A summary of this weeks activity and downloadable files of new reports published by the self-proclaimed, “world’s premier independent agency for accident investigation.”

TOTAL PRESS RELEASES ISSUED THIS WEEK – 2

TOTAL AVIATION SAFETY RECOMMENDATION LETTERS ISSUED THIS WEEK – 0

TOTAL AVIATION MISHAP REPORTS ISSUED THIS WEEK – 43

• New reports released this week – 43
• Revised reports released this week – 0

AVIATION PRELIMINARY REPORTS RELEASED THIS WEEK – 22 – AVERAGE LATENCY 12 DAYS

AVIATION FACTUAL REPORTS RELEASED THIS WEEK – 14

• Field Investigations (NTSB) – 1 (7%) – AVERAGE LATENCY 452 DAYS AFTER EVENT
• Limited Investigations (delegated to FAA) – 9 (64%) – AVERAGE LATENCY 249 DAYS AFTER EVENT
• Data collection reports (CA) – 3 (21%) – AVERAGE LATENCY 272 DAYS AFTER EVENT
• Incident report (IA) –  0 (0%)
• Other (public use, foreign, etc.) – 1 (7%)
• Number of factual reports more than one year old issued this week – 5

REPORTS OF PROBABLE CAUSE RELEASED THIS WEEK – 6 NEW – 0 REVISED

SUMMARIES OF NEW REPORTS:

• List of Newly Released Reports
• Air Carrier, Turbine Powered & Large Aircraft Reports
• General Aviation Reports
• Homebuilt, Experimental, or Light Sport Aircraft

REPORTS OF THE WEEK (See the above links for more details)

This has to be one of the best factual (albeit misleading) reports we’ve ever seen and we hereby present:

The Obfuscation and Misdirection Award
(with silver BS device for deceptive marketing)

WPR11FA093  PIPER PA46-500TP
“On January 9, 2011, at 1358 mountain standard time, a Piper PA-46-500TP, single-engine turboprop airplane, N5365D, sustained substantial damage following a loss of directional control and subsequent runway excursion during landing roll at Phoenix Sky Harbor International Airport (KPHX), Phoenix, Arizona. The private pilot and three passengers were not injured. “

The Piper PA46 series of aircraft are known for their minor vice of running off the side of the runway – loss of directional control. No big deal as they are rarely fatal.

In our database of nearly five hundred PA46 mishaps from around the world, we have found 63 of these loss of directional control events – 13% of the events.  Some of these events are, of course, due to fumble footed pilots, but these aircraft are known for two problems affecting the nosewheel steering – steering horns that bend and cracked engine mounts.  There are quite a number of Service Difficulty Reports and accident reports on these problems, if anyone cared to look.

So in an effort to get to the bottom of this problem once and for all – let’s remember they haven’t solved the PA46 in-flight breakup mystery, yet – the NTSB conducted a full-fledged field investigation of this mishap.  (VERY unusual for a non-fatal event.)  The IIC and two representatives from Piper declared themselves to be the “Structures Group” and prepared a full report.  To no one’s surprise, they found no defect in design and no failed parts.  Gotta be the pilot’s fault for going on the weed tour, right?. 

Here’s a link to the Piper Customer Information Letter included in the NTSB docket:

In apparently responding to “customer concerns” about nose gear steering, Piper not only avoided mention of the known problems in the system, they managed to make their “fix” sound like a product improvement.  Here’s some highlights:

“Some Piper customers have expressed concerns about the nose gear steering on the PA46 “Malibu” series of aircraft models. This document explains Piper’s response to those concerns and provides specific actions that owners can take to ensure that their aircraft continues to operate properly and conform to factory specifications. ….

When the Meridian was first introduced in 2000, some of these early customers reported an occasional pull to the right at the instant of touchdown. Piper immediately began an extensive testing program in an effort to understand this phenomenon. Although Piper was unable to duplicate the reported condition (either then or since, under varied and extreme conditions), analysis of the test data, combined with research into the dynamic behavior of the steering geometry, has resulted in a two-fold design improvement to the Meridian in 2002 which allows the pilot to better control the steering forces involved:

• • A higher tire pressure was used to reduce the size of the rolling contact patch, thereby reducing the magnitude of the steering forces. An 8-ply tire inflated to 70 psi replaced a 6-ply tire inflated to 50 psi….”

That’s right – to keep pilots from running off the side of the runway, Piper has reduced the ability of the nosewheel to steer the aircraft.  And they call it a “design improvement.” 

And they closely inspected the nose gear to insure design conformity, but failed to validate the design.  Genius.  Brilliant marketing.

The full docket file is available here.

A summary of this weeks activity and downloadable files of new reports published by the self-proclaimed, “world’s premier independent agency for accident investigation.”

TOTAL PRESS RELEASES ISSUED THIS WEEK – 2

TOTAL AVIATION SAFETY RECOMMENDATION LETTERS ISSUED THIS WEEK – 0

TOTAL AVIATION MISHAP REPORTS ISSUED THIS WEEK – 85

• New reports released this week – 80
• Revised reports released this week – 5

AVIATION PRELIMINARY REPORTS RELEASED THIS WEEK – 18 – AVERAGE LATENCY 12 DAYS

AVIATION FACTUAL REPORTS RELEASED THIS WEEK – 32

• Field Investigations (NTSB) – 9 (28%) – AVERAGE LATENCY 555 DAYS AFTER EVENT
• Limited Investigations (delegated to FAA) – 10 (31%) – AVERAGE LATENCY 387 DAYS AFTER EVENT
• Data collection reports (CA) – 11 (34%) – AVERAGE LATENCY 36 DAYS AFTER EVENT
• Incident report (IA) –  0 (0%)
• Other (public use, foreign, etc.) – 2 (6%)
• Number of factual reports more than one year old issued this week – 14

REPORTS OF PROBABLE CAUSE RELEASED THIS WEEK – 31 NEW – 0 REVISED

 SUMMARIES OF NEW REPORTS:

• List of Newly Released Reports
• Air Carrier, Turbine Powered & Large Aircraft Reports
• General Aviation Reports
• Homebuilt, Experimental, or Light Sport Aircraft

REPORTS OF THE WEEK (See the above links for more details)

Shades of things to come?  Bring on the drones.
CEN10LA487 SHPAKOW THOMAS SA 750
On August 14, 2010, approximately 1100 mountain daylight time, N28KT, a Shpakow SA 750 bi-plane, was substantially damaged when it collided with a radio controlled AJ Slick airplane, while performing a go-around at the Van-Aire Estates Airport (CO12), Brighton, Colorado.  The pilot and his passenger were not injured.

A nicely done investigation demonstrating how everyone thinks the system works.  An attaboy to the IIC.
WPR10LA121 AMERICAN CHAMPION AIRCRAFT 8KCAB      
In the RECOMMENDATION section of the National Transportation Safety Board (NTSB) accident reporting form, the CFI reported that the front seat 5-point Hooker Aerobatic harness had a tendency to drape itself over the right rear cockpit rudder/brake pedal assembly. He stated that this could have caused the right brake to be inadvertently activated when full left rudder was applied.

FAA inspectors from the Chicago Aircraft Certification Office visited both American Champion in Rochester, Wisconsin, and Gauntlet Warbirds, in Aurora, Illinois, to review possible rudder interference by the lap belt installation on the 8KCAB model airplane. They found that the lap belts typically cleared the rudder pedals by less than 1 inch. Factors that affected the clearance included seat cushion padding, physical size of the pilot, centering of the belt cushion on the pilot, and tightness of the lap belt when secured. As a result of that review, an Airplane Flight Manual Supplement (AFMS) was issued by American Champion, and approved by the FAA. It called for both a pre start and pre flight check of the lap belts for proper tension and clearance from the aft seat rudder pedals. The FAA also issued a Special Airworthiness Information Bulletin (SAIB CE-10-39, dated July 23, 2010. The SAIB notified pilots of the AFMS issuance. It also recommended that airplanes equipped with the Hooker Aerobatic dual lap belts use floor mounted attach lugs. The upper or secondary lap belt should be moved from the outside of the outer attach lug to the inside of the outer attach lug per a service bulletin in order to provide additional clearance between the belt and pedal assembly.

Oops – removed three out of four tiedowns
CEN12CA191 BELL 206L-3
The helicopter was tied down overnight on the helideck of an offshore oil platform. The pilot stated the helicopter preflight had been completed hours prior to the first flight. During the walk-around prior to the first flight of the day, he overlooked the right rear tie-down which was one of four connected to the fuselage. The pilot attempted to takeoff with the tie-down still attached to the helicopter which resulted in a dynamic rollover. The helicopter remained on the helideck. Substantial damage resulted to the tailboom and the right side of the helicopter.

Oops – forgot the caps
CEN12LA094 CESSNA 305
The pilot reported that he had placed the caps on the fuel vent lines to keep insects out of the lines and the fuel tanks and forgot to remove them during his preflight inspection.

So where did the contaminants come from?  Why bother with a half-fast report?
CEN10LA494 CESSNA 310F
The right engine was removed from the airplane and shipped to Teledyne Continental Motors, Mobile, Alabama, where it underwent an engine run under the supervision of the National Transportation Safety Board Investigator-in-Charge for the accident investigation. Prior to the engine run, the fuel control unit screen was removed and noted to contain contaminants that were consistent with cloth/fabric fibers. The fuel servo screen was reinstalled without removal of the fuel control unit screen contaminants. A test club propeller was installed onto the engine for the test.

Interesting report on an aircraft tanked for a trans-Pacific ferry flight
WPR11FA059 MOONEY M20R      
On November 25, 2010, at 0628 Pacific standard time, a Mooney M20R, Australian registration VH-PPA, collided with terrain in a plowed field shortly after takeoff from Hollister Municipal Airport (CVH), Hollister, California. Australian Air Ferry Pty Ltd operated the airplane under the provisions of Title 14 Code of Federal Regulations Part 91, as a trans-Pacific ferry flight. The certified airline transport pilot sustained fatal injuries, and the airplane sustained substantial damage. The flight departed Hollister about 0624, with a planned destination of Honolulu International Airport (HNL), Honolulu, Hawaii. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed.

A summary of this weeks activity and downloadable files of new reports published by the self-proclaimed, “world’s premier independent agency for accident investigation.”

TOTAL PRESS RELEASES ISSUED THIS WEEK – 1

TOTAL AVIATION SAFETY RECOMMENDATION LETTERS ISSUED THIS WEEK – 0

TOTAL AVIATION MISHAP REPORTS ISSUED THIS WEEK – 62

• New reports released this week – 61
• Revised reports released this week – 1

AVIATION PRELIMINARY REPORTS RELEASED THIS WEEK – 11 – AVERAGE LATENCY 10 DAYS

AVIATION FACTUAL REPORTS RELEASED THIS WEEK – 23

• Field Investigations (NTSB) – 2 (9%) – AVERAGE LATENCY 731 DAYS AFTER EVENT
• Limited Investigations (delegated to FAA) – 10 (44%) – AVERAGE LATENCY 258 DAYS AFTER EVENT
• Data collection reports (CA) – 4 (17%) – AVERAGE LATENCY 52 DAYS AFTER EVENT
• Incident report (IA) –  1 (4%)
• Other (public use, foreign, etc.) – 6 (26%)
• Number of factual reports more than one year old issued this week – 4

REPORTS OF PROBABLE CAUSE RELEASED THIS WEEK – 28 NEW – 0 REVISED

SUMMARIES OF NEW REPORTS:

• List of Newly Released Reports
• Air Carrier, Turbine Powered & Large Aircraft Reports
• General Aviation Reports
• Homebuilt, Experimental, or Light Sport Aircraft

REPORTS OF THE WEEK (See the above links for more details)

Interesting Report Format – Russian Helicopters Operating on FAA 135 Certificate – Twelve Year Investigation
IAD99GA036  MI-8MTV-1
INTERNATIONAL CHARTER INC. OF OREGON, Mi-8MTV-1, RA-25464, PORT-AU-PRINCE
On March 14, 1999, about 1945, a Mil Mi-8MTV-1, registration RA-25464, operated by International Charter Inc., of Oregon (ICI), impacted mountainous terrain, 15 miles west-southwest of Hinche, Haiti.  The flight had a dual mission of emergency medical evacuation (medevac) pickup, and the transport of maintenance and security personnel to assist a sister helicopter, RA-25463 (RA-63). All 13 persons on board RA-64 sustained fatal injuries. ICI, in contract with Vladivostok Air (V/A), provided two Mi-8 helicopters in Haiti, and flight and maintenance personnel. The operator was brought to Haiti by letter of agreement between the U.S. Embassy and the Haitian government, to replace CH-47 Chinook helicopters in a transport mission. ICI held FAA certificate number 17CA0811, effective January 8, 1998, and was certified to operate as an “air carrier and conduct common carriage operations,” in accordance with 14 CFR Part 135. The Mi-8s were certified in Russia for flight and maintenance in accordance with Russian Civil Aviation Regulation no. 15.07.91r-17.07.91. RA-64 held Airworthiness Certificate no. DB-645, dated March 26, 1998, and was registered in Russia under Certificate of Registration no. 3231, dated April 20, 1998 RA-25464. The flightcrew was comprised of two pilots and a flight engineer (Russian citizens). An ICI corporate officer, who was a U.S. citizen, served as the aviation officer, stationed in the cabin. The passengers consisted of three Russian maintenance personnel (to performance maintenance on RA-63) and six Argentine Gendarmeria security personnel, serving in the United Nations civil police mission to Haiti (MIPONUH). RA-64 was verbally tasked by the tasking officer of the UN mission to Haiti for the emergency medevac. Flight orders for a Canadian utility helicopter squadron, which ICI replaced, were on file at ICI base operations. A specific flight plan was not filed for the accident flight (The operator provided Attachment 3, regarding the flight plan. The attachment outlines a radio check with operations base to “Open my flight plan”).

Nobody Saw Nuttn’ Award – The Wings Were Being Replaced, But No One Could Determine The Extent of the Damage.  (These PA46 Events Don’t Usually End This Well.)
DEN03LA152
On June 13, 2003, approximately 1130 mountain daylight time, a Piper PA-46-500TP, N211EZ, was substantially damaged when it encountered turbulence during descent to Santa Fe Municipal Airport (SAF), Santa Fe, New Mexico. The private pilot and his two passengers were not injured. Unable to determine the extent of damage, the accident was not reported either by the pilot, the airframe manufacturer, or the local FAA Flight Standards District Office. NTSB learned of this accident in a conversation with a local repair facility that was corroborated by the airplane insurance company.  According to the pilot, he was at FL290 and was circumnavigating isolated thunderstorms. Flight Watch informed him of a SIGMET for thunderstorms forming between Colorado and New Mexico. At the suggestion of Flight Watch, the pilot turned toward Tucumcari, New Mexico, but he had to continually change heading due to rapidly developing cells. He did not have enough fuel to fly to Tucumcari, so he pilot elected to divert to Santa Fe, New Mexico. All anti-ice equipment was turned on. During the descent through the clouds, mixed icing started to rapidly accumulate on the aircraft. As the pilot initiated a 180-degree turn to leave the icing conditions, the plane encountered severe downdrafts. The pilot declared an emergency and landed at Santa Fe in visual meteorological conditions without further incident.  Postaccident examination revealed the inboard panels of both bonded wings were wrinkled, necessitating the replacement of the entire wing assembly.

Pretty Tough Airplane – If This Is Substantial Damage, What Would Destroyed Look Like?
ANC10FA100
On August 21, 2010, about 1412 Alaska daylight time, a de Havilland DHC-2 airplane, N9313Z, sustained substantial damage when it impacted ocean water near Katmai National Park, Alaska. Only fragmented portions of the airplane have been found washed up on the ocean shoreline near the presumed crash site. The commercial pilot and three passengers remain missing, and are presumed to have sustained fatal injuries.

Propeller Propping Mishap of the Week
WPR11LA487
On August 17, 2011, about 1500 Pacific daylight time, a two seat tandem seating configuration Piper J3C-65, N3453K, was not damaged during an engine start at the Rohnerville Airport (FOT), Fortuna, California. The commercial pilot and his passenger were not injured and one person assisting in starting the airplane sustained serious injuries. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight.

Stupid Pilot Trick – How to Turn a Problem In To a Disaster Division
WPR12CA102
The pilot reported that while flying, he observed injured snowmobilers waving for help. After radioing for assistance, the pilot gathered emergency supplies from within the airplane and prepared to air drop the supplies to the snowmobilers and configured the airplane for a slow approach over their location. After a successful drop, he applied full power and banked left to avoid terrain. The airplane encountered a downdraft and started to descend with the left wing low. Despite the pilot’s control inputs, the airplane continued to lose altitude until it impacted the glacier below. The airplane’s firewall and both wings were substantially damaged. The pilot reported no mechanical failures or malfunctions that would have precluded normal flight.

A summary of this weeks activity and downloadable files of new reports published by the self-proclaimed, “world’s premier independent agency for accident investigation.”

TOTAL PRESS RELEASES ISSUED THIS WEEK – 1

TOTAL AVIATION SAFETY RECOMMENDATION LETTERS ISSUED THIS WEEK – 0

TOTAL AVIATION MISHAP REPORTS ISSUED THIS WEEK – 79

• New reports released this week – 77
• Revised reports released this week – 2

AVIATION PRELIMINARY REPORTS RELEASED THIS WEEK – 23 – AVERAGE LATENCY 25 DAYS

AVIATION FACTUAL REPORTS RELEASED THIS WEEK – 24

• Field Investigations (NTSB) – 7 (29%) – AVERAGE LATENCY 367 DAYS AFTER EVENT
• Limited Investigations (delegated to FAA) – 9 (38%) – AVERAGE LATENCY 348 DAYS AFTER EVENT
• Data collection reports (CA) – 2 (8%) – AVERAGE LATENCY 32 DAYS AFTER EVENT
• Incident report (IA) –  2 (8%)
• Other (public use, foreign, etc.) – 4 (17%)
• Number of factual reports more than one year old issued this week – 6

REPORTS OF PROBABLE CAUSE RELEASED THIS WEEK – 32 NEW – 0 REVISED

SUMMARIES OF NEW REPORTS:

• List of Newly Released Reports
• Air Carrier, Turbine Powered & Large Aircraft Reports
• General Aviation Reports
• Homebuilt, Experimental, or Light Sport Aircraft

REPORTS OF THE WEEK (See the above links for more details)

A reminder that multiple modifications of an airframe may have unexpected effects
ERA10FA140
On February 15, 2010, about 1542 eastern standard time, a Cessna T337G, N12NA, collided with terrain following an in-flight separation of the outboard section of the right wing while overflying runway 32 at the Monmouth County Executive Airport (BLM), Farmingdale, New Jersey. The three adults and two minors on board were killed. The airplane incurred substantial damage.
During the initial structural examination, fatigue cracks were found in the left wing upper skin which indicated the airplane’s wing was subject to stresses that warranted further investigation. A re-evaluation of the STC’s by the Federal Aviation Administration revealed that revised operating limitations should be disseminated and implemented based on the findings in this investigation.

NEWS FLASH – The birds were here first – don’t expect a NOTOM
DEN08CA143
During initial takeoff climb at 300 feet above ground level (agl) at 140 knots, the pilot noticed a “buzzard” to the front and slightly above the airplane. The pilot lowered the pitch and right wing; however, the “bird folded his wings and dove toward me.” The bird impacted the right wing leading edge. The pilot “conducted a controllability check” and noticed a slight vibration with the right aileron. The pilot continued to Southeast Texas Regional Airport (BPT), Beaumont, Texas, located 56 nautical miles from the departure airport, because BPT had emergency services. The airplane landed uneventfully. Prior to the flight, the pilot was unaware of any reported bird activity in the area.

No word on if there was a cat or duck involved.
CEN11FA417
On June 24, 2011, approximately 1935 eastern daylight time, a Beech A36 single-engine airplane, N88MN, sustained substantial damage when it impacted terrain and a residential garage while maneuvering near Charlevoix, Michigan. The private pilot, one passenger, and one dog sustained fatal injuries, one passenger sustained serious injuries, and one dog was not injured.

The paperwork makes the airplane fly, doesn’t it?
WPR09FA428
On August 30, 2009, about 0927 Pacific daylight time, a Piper PA-22-150 (Tri-Pacer), N2967P, cruised into a mountainside about 1.2 miles south of Canyonville, Oregon. The pilot and passenger co-owned and operated the airplane, and they were killed. According to the Federal Aviation Administration (FAA), neither of the occupants in the airplane held a pilot certificate. Instrument meteorological conditions existed in the vicinity of the accident site, and no flight plan had been filed.

Don’t see many of these at the local FBO
DCA12PA049
On March 6, 2012 at 0914 pacific standard time, an Israel Aircraft Industries (IAI) Kfir F-21C2 single-seat turbojet fighter type aircraft, registration N404AX, operated by Airborne Tactical Advantage Company (ATAC) under contract to Naval Air Systems Command (NAVAIR) as a civil pubic aircraft operation, crashed upon landing at Naval Air Station Fallon, Fallon, Nevada. The sole occupant pilot aboard was killed, and the airplane was substantially damaged by impact forces and fire. The flight had departed Fallon at 0752 the same day, and attempted to return following an adversary training mission. The pilot initiated two Ground Control Approach (GCA) radar approaches to Fallon and then attempted to divert to Reno but was unable to land there as the field was reporting below minimum weather conditions. The pilot then turned back toward Fallon and stated to air traffic controllers that he was in a critical fuel state. The pilot descended and maneuvered first toward runway 31, then toward runway 13. The airplane struck the ground in an open field in the northwest corner of the airport property and impacted a concrete building on the field. Weather at the time of the accident was reported as snowing with northerly winds of 23 knots gusting to 34 knots, and visibility between one-half and one and one-half miles.

Or these
CEN10CA030
Upon touchdown, the World War II era, Curtis Wright P-40E, tailwheel-equipped airplane experienced an uncontrollable swerve as the right main landing gear began to collapse. As the right main gear exited the edge of the runway, the airplane rocked forward onto its nose and the propeller and left wing tip impacted the ground. The airplane rocked back and came to rest partially off the runway in an upright and right wing low position. An examination of the landing gear retraction system revealed that the landing gear handle detent was contaminated with paint. Subsequently, the landing gear handle did not stay in the detent which resulted in the right landing gear downlock pin to partially retract, followed by the partial retraction of the right main landing gear.

Note to self – don’t give bigfoot an airplane ride
CEN11FA433
On June 29, 2011, approximately 1945 central daylight time, a Klemp Challenger II experimental amateur-built airplane, N12911, impacted trees and terrain during a forced landing following a loss of engine power near Neshkoro, Wisconsin.
While maneuvering the airplane for the forced landing to the airstrip, the pilot felt his left rudder pedal pressed to the floor (The front and aft seat rudder pedals are interconnected). The pilot felt the passenger may have been frightened and “froze on the rudder pedal.” The pilot instructed the passenger to release the rudder pedal as the airplane entered into a slip and was losing altitude; however, the passenger did not respond to the pilot. Due to the loss of altitude, the airplane was no longer going to make it to the airstrip, and the pilot then attempted to land off the airstrip with the jammed left rudder. During the landing, the airplane impacted trees and terrain. The airplane came to rest on its right side in tall grass adjacent to trees.