Aviation Accident Summaries

Aviation Accident Summary ERA17FA248

Towanda, PA, USA

Aircraft #1

N601PH

AIRCRAFT MFG & DVLPMT CO CH601XLi SLSA

Analysis

The student pilot had just completed a 20-minute local flight and had returned to the airport to conduct touch-and-go takeoffs and landings. During the pilot's second touch-and-go landing, witnesses reported that the engine seemed to be producing partial power during the initial climb and the airplane appeared to stall and recover three times during climb out. As the pilot continued to climb, he bypassed several areas off the departure end of the runway and north and west of the extended runway centerline in which to conduct a forced landing in an open field. The airplane made a shallow turn to the right, then, about 1.5 miles southwest of the airport, it made left a turn south. The pilot declared an emergency over the airport's common traffic advisory frequency, stating that he was attempting to return to the runway; the airplane continued to turn left towards rising terrain. During the turn, the left wing dropped and the airplane descended at a steep angle into trees and rising terrain. The airplane's ballistic recovery system was activated; however, it could not be determined if it was deployed before impact or if accident dynamics caused activation of the system. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation; however, the scope of the examination was limited due to thermal damage. The weather conditions at the time of the accident were in the area of a carburetor icing probability chart that was conducive to the formation of serious carburetor icing at descent power and light carburetor icing at cruise or descent power. The pilot operating handbook for the airplane required the application of carburetor heat before landing. If the pilot did not apply carburetor heat during the approach and landing, carburetor ice may have formed, and when he added power for the subsequent takeoff, the engine power would have been reduced. However, the carburetor heat lever could not be functionally tested due to impact and thermal damage, so it could not be determined whether the pilot used the carburetor heat or not; thus the reason for the partial loss of engine power could not be determined. Suitable off airport landing locations were available on the extended runway centerline and to the northwest of the extended runway centerline; however, the pilot elected to turn south toward rising terrain. The pilot subsequently exceeded the airplane's critical angle of attack while attempting to return to the airport following the partial loss of engine power, resulting in an aerodynamic stall and loss of control. The pilot had significant heart disease with an enlarged heart, aortic valve replacement, and some arrhythmia that required treatment with a pacemaker, all of which put him at increased risk for sudden incapacitation. However, his heart disease would not have affected his decision-making nor his ability to respond to an inflight emergency, and there is no evidence that his heart disease contributed to the accident.

Factual Information

HISTORY OF FLIGHTOn July 19, 2017, at 1130 eastern daylight time, an Aircraft Manufacturing & Design (AMD) CH601XLi special light sport airplane (S-LSA), N601PH, was destroyed when it collided with terrain shortly after takeoff from Bradford County Airport (N27), Towanda, Pennsylvania. The student pilot, who was also the owner of the airplane, was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight, which departed about 1110. Several witnesses at N27 reported that the pilot departed the traffic pattern for a 20-minute local flight before returning to the airport to perform touch-and-go landings on runway 23. The first touch-and-go appeared normal. During takeoff following the second touch-and-go landing, the engine seemed to be producing partial power during initial climb; one witness reported, "It was clearly behind the power curve." The airplane climbed on runway heading and the airplane "stalled and recovered three times." The airplane made a shallow turn to the right, then, about 1 1/2 miles southwest of the airport, it made a shallow left turn south towards rising terrain. Shortly thereafter, the pilot declared an emergency over the airport's common traffic advisory frequency, stating that he was attempting to return to the airport. The pilot continued the left turn back toward the airport. During the turn, the left wing dropped; the airplane descended at a steep angle and impacted trees and rising terrain. Witnesses observed the airframe ballistic parachute rocket deploy immediately before seeing black smoke from the accident site. PERSONNEL INFORMATIONThe pilot, age 53, held a student pilot certificate. He did not possess a Federal Aviation Administration (FAA) medical certificate, nor was he required to in order to operate the light sport airplane. The pilot's logbook was not recovered. According to his flight instructor, the pilot mentioned that he had lost his previous flight records. They started flying together on September 20, 2016; when the pilot accumulated 19 hours of dual instruction, on November 17, 2016, he was given a 90-day solo flight endorsement. On April 10th and 14th, 2017, he received an additional 1.2 and 1.0 hours of instruction, respectively, and a new 90-day solo endorsement, which expired 3 days before the accident. AIRCRAFT INFORMATIONThe airplane was issued a special airworthiness certificate for S-LSA on July 18, 2007. According to FAA airworthiness records, the pilot purchased the airplane on January 6, 2014. The airplane was an all-metal, side-by-side, two-seat, fixed landing gear airplane equipped with a Continental O-200, 100-horsepower engine driving a Sensenich two-bladed wooden propeller. According to the airframe maintenance logbook, the most recent condition inspection was performed on September 16, 2016, at 264.7 total airframe hours and no discrepancies were noted. The previous condition inspection was conducted on August 15, 2015, at 258.2 total airframe hours and no discrepancies were noted. On July 5, 2013, an oil analysis was conducted, and the findings indicated wear consistent with normal operation. The airplane was equipped with a Ballistic Recovery Systems, Inc. (BRS) emergency parachute recovery system installed in the rear baggage compartment. Two days before the accident flight, the pilot fueled the airplane with 18.79 gallons of 100LL aviation fuel. The airplane held a total of 30 gallons of fuel between two wing tanks, 28 gallons of which were usable. The pilot then conducted a 20-minute local solo flight. The airplane was not flown again until the day of the accident. The AMD Pilot Operating Handbook (POH) for the accident airplane make and model specified the following approach and prelanding procedures: Auxiliary Fuel Pump…ON Mixture……………….RICH Carburetor Heat…….ON Flaps…………….. … AS Required Speeds………………. As Required Harness………………Tight Lights………………. As Required The Emergency Procedures section of the POH stated: Engine roughness is usually due to carburetor icing, which is indicated by a drop in RPM, and may be accompanied by a loss of airspeed or altitude. If too much ice is allowed to accumulate, restoration of full power may not be possible; therefore, prompt action is required. Pull carburetor heat on. RPM will decrease slightly, and roughness will increase. Wait for a decrease in engine roughness and increase in RPM, indicating ice removal. Additionally, the POH described expanded procedures in the event of an engine power loss during takeoff: Any turn will increase the risk of a stall or stall spin, fatal at low altitude. Land as straight ahead as practical and maintain a safe airspeed and make only very shallow turn if necessary, to avoid obstructions… METEOROLOGICAL INFORMATIONAt 1153, the weather conditions reported at Elmira/Corning Regional Airport (ELM), 32 miles northwest of N27, included a clear sky, wind from 230° at 7 knots, 10 statute miles visibility, temperature 28°C, dew point 19°C, and an altimeter setting of 30.07 inches of mercury. An FAA carburetor icing probability chart indicated that the temperature and dew point conditions were in the area of the chart that was conducive to the formation of serious icing at descent power and light icing at cruise or descent power. AIRPORT INFORMATIONThe airplane was issued a special airworthiness certificate for S-LSA on July 18, 2007. According to FAA airworthiness records, the pilot purchased the airplane on January 6, 2014. The airplane was an all-metal, side-by-side, two-seat, fixed landing gear airplane equipped with a Continental O-200, 100-horsepower engine driving a Sensenich two-bladed wooden propeller. According to the airframe maintenance logbook, the most recent condition inspection was performed on September 16, 2016, at 264.7 total airframe hours and no discrepancies were noted. The previous condition inspection was conducted on August 15, 2015, at 258.2 total airframe hours and no discrepancies were noted. On July 5, 2013, an oil analysis was conducted, and the findings indicated wear consistent with normal operation. The airplane was equipped with a Ballistic Recovery Systems, Inc. (BRS) emergency parachute recovery system installed in the rear baggage compartment. Two days before the accident flight, the pilot fueled the airplane with 18.79 gallons of 100LL aviation fuel. The airplane held a total of 30 gallons of fuel between two wing tanks, 28 gallons of which were usable. The pilot then conducted a 20-minute local solo flight. The airplane was not flown again until the day of the accident. The AMD Pilot Operating Handbook (POH) for the accident airplane make and model specified the following approach and prelanding procedures: Auxiliary Fuel Pump…ON Mixture……………….RICH Carburetor Heat…….ON Flaps…………….. … AS Required Speeds………………. As Required Harness………………Tight Lights………………. As Required The Emergency Procedures section of the POH stated: Engine roughness is usually due to carburetor icing, which is indicated by a drop in RPM, and may be accompanied by a loss of airspeed or altitude. If too much ice is allowed to accumulate, restoration of full power may not be possible; therefore, prompt action is required. Pull carburetor heat on. RPM will decrease slightly, and roughness will increase. Wait for a decrease in engine roughness and increase in RPM, indicating ice removal. Additionally, the POH described expanded procedures in the event of an engine power loss during takeoff: Any turn will increase the risk of a stall or stall spin, fatal at low altitude. Land as straight ahead as practical and maintain a safe airspeed and make only very shallow turn if necessary, to avoid obstructions… WRECKAGE AND IMPACT INFORMATIONThe airplane impacted steep, wooded terrain in an inverted attitude about 1 1/2 miles from the departure end of runway 23. All major components of the airplane were accounted for at the scene. The forward fuselage, cockpit, and instrumentation were consumed by postimpact fire. Both wings were separated from the fuselage but were found in the immediate vicinity of the accident site. The empennage impacted a tree. The carburetor heat controls could not be examined due to impact and fire damage. Control continuity was established from the cockpit to the flight control surfaces through several breaks consistent with overload separation and cuts made by first responders. Continuity of the fuel system could not be confirmed. Both fuel tanks were breached; the right fuel tank exhibited thermal damage and the left fuel tank was heavily impact damaged. The fuel selector valve and fuel lines were damaged by impact forces and the postimpact fire; the selector position could not be determined. The engine remained attached to its mounts and was found inverted. It exhibited postimpact fire and impact damage but remained largely intact. All cylinders remained attached to the crankcase. The engine could not be rotated by hand via the propeller hub or through the accessory section. The accessories were removed and the engine crankcase was opened to expose the crankshaft, camshaft, and valvetrain, revealing seized lifters consistent with exposure to high temperatures. There were no pre-impact anomalies noted with the crankshaft. The camshaft remained intact and displayed thermal damage consistent with the post-impact fire. All four pistons and their respective connecting rods showed normal wear and all overhead components (valves, valve springs, and rocker arms) displayed normal operating and lubrication signatures. The Nos. 1 through 4 main bearings showed discoloration consistent with a post-impact fire; no anomalies were noted. Several ounces of oil drained from the engine during the examination and all internal engine components appeared lubricated. The left and right magnetos remained attached to their installation points and displayed thermal and impact damage. The ignition harness displayed impact and thermal damage to all ignition leads. The left and right magnetos did not produce spark at the leads when rotated; the housings of both magnetos were thermally damaged and partially melted and the internal gears of both magnetos indicated damage when rotated. All spark plugs remained installed in their cylinders. The top spark plugs were automotive style plugs and the bottom plugs were aviation plugs. When compared to the Champion Check-a-Plug chart, both sets of spark plugs and their respective electrodes displayed normal wear and signatures, although the top spark plugs were covered with oil consistent with the engine's inverted position following the accident. The carburetor was removed for examination; it was thermally damaged. Both carburetor floats were melted and had separated from their attach points consistent with a post-impact fire. The needle valve remained intact and was capable of normal operation when manually operated. The fuel inlet screen was clear of any contaminants. There were no mechanical anomalies noted with the carburetor. The fuel pump was damaged by impact and fire; it was partially melted and deformed. The oil filter was disassembled; the internal paper filter was damaged by heat and was heavily carbonized. No metal or ferrous material was found internally. The oil filter screen was clear and free from obstructions and no anomalies were noted. The oil sump remained attached and displayed impact and thermal damage. There were no anomalies noted with the oil sump. The oil pump was capable of rotation and displayed no anomalies. The exhaust system displayed impact and thermal damage signatures. There were no signs of exhaust leaks. The propeller displayed thermal and impact damage. One of the propeller blades fractured from the hub and was found 25 ft from the main wreckage. The second blade was destroyed by fire. The blade hub was exposed to significant heat and was heavily charred. The BRS emergency airframe parachute deployed and was found immediately adjacent to the wreckage. The envelope was partially opened and suspended on tree branches about 40 ft above the ground. The suspension lines were connected to the parachute and suspended against several nearby trees and were damaged by heat. The BRS container was destroyed by impact forces and heat. Impact and fire damage to the cockpit precluded examination of the BRS handle. MEDICAL AND PATHOLOGICAL INFORMATIONThe Lourdes Hospital Department of Pathology, Binghamton, New York, performed an autopsy on the pilot and the report stated that the cause of death was severe thermal injury. A pacemaker was identified in the pilot's chest, but no data was recovered from the device. The pilot's heart was enlarged at 640 gm. Average for a man of his weight is 345 gm with a range of 261-455 gm. In addition, there was evidence of a surgical aortic valve replacement, but no evidence of coronary artery disease. The FAA Forensic Sciences Laboratory performed toxicology testing on specimens from the pilot. The testing identified minoxidil in the urine but not in blood. Minoxidil is an antihypertensive drug which, when used topically, may cause hair re-growth. It is not generally considered impairing. Additional toxicology testing by NMS Laboratories, Willow Grove, Pennsylvania, identified caffeine and 5% carboxyhemoglobin.

Probable Cause and Findings

A partial loss of engine power for reasons that could not be determined based on the available information, and the pilot's exceedance of the airplane's critical angle of attack during an attempted return to the airport, which resulted in an aerodynamic stall and loss of control. Contributing to the accident was the pilot's decision to return to the airport following a partial loss of engine power.

 

Source: NTSB Aviation Accident Database

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