter, the pilot had spent time over the last 2 years trying to eliminate a "strange noise" that occurred on nose landing gear extension. She stated that friends of the pilot had told her, that in the days leading up to the accident, the pilot was "a little bit short of temper" due to the fact that he felt "rushed" to eliminate the noise before he brought the airplane to SFQ for possible sale. The daughter stated that the pilot conducted the flight to SFQ frequently, and that he knew the journey “like the back of his hand.” She further stated that, to her knowledge, on flights from his home airport, her father never made any interim stops prior to reaching SFQ A representative of Lockheed Martin Flight Services reported that "no services were provided to N91HR by Lockheed Martin Flight Services or DUATS" on the day of, or the day prior to, the accident. No other information regarding the pilot's planned activities was able to be obtained.

Probable Cause and Findings

The pilot’s failure to properly align the airplane with the final approach path to the runway and his subsequent loss of control during his attempts to correct the flight path. Contributing to the accident was the pilot’s progressive cognitive decline due to Alzheimer’s disease.

 

Source: NTSB Aviation Accident Database

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