Aviation Accident Summaries

Aviation Accident Summary WPR14FA381

Borrego Springs, CA, USA

Aircraft #1

N3037H

CESSNA AIRCRAFT CO 162

Analysis

The commercial pilot took off for a personal flight and flew uneventfully for about 44 minutes, including a touch-and-go landing at another airport about 10 minutes before the accident, after which the pilot made several turns in the area. According to the recovered flight data from the airplane's avionics system, during the last minute of the recorded data, the airplane was in a gradual climb with a pitch-up attitude of about 7 degrees and a left bank of about 5 degrees; the airspeed was gradually decreasing. In the next 30 seconds, the airplane's pitch increased to a maximum of 28 degrees nose up, and the airspeed decreased to a minimum of 38 knots indicated airspeed. The engine maintained about 2,200 rpm during this time. The airplane's Pilot's Operating Handbook (POH) states that the stall speed for the airplane is 41 knots indicated airspeed with the flaps up and power at idle. The data were consistent with a power-on stall. The POH states that for power-on stall recovery, the pilot is to simultaneously decrease power and lower the nose. Following the stall, the airplane's pitch then decreased to a maximum of 69 degrees nose down before it stabilized about 30 degrees nose down for the remainder of the recording with a descent rate of about 4,500 ft per minute. The airplane then banked from 76 degrees left to 75 degrees right in about 1 second; at this point, the engine power began to decrease. The bank stabilized about 10 degrees right for the remainder of the recording. Spins completed about every 2 seconds were recorded during the final 20 seconds. Further, during this final 20 seconds, the airplane's engine rpm decreased from 2,100 to 1,800 rpm. The POH lists recovery procedures to accomplish should an inadvertent spin occur. The first step is to immediately retard the throttle to the idle position. The next steps are to place the ailerons in the neutral position and then apply and hold full rudder opposite to the direction of rotation. The POH has a warning that recommends spin procedures be memorized to ensure prompt and proper recovery techniques are used in the event that an inadvertent spin is encountered. The recorded data revealed that, although the pilot pitched the nose down following the power-on stall, he did not simultaneously reduce the power. Further, the airplane's engine throttle was not immediately retarded to the idle power position when the spin began, and the pilot did not apply the appropriate controls. Postaccident examination of the airplane revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Factual Information

On September 19, 2014, about 0754 Pacific daylight time, a Cessna 162, light sport airplane, N3037H, sustained substantial damage when it impacted terrain about 6 miles east of the Borrego Valley Airport (L08) Borrego Springs, California. The airplane was registered to Jacksonair Services LLC and operated by the pilot under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot, sole occupant of the airplane, was fatally injured. Visual (VMC) meteorological conditions prevailed, and no flight plan had been filed. The local personal flight departed Jacqueline Cochran Regional Airport (TRM), Palm Springs, California, about 0709. The Federal Aviation Administration (FAA) issued an Alert Notification (ALNOT) for the missing airplane after the pilot failed to return the airplane. A search ensued and the following morning a Civil Air Patrol airplane located the airplane wreckage on a hillside near Borrego Springs. The airplane was equipped with a Garmin G300 Integrated Cockpit System which included flight displays, air data computers, attitude/heading/reference systems, and communications. Each display included a Secure Digital (SD) Memory Card that had a flight data log feature. The pilot's display SD card was recovered and sent to the National Transportation Safety Board (NTSB) Vehicle Recorder Laboratory for the download of the data. (A published report on the recorded flight data obtained from the accident airplane is available in the public docket). According to the SD card, the accident flight on September 19, 2014, was recorded. The data revealed that after takeoff, the airplane made a right turn and flew between 2,000 and 3,000 feet mean sea level (msl) for about 20 minutes. The airplane made another right turn toward Borrego Springs and overflew L08 and then entered its traffic pattern. At 0745, the airplane maneuvering was consistent with accomplishing a touch and go landing. The airplane then departed L08, climbed out, and turned right. The airplane maneuvered for another 10 minutes before the data stopped recording at 0754. The final minute of the data recording initially showed the airplane at about 2,200 feet msl and at 65 knots indicated airspeed. The data depicted that the airplane then pitched up to 7 degrees nose high attitude with 5 degrees of left bank. The airplane's pitch was continuously increased to a maximum of 28 degrees nose high, while the airplane's airspeed continuously decreased to a minimum of 38 knots indicated airspeed. The engine rpm was continuously steady at about 2,200 rpm during this time. The airplane's pitch then decreased to a maximum of 69 degrees nose low before it stabilized at about 30 degrees nose low for the remainder of the recording. The altitude was decreasing at a rate of about 4,500 feet per minute. The airplane's bank went from 76 degrees left to 75 degrees right in about a second and then stabilized at about 10 degrees right for the remainder of the recording. A spin of 360 degrees about every 2 seconds was recorded during the final 20 seconds. Further, during this final 20 second period, the airplane's airspeed was between 40-50 knots indicated airspeed and the engine rpm was between 1,800 to 2,100 rpm. PERSONNEL INFORMATION The pilot, age 69, held a commercial pilot certificate with an airplane single engine and helicopter ratings. The pilot was issued a first-class airman medical certificate on May 1, 1978, with no limitations stated. The pilot stated during the examination that he had accumulated a total of 135 flight hours. Not all the pilot's logbooks were located and a current total flight time could not be determined. Though the pilot's total flight time was unknown, a recent logbook indicated that he flew the accident airplane for about 19.4 hours (mostly with an instructor) since May 2, 2014. Three of the instructional logbook entries listed stalls, under the remarks, procedures, and maneuvers section. The light sport airplane category requirements do not require a current FAA medical and the pilot possessed a current driver's license. AIRCRAFT INFORMATION The two-seat, high-wing, fixed-gear airplane, serial number (S/N) 1620115, was manufactured in 2011. It was powered by a Continental-O-200 D1 engine, serial number (S/N) 1003178, rated at 100 horsepower. The airplane was also equipped with a McCauley model IL100LSA6754, serial number (S/N) AFG01003, fixed-pitch propeller. A review of the maintenance logbooks revealed that the annual inspection was completed on August 19, 2014, at an airframe total time of 1,344 hours. The airplane's weight and balance during the accident flight, was calculated to be within prescribed weight and center of gravity limitations. The airplane's Pilots Operating Handbook (POH) states that the stall speed is 41 knots indicated airspeed with the flaps up and power at idle, and 37 knots indicated airspeed with the flaps full. The engine's normal operating range is listed as 2,000 rpm to 2,750 rpm. During stalls and power on stalls, the POH recommends a slow deceleration. The power-on stall recovery should be initiated by simultaneously lowering the nose while reducing power, after which normal power-off stall recovery techniques should be accomplished. A caution is listed on intentional power-on stalls that states the pitch should be limited to 30 degrees nose up attitude, because exceeding 30 degrees requires high power and accelerated stall entry, which may result in pilot disorientation. The POH has a warning that recommends spin procedures be memorized to ensure prompt and proper recovery techniques are used in the event that an inadvertent spin is encountered. The POH lists recovery procedures to accomplish should an inadvertent spin occur. The first step is to immediately retard the throttle to the idle position. The next step is to place the ailerons in the neutral position. The procedures then state to apply and hold full rudder opposite to the direction of rotation. Subsequently, just after the rudder reaches the stop, move the control briskly forward far enough to break the stall. These control inputs are to be held until the rotation stops, and then a recovery from the dive can be accomplished. METEOROLOGICAL INFORMATION A review of recorded data from TRM, Palm Springs, California, automated weather observation station, located about 19 miles northeast from the accident site, revealed at 0752 conditions were wind from 320 degrees at 11 knots, visibility 10 statute miles, clear sky, temperature 27 degree Celsius, dew point 16 degrees Celsius, and an altimeter setting of 29.75 inches of mercury. WRECKAGE AND IMPACT INFORMATION Examination of the accident site by the NTSB, investigator-in-charge, revealed that all the major components of the airplane were contained within the main wreckage site. The airplane impacted into the side of elevated terrain about 596 feet and left no debris trail, with the exception of the nose gear strut and tire that was located about 20 feet below the airplane wreckage. The airplane came to rest inverted on a heading of about 255 degrees magnetic. Examination of the airframe revealed that both wings were partially attached to the fuselage. The left wing was bent downward about 45 degrees and the right wing sustained compression damage. The fuselage was bent at several locations and the bottom of the cabin was bent inward. The empennage section's vertical stabilizer upper portion was damaged but the horizontal stabilizers were intact. Flight control continuity could not be established on site, due to the precarious position of the airplane on the terrain. All flight control surfaces remained attached at all their respective attachment points, with the exception of the right aileron, which had sustained damage and was attached only by its outer most attachment point. The flaps were observed to be up. The stabilizer trim was observed to be about ½ inch down from the neutral position. The examination of the airplane at the accident site revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The wreckage was recovered to a secure location for further examination. MEDICAL AND PATHOLOGICAL INFORMATION The County of San Diego, Office of the Medical Examiner conducted an autopsy on the pilot on September 21, 2014. The medical examiner determined that the cause of death was "multiple blunt force injuries." The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report, cyanide, volatiles, and drugs were tested, and had negative findings with the exception of Salicylate detected in the urine. Salicylate is a major ingredient in aspirin and other pain-relieving medications and is also found in many fruits and vegetables. TESTS AND RESEARCH Further examination of the airframe and engine revealed that the left wing was bent downward about 45 degrees from the fuselage and the right wing sustained compression damage. In the empennage section, the top portions of the vertical stabilizer and rudder were damaged. Flight control continuity was established with the cockpit controls. Examination of the engine revealed that it remained partially attached to the airframe by the engine mounts. The engine accessories remained attached to the engine via their respective mounts. All rocker covers were removed and the cylinder overhead areas were lubricated and unremarkable. The crankshaft was rotated by hand utilizing the propeller and rotational continuity was established throughout the engine and valve train. During crankshaft rotation thumb compression and suction were attained on all cylinders. A borescope inspection of the cylinders revealed evidence of normal operational conditions. The left magneto and right magneto were removed and a spark was produced at all the respective leads during hand rotation. The sparkplugs were removed and all sparkplug electrodes exhibited normal wear signatures when compared to the Champion Check-A-Plug comparison chart. The carburetor was removed and disassembled for examination. The inlet filter was free from any obstructions and no anomalies were noted with the internal components. The two-bladed propeller remained attached to the crankshaft flange. The blades were attached, with one blade fractured and the other blade cracked, both about at mid-span. The spinner remained attached to the propeller. Impact marks and abrasions were observed on the spinner. The examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Probable Cause and Findings

The pilot’s failure to recover from a stall, which resulted in a subsequent spin from which he did not recover because he did not immediately apply the proper stall and spin recovery techniques.

 

Source: NTSB Aviation Accident Database

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