Aviation Accident Summaries

Aviation Accident Summary ERA22FA233

Wayne, NE, USA

Aircraft #1

N76075

CESSNA 140

Analysis

The accident pilot had planned to participate in an aviation event that involved a form of air racing called short takeoff and landing drag racing (STOL Drag). On the day of the accident, in the afternoon, the aviation event was supposed to begin with STOL Drag qualification racing; however, the air racing was postponed to the following day due to gusting wind conditions that were oriented in an unfavorable direction relative to the orientation of the racecourse. After the postponement decision was made, several of the competing pilots expressed a desire to perform traditional STOL (without any drag racing component) on a grass runway where a more favorable, but gusty, headwind prevailed. A safety briefing was held with representatives of the event organizer, Federal Aviation Administration (FAA) inspectors who were on site to supervise the STOL Drag event, and pilots who planned to fly in the traditional STOL. A representative of the STOL Drag event organizer informed the pilots that the flying was optional, and it was not a part of the formal air race competition. To limit traffic pattern congestion, multiple groups of 5 airplanes were organized. According to witnesses and video/photographic evidence, the accident airplane was the last airplane within a group of 5, and all 5 airplanes had each performed two landings without incident. During the third approach, while the accident airplane was on final approach following a slower airplane ahead also on final approach, the accident airplane descended and appeared to be lower than the airplane ahead of it. Subsequently, the accident airplane’s pitch attitude increased, it rolled to the right, completed a 3/4-turn right spin, and impacted terrain in a near-vertical attitude. Postaccident examination of the airframe and engine found no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Based on this information, it is likely that the accident pilot allowed the airplane to exceed its critical angle of attack while on final approach and the airplane entered an aerodynamic stall and spin at too low an altitude to successfully recover. The strong, gusting wind conditions increased the likelihood of a sudden increase in angle of attack as the pilot approached the runway at a slow speed, already operating near the airplane’s critical angle of attack. The evidence further showed that the accident pilot turned onto final approach early and, as a result, may have been altering his approach path and speed to maintain spacing behind the slower airplane ahead. If the pilot observed his airspeed decaying, given the lack of spacing ahead, adding engine power and/or increasing airspeed would only exacerbate the already close spacing with the airplane ahead. In this case, the only alternative would have been for the pilot to execute a go-around. Additionally, review of high-resolution photographs showed no evidence that the airplane’s flaps had been extended on final approach, despite having used flaps for the prior landings. Data from the airplane’s operations manual showed that extending the flaps would result in the airplane’s stall speed being about 5 mph slower, all other factors being equal. It could not be determined whether the pilot inadvertently forgot to extend the flaps during the landing attempt or had chosen not to extend them due to the gusting wind conditions. The pilot’s loss of control occurred during non-traditional traffic pattern operations, and other factors may also have contributed to the pilot’s loss of control in flight. The pilot was flying an approach in which his touchdown and landing distance would be measured and judged by spectators and fellow pilots. Regardless of whether the STOL activity being conducted at the time of the accident was part of an official competition, it is likely that the pilot’s approach was influenced by the competitive environment. The gusting wind should have resulted in the pilot increasing the airplane’s speed on final approach; however, doing so would conflict with the desire to perform a competitive STOL landing. Additionally, while the accident pilot had completed STOL Drag training and was certified to compete in STOL Drag racing, no training was required of the pilots participating in the impromptu traditional STOL operations, which was a characteristically different flight activity as compared to STOL Drag racing in which airplanes do not exit ground effect. An FAA-issued a Certificate of Waiver (CoW), outlined several exceptions to aviation regulations that were required in order to conduct the STOL Drag event. The CoW, in addition to a National Air Race Accreditation Letter and associated policies and procedures, incorporated risk mitigations that included a variety of elements, such as requirements for pilot training and certification, as well as operational wind limitations; however, these risk management controls were not present for the impromptu traditional STOL operations in which the accident pilot was participating. Had risk mitigations like those that were planned for the STOL Drag event been in place and adhered to by the event organizers and the FAA personnel present, it is possible that the accident could have been avoided.

Factual Information

HISTORY OF FLIGHTOn May 20, 2022, about 1842 central standard time, a Cessna 140 airplane, N76075, was substantially damaged when it impacted terrain near the Wayne Municipal Airport (LCG), Wayne, Nebraska. The private pilot was fatally injured. The airplane was operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. According to a representative with STOL Drag Events LLC, who was a participant organization in the 2022 Wayne County Mayday STOL Drag Races, the day before the accident the event began with short takeoff and landing drag racing (STOL Drag) training. The course was oriented to parallel runway 5-23 at LCG. On the day of the accident, additional STOL Drag training had been completed in the morning and qualifying STOL Drag races were planned for the afternoon. However, due to the northwest gusting winds, the qualifiers were postponed until the next day. After the postponement decision was made, several of the competing pilots expressed a desire to perform traditional STOL (without any drag racing component) on the grass runway 31, given the favorable headwinds. A safety briefing was held with STOL Drag representatives, FAA inspectors who were present to provide oversight of the aviation event, and pilots who planned to fly in the traditional STOL. A representative with STOL Drag informed the pilots that the flying was optional and not a part of the formal STOL Drag competition. In order to limit pattern congestion, multiple groups of 5 airplanes were organized. According to multiple witnesses and video/photographic evidence, the accident airplane was the last airplane within the third group of 5 airplanes, and each of the airplanes in that group had performed two landings without incident. During the third approach, with the accident airplane on final approach and following a Zenith STOL 701, the accident airplane descended and appeared to be lower than the airplane ahead. Subsequently, the pitch attitude increased, the airplane rolled to the right, completed a 3/4-turn right spin, and impacted terrain in a near-vertical attitude. Figure 1 depicts a series of four photographs taken by a witness during the approach and descent toward impact, with the accident airplane circled in red. Figure 1: Four photographs showing the right roll and descent. The STOL Drag representative who coordinated the traffic pattern operations over the radio, and who was standing near the runway threshold when the accident occurred, reported that about 45 seconds before the accident, he stated over the radio to the accident pilot, “lower your nose you look slow.” From his view, the accident airplane turned final approach early and appeared slow. About 15 seconds before the airplane’s roll and descent, he stated again to the accident pilot, “lower your nose.” There were no communications received from the accident pilot and none of the other pilots in the pattern were talking on the radio around the time of the accident. The pilot of the Zenith airplane who was ahead of the accident airplane on final approach reported that his approach speed on final approach was about 50 MPH. He recalled that although the wind during the approach to land was gusting, it was not any different on the accident approach than it had been during the previous two approaches. PERSONNEL INFORMATIONReview of the accident pilot’s logbook revealed that he had accumulated about 310 hours of flight experience in tailwheel-equipped airplanes, with the majority of the flight experience taking place in the accident airplane. On October 16, 2021, while attending the STOL Drag Events LLC. High Sierra Fly-in event, the pilot was issued a letter from the STOL Drag Chief Flight Instructor denoting that he had satisfactorily completed the STOL Drag training course and had full permission to participate at any sanctioned STOL Drag Events LLC race event. The letter was valid for 24 months and the pilot subsequently competed in the STOL Drag racing at the High Sierra event. AIRCRAFT INFORMATIONThe airplane’s operation manual provided a stalling speed table (Figure 2) for pilot reference. The manual also suggested that a glide speed to landing should be 65-70 MPH. Figure 2: Stall speed table provided within the airplane operating manual. Review of several videos and photographic evidence showed no sign that the flaps had been extended on the accident final approach. The video also showed the flaps were utilized for a previous landing. Per the airplane’s stall speed table, this would have resulted in a stall speed between about 49 to 40 MPH dependent upon the pilot’s application of engine power. METEOROLOGICAL INFORMATIONAbout the time of the accident at the airport, an hourly observation reported that wind was from 290° at 15 knots, gusting to 21 knots, which was consistent with witness video that showed the movement of tall flags positioned at the runway threshold. The video showed that the gusting wind varied from about 290° to a direction nearly aligned with runway 31. AIRPORT INFORMATIONThe airplane’s operation manual provided a stalling speed table (Figure 2) for pilot reference. The manual also suggested that a glide speed to landing should be 65-70 MPH. Figure 2: Stall speed table provided within the airplane operating manual. Review of several videos and photographic evidence showed no sign that the flaps had been extended on the accident final approach. The video also showed the flaps were utilized for a previous landing. Per the airplane’s stall speed table, this would have resulted in a stall speed between about 49 to 40 MPH dependent upon the pilot’s application of engine power. WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest about 1,600 ft from the runway 31 threshold and about 250 ft right of the extended centerline. During a postaccident examination, flight control continuity was established from the cockpit to the corresponding control surface with no preimpact anomalies noted. Fuel remained in both wings. The flap position and flap handle could not be correlated to a flap setting position due to impact-related damage. The engine had crushed rearward into the cockpit. The airspeed indicator needle was found indicating about 57 MPH and a rub mark at this speed was observed on the face of the instrument. Examination of the engine found no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The airplane was not equipped with shoulder harnesses. ORGANIZATIONAL AND MANAGEMENT INFORMATIONFAA Certificate of Waiver Review of the STOL Drag Events LLC. organization website found that they conducted multiple STOL Drag Racing events around the country yearly, and as of this writing, continue to conduct air race events. This was the second STOL Drag event held at LCG, with the first event occurring April 28 - May 1, 2021. In a letter from the FAA, dated April 26, 2021, and signed by the manager of the FAA Flight Standards Technical Branch (AFS-840), STOL Drag Events LLC. was qualified to be the responsible person of a STOL Drag race event and was allowed to apply for a Certificate of Waiver (CoW) using FAA Form 7711-2, Application for a Certificate of Waiver or Authorization of an Aviation Event. The letter also established that STOL Drag Events LLC was accredited to act as an air race organization. The STOL Drag Events LLC. accreditation and air racecourse approval letter were effective April 28, 2021, and valid through April 30, 2023. On April 14, 2022, the Lincoln, Nebraska FAA Flight Standards District Office (FSDO) issued a CoW to STOL Drag Events LLC. as part of the 2022 Wayne County Mayday STOL Drag aviation event. The waiver outlined specific Federal Aviation Regulations that were to be waived and noted operations authorized in accordance with operational policies submitted by STOL Drag. The FAA CoW was effective from 0900 local May 19, 2022, to 1500 May 22, 2022 and a schedule of waiver periods was outlined for the entire weekend of activities. On the day of the accident, the waiver time was scheduled from 0800 to 1900, with qualification racing scheduled as a waivered event from 1600 to 1900. A corresponding NOTAM had closed the airport until 1901, which remained published at the time of the accident, in addition to the runway 31 closure NOTAM. Review of the FAA CoW and the attached document found no authorization, operational procedure, or policies for traditional STOL operations to be conducted during the aviation event. Two specific regulations were waived as part of the CoW: 91.119(c) Minimum Safe Altitudes Federal regulation 91.119(c), minimum safe altitudes, stated in part that, except when necessary for takeoff or landing, no person may operate an aircraft below certain altitudes. Section c stated that, over other than congested areas, an altitude of 500 feet above the surface must be maintained, except over open water or sparsely populated areas. In those cases, the aircraft may not be operated closer than 500 feet to any person, vessel, vehicle, or structure. 91.126(b)(1) Operating on or in the vicinity of an airport in Class G Airspace Federal regulation 91.1269(b)(1) required in part that pilots in class G airspace make all turns to the left in the vicinity of the airport unless specific signage or lights at the airport requires turns to the right. The accident airport had no such signage or lights that the investigation located. According to the president of STOL Drag Events LLC., wind limitations in order to conduct STOL Drag racing were a part of their National Air Race Accreditation letter, which was issued by the FAA. During the accident day, he reported that crosswind and tailwind limitations were exceeded. The FAA inspector overseeing the event reported that a 10-knot tailwind limitation had been exceeded to conduct STOL Drag racing. As part of the accreditation letter, STOL Drag Events LLC., was given the authority to conduct STOL Drag racing flight training and issue and sign air race pilot certificates for competing pilots, which was a requirement of pilots in order to fly in the races. Traditional STOL Preflight Briefing According to the president of STOL Drag Events LLC, following the postponement of the STOL Drag qualifiers, several competition pilots asked whether they could fly traditional STOL on the grass runway 31, given the favorable headwinds. About 1630, a pilot briefing was led by the STOL Drag Events LLC president. According to a statement provided by him, “STOL Drag LLC made it very clear during that briefing, with all pilots and the FAA in attendance, that this was flying at your own risk and the event was over for the day. The pilot group decided to organize a short take-off and landing practice session.” During additional interviews with the president of STOL Drag Events LLC, he reported that he stated during the pilot briefing that “STOL Drag is done for the day” and repeated that the traditional STOL flying was voluntary and not a part of any official competition. He subsequently organized four groups of five airplanes on a sheet of paper, in order to limit the number of aircraft in the traffic pattern at one time. It was his view that, if he did not help with this group organization, all of the airplanes would have attempted to fly at the same time. The accident pilot was placed in group three of four, and he was the last airplane in the group. The president of STOL Drag Events LLC reported that traditional STOL was not planned as part of the event program nor was traditional STOL commonly performed at other STOL Drag Events. He further reported that in attendance at the traditional STOL pilot briefing was the FAA inspector-in-charge (IIC), two additional FAA inspectors, and airport authority personnel. The president of STOL Drag Events LLC., reported that the FAA IIC approved traditional STOL to be conducted during the scheduled/waivered airport closure period. Additionally, he stated that the FAA IIC told him, “the waiver and the NOTAM [are] protecting you guys. yeah go fly.” The president explained that the NOTAM and waiver was valid until 1900 and that the FAA IIC was not going to allow the flight activity to go beyond 1900. Traditional STOL Operations The president of STOL Drag Events LLC coordinated the right traffic pattern operations over the radio standing near the runway threshold. The runway 31 boundaries had been altered from their normal length and width with a new white line threshold and cones (figure 3). Figure 3: Additional view of runway 31 and airplane’s arriving, about 30 seconds prior to the accident. Video of the traditional STOL operations showed individuals, one with a jacket with a “STOL Drag” logo completing measurements after STOL attempts. According to the president of STOL Drag Events LLC., “generic measurements” were being taken during the traditional STOL and the activity was not a part of any official planned competition. Witness video and photo evidence captured the accident pilot’s takeoff attempts. The video also showed the location of the crowd and car lines paralleling the runway on the airport property (figure 4). Figure 4: View of the accident airplane’s takeoff and crowd line at the aviation event. According to the president of STOL Drag Events LLC., the FAA IIC supervised the traditional STOL operations. During the traditional STOL, a representative with STOL Drag Events requested permission from the FAA IIC to continue traditional STOL past 1900 shortly before the accident occurred, however, the FAA IIC verbally denied this request. FAA Inspector-in-Charge The FAA IIC supervising the STOL Drag event reported that the aviation event was no longer taking place at the time of the accident. He reported that the 10-knot tailwind that would have been present on the 05-23 oriented racecourse was the reason that the STOL Drag racing was postponed. The FAA IIC reported that he attended the pilot briefing preceding the traditional STOL operations. He recalled that STOL Drag representatives postponed the waivered event and then they decided to conduct traditional STOL on runway 31. He could not recall agreeing or disagreeing with these decisions. The FAA IIC further added that he was asked by STOL Drag representatives shortly before the accident occurred, to continue traditional STOL operations beyond 1900 local (which was the end of the originally scheduled waiver and airport closure period), and he said no to this request.

Probable Cause and Findings

The pilot’s exceedance of the airplane’s critical angle of attack on final approach while conducting traditional short takeoff and landing operations in gusting wind conditions, which resulted in an aerodynamic stall and spin from which the pilot could not recover. Contributing to the accident was the competitive environment, which likely influenced the pilot’s approach speed and the subsequent loss of control.

 

Source: NTSB Aviation Accident Database

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