Aviation Accident Summaries

Aviation Accident Summary MIA06LA033

Opa-Locka, FL, USA

Aircraft #1

N86AB

Piper PA-25-235

Analysis

Earlier that day, the pilot reportedly advised several company employees of a discrepancy with the No. 2 position tow-release hook; he was advised to use only the Nos. 1 and 3 positions. The flight departed for the first banner tow flight of the day, returned to the departure airport after flying the banner, dropped it, then picked up a second banner on the No. 3 position. He flew the banner then returned to the departure airport and dropped it with no reported discrepancies. A company employee reported that the pilot released the second banner late and after landing when asked why, the pilot advised him the No. 3 release wasn't working properly. The pilot installed banner tow hooks at the Nos. 1 and 3 positions, and departed to pick up a billboard using the No. 1 position but reported the airplane would not climb, and he released the banner. He then threw out the hook for the No. 3 position, and returned to pick-up the billboard which was set up for an easterly direction. He approached the location at 85 mph, and the climb-out, "...was even worse. I had no thrust or power at all, only the momentum carried me up to 200 [feet] where I leveled off with an airspeed of about 55 mph and noticed low oil pressure while losing altitude." He immediately pulled the No. 3 banner release handle but "everything came out the panel." He then felt "pulled by the tail with no thrust", and braced for impact on the airport property. No ground crew members reported hearing an engine discrepancy during the climb out. Postaccident examination of the airplane revealed the tow rope remained secured to the No. 3 tow-release hook. A safety link designed to break at 650 pounds was installed between the tow-release hook and the tow rope. The operator reported that the safety link will not break due to a "hot hook", or a banner dragging on the ground. Also, the No. 3 banner release handle/cable assembly was separated from the instrument panel and extended into the cockpit approximately 12 inches. The cable was not fractured; the cable housing was secured by a plastic tie-wrap near the pilot's seat, then by 3 adel clamps. The closest adel clamp to the cockpit was located approximately 10 feet aft of the plastic tie wrap. The cable housing was required to be clamped by 6 adel clamps. Postaccident operational testing of the engine revealed it produced approximately 2,400 rpm (near full static) with a serviceable propeller installed. The oil pressure was noted to be in the green arc when operating above 1,700 rpm, but was indicating low with the engine operating at 1,000 and 1,300 rpm. A METAR taken on the airport approximately 5 minutes after the accident indicates the wind was from 270 degrees at 7 knots, though the ground crew set up for an east approach. The operator's "Training Manual & General Operating Procedures" revealed that with respect to "Downwind Pickups", it states, "Downwind pickups are not to be attempted by any pilot at any time! Failure to abide by this rule will result in the pilots' immediate termination!" The training manual also indicates with respect to downwind pickups that if the wind direction changes and, "...your banner is no longer set up into the wind you must land, taxi to the banner area, and help the ground crew realign your banner for an upwind pickup."

Factual Information

On December 18, 2005, about 1248 eastern standard time, a Piper PA-25-235, N86AB, registered to and operated by Aerial Banners, Inc., was substantially damaged during a forced landing shortly after a banner pick-up at Opa-Locka Airport, Opa-Locka, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91, local, banner tow flight from Opa-Locka Airport. The airplane was substantially damaged and the commercial-rated pilot, the sole occupant, sustained minor injuries. The flight originated about 15 minutes earlier from Opa-Locka Airport. The pilot stated in writing that before the first flight of the day he mentioned to another employee of Aerial Banners, Inc., that he previously had a "hot hook" at the No. 2 position because it would not release. The other employee recommended that he use only the Nos. 1 and 3 positions. The pilot also reportedly brought this to the attention of another company employee who was busy but concurred with the recommendation to only use the Nos. 1 and 3 positions. He installed a grappling hook at all 3 positions, then departed and flew to the Opa-Locka Airport (KOPF) where he landed, and fueled the airplane. After fueling he checked the fuel tank and gascolator for contaminants; none were reported. The flight departed from KOPF, and picked up his first banner using the No. 1 position while on an east operation. He then flew the banner for approximately 30 minutes, returned to KOPF, dropped off the banner, then picked up his second banner with the No. 3 hook. After flying the second banner he returned to KOPF, and dropped the banner installed at the No. 3 hook with no reported discrepancies. He then landed at KOPF, installed a grappling hook at the No. 1 position, and moved the grappling hook from the No. 2 position to the No. 3 position. He boarded the airplane, and noticed the right engine cowling was opened; another company employee secured it at his request. He performed an engine run-up before the flight departed; no discrepancies were reported. After takeoff from runway 12, he tossed out the grappling hook installed at the No. 1 position, and picked up a "billboard", but the airplane would not climb after the pickup. He released the banner, and tossed out the grappling hook installed at the No. 3 position. He remained in the traffic pattern, and returned to pick-up the billboard but was advised that his approach speed appeared to be slow. He returned to pick-up the billboard, approached the east pick-up location at 85 miles-per-hour (mph), and the climb-out "...was even worse. I had no thrust or power at all, only the momentum carried me up to 200 [feet] where I leveled off with an airspeed of about 55 mph and noticed low oil pressure while losing altitude." He immediately pulled the No. 3 banner release handle but "everything came out the panel." He then felt "pulled by the tail with no thrust", and braced for impact. After impact he "woke up", released his restraint, exited the airplane, and was later taken to a hospital for examination. He later reported that at the time of the accident the wind was from the west, though he was picking up to the east, which was set up by the ground crew. One company employee who was a witness to the accident reported that earlier that day, the pilot had trouble activating the No. 3 release which required him to use both hands. The employee inspected the No. 3 release and in his opinion it was not safe to use until after it was fixed. He attended to other duties and the accident pilot then departed and returned to pick up his next banner. The accident pilot's approach, altitude, and airspeed to pick-up the banner to him appeared fine initially, but immediately after he "pulled back to pick, I could tell that the planes nose was [too] high." The banner was pulled approximately 5 feet off the ground before it began to descent and drag on the ground. Other employee personnel advised the pilot to release the banner, which he did. The pilot returned to pick-up the same banner using the No. 3 position, and again his approach into the banner field, his altitude, and airspeed looked fine. He reported that at that time the engine sounded fine. He informed the pilot when the hook grabbed the rope between the pick-up poles and again noticed that the airplane was in a nose-high attitude, "...for [too] long and that it had not leveled out." He noticed that the airplane was sinking towards the ground and advised the pilot on the radio to drop the banner and to push the nose forward. When the banner rope became tight,, the banner began to drag on the ground. While still in a nose-high attitude, the airplane impacted the ground approximately 70 yards from the point where he was standing. He ran to the airplane which had nosed into the ground, and fire rescue responded shortly and took control of the situation. Another company employee reported that when the accident pilot returned from a banner tow flight to drop the banner, he noticed that the flight was low and he advised the pilot to drop the banner. The banner dragged on the ground approximately 50 feet before it was released. The pilot landed and when the employee asked him why he had not dropped the banner when advised, the pilot responded that the No. 3 release "wasn't working properly." The accident pilot showed him "the release and it was hanging out." The accident pilot departed, returned to pick up the banner, and it appeared to him that "...when he picked he was too shallow so I told N86AB to climb." He then noticed that the billboard was falling and after seeing that the airplane was not climbing, he informed the pilot to release the banner. The banner was released and he asked the pilot what was wrong, the pilot replied the airplane would not climb. When the pilot flew westbound he heard a "brief popping sound." He asked the other company employee who was with him what that was and he responded that it was normal. The accident pilot returned to pick-up the banner and, "As he picked he looked like nose was very high and might flip the plane backwards. Then I saw N86AB start to level off and was falling when he did Chris told him to drop-drop-drop." At that time the banner was only 2-3 feet off the ground, and the accident airplane descended with the banner attached. The airplane, "...started to fall and veer off to the right or the south of the airport. I saw N86AB level off three times before hitting the ground." Examination of the airplane by an FAA inspector revealed the No. 3 banner release handle/cable assembly was separated from the instrument panel and extended into the cockpit. The airplane was recovered for further examination. NTSB review of photographs taken by the Miami-Dade Aviation Department of the airplane at the accident site revealed a tow rope remained connected to the No. 3 tow-release hook, which was displaced to the right approximately 55 degrees. A safety link was installed between the end of the tow rope and the hook that was connected to the No. 3 tow-release hook. NTSB examination of the airplane following recovery revealed the No. 3 banner release cable was not fractured; the release cable housing, cable, and handle extended into the cockpit approximately 12 inches. Further examination of the No. 3 banner release cable revealed the housing was secured by a plastic tie wrap to structural tubing near the pilots seat, and was next secured by a clamp approximately 10 feet later by the leading edge of the horizontal stabilator, again near the aft edge of the horizontal stabilator, and again near the midpoint of the elevator. The instrument panel adjacent to the nut used to secure the No. 3 banner release cable to the instrument panel was scratched around the nut. The Nos. 1 and 2 positions operationally checked good. None of the banner release cables were secured to structure forward of the release handles in the cockpit. The two-position fuel selector valve was in the on position; the valve was not capable of being controlled from the cockpit by hand. The stall vane and light operationally tested good. An estimated 58 gallons of fuel were noted in the single fuel tank. Operational testing of the auxiliary fuel pump revealed fuel flow to the carburetor inlet. The fuel tank vent line was clear of obstructions. NTSB examination of the engine following recovery of the airplane revealed one propeller blade was bent aft approximately 90 degrees, while the other propeller blade was bent aft approximately 30 degrees. The carburetor inlet box was crushed up; no other obstructions of the air induction system were noted. The oil sump contained approximately 11 quarts of oil. A sample of fuel taken from the fuel strainer revealed aluminum slivers, and a sliver of unknown material was noted on the carburetor inlet screen. A replacement propeller of the same make and model was installed for an attempted engine run which was accomplished using the fuel that remained in the undamaged fuel tank. The engine was started and operated to approximately 2,400 rpm (near full static rpm), using only the engine-driven fuel pump. A check of each magneto was performed with the engine operating at 1,700 rpm; each magneto drop was less than 100 rpm. With the engine operating at 1,700 rpm, the oil pressure was noted to be in the green arc. With the oil temperature at the lower edge of the green arc, and the engine rpm at 1,000 and 1,300 rpm, the oil pressure was less than the green arc. The oil pressure was noted to be in the green arc when operating at full static rpm. The tachometer was not marked with a red line indicating maximum rpm. Rapid full throttle advance from 1,700 rpm to full throttle revealed no hesitation. A review of the FAA Form 337 titled "Major Repair And Alteration", dated May 31, 2002, associated with the installation of the banner release mechanism, indicates that "...6 adel clamps to mount the release cables to the tubular airframe...." As previously reported, only adel 3 clamps and a plastic tie wrap were noted securing the banner release cables. A review of the airplane maintenance records revealed the airplane was last inspected in accordance with a 100-Hour inspection on October 10, 2005. The entry also indicates that the airplane was disassembled, cleaned, and all metal parts were flushed with "salt away & Corrosion X." The operator reported that the installed safety link at the banner release point is designed to break at 650 pounds, and in his experience, a banner dragging on the ground called a "hot hook", will not cause the safety link to break. A METAR taken at the Opa-Locka Airport on the day of the accident at 1253, or approximately 5 minutes after the accident, indicates in part that the wind was from 270 degrees at 7 knots. As previously reported by the pilot, he was picking up to the east due to ground crew placement of the banner. A review of the operator's "Training Manual & General Operating Procedures" revealed that with respect to "Downwind Pickups", it states, "Downwind pickups are not to be attempted by any pilot at any time! Failure to abide by this rule will result in the pilots' immediate termination!" The training manual also indicates with respect to downwind pickups that if the wind direction changes and, "...your banner is no longer set up into the wind you must land, taxi to the banner area, and help the ground crew realign your banner for an upwind pickup." The training manual also indicates that when landing with a banner attached or "A Hot Hook", there is "...nothing to fear about landing with a banner." A review of the pilot's training records revealed he was signed off on December 8, 2005, as completing 20 total ground hours and 13 total flight hours to include emergency procedures. The emergency procedures included: 1) failure of the banner release, 2) loss of rudder control, 3) partial loss of power, and 4) engine failure with banner. A FAA inspector from "FSDO-17" observed the in-flight operation of the accident pilot on December 8, 2005, and signed off as indicating the airman's performance was satisfactory.

Probable Cause and Findings

The failure of the pilot-in-command to maintain airspeed following a reported loss of engine power, resulting in a stall/mush, uncontrolled descent, and in-flight collision with terrain. Factors in the accident were the pilot's intentional operation of the airplane with known deficiencies (inoperative No. 3 banner release), and inadequate installation of the banner tow-release hook assembly by company maintenance personnel.

 

Source: NTSB Aviation Accident Database

Get all the details on your iPhone or iPad with:

Aviation Accidents App

In-Depth Access to Aviation Accident Reports