Aviation Accident Summaries

Aviation Accident Summary ERA09LA398

Switzerland, FL, USA

Aircraft #1

N132JB

BARBER JOHN A GLASAIR

Analysis

On the morning of the accident, the pilot made two flights southbound in the experimental amateur-built airplane and then picked up a pilot-rated passenger with the intention of returning north to the accident pilot's home airport. On the return flight the accident pilot joined up in aerial formation with a pilot-friend in another airplane and the two airplanes proceeded northbound. While enroute they practiced formation flight maneuvers. During one of the maneuvers the other pilot lost sight of the accident airplane, was unable to re-establish visual or radio contact, and concluded that the accident pilot had departed the area. Several eyewitnesses saw the two airplanes maneuvering together. At least one eyewitness reported that the accident airplane was conducting rolls, saw the airplane enter a cloud immediately after a roll, and then observed it in a descending spiral. The following day the wreckage was located in a remote, wooded area, about 2 miles from where the other pilot last saw the airplane operating. The vegetation scars were indicative of a steep impact angle and the airplane was highly fragmented. Postaccident examination of the airplane and engine did not reveal any evidence of preimpact failures or anomalies and indicated that the engine was operating at the time of impact. Autopsy and toxicological testing did not reveal any conditions which might have led to the accident. Meteorological and witness reports indicated low clouds and rain showers in the vicinity, and a broken cloud layer at 3,200 feet. Witness statements and global positioning system data indicated that the airplane never reached an altitude greater than about 1,600 feet during the maneuvers. The accident airplane Owner's Manual contained multiple recommendations that aerobatic maneuvers should "never be conducted below 3,000 feet" above ground level in order to provide sufficient terrain clearance for recovery.

Factual Information

HISTORY OF FLIGHT On July 11, 2009, about 1300 eastern daylight time, an experimental amateur-built Barber SHA Glasair RG, N132JB, was destroyed when it impacted terrain while maneuvering near Switzerland, Florida. The certificated airline transport pilot/owner and the commercial pilot-rated passenger were fatally injured. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight. The pilot/owner of a Nanchang CJ6 stated that he was a friend of the accident pilot, and that they both based their airplanes at Herlong Airport (HEG), Jacksonville, Florida. On the morning of the accident, the two pilots and their airplanes departed HEG and flew south in formation to Haller Airpark (7FL4), Green Cove Springs, Florida, for an Experimental Aircraft Association meeting that started at 1000. After the meeting, the accident pilot departed 7FL4 in the accident airplane, destined for Palatka Municipal Airport (28J), Palatka, Florida, located about 16 miles south of 7FL4. There he picked up his pilot-rated passenger with the intention of returning to HEG. On the northbound return flight, when the accident pilot and his passenger approached 7FL4 from 28J, they joined up in an aerial formation with the CJ6 and two other airplanes for a photo opportunity above 7FL4. After the photo passes, the CJ6 and the accident airplane proceeded north in formation. The CJ6 pilot reported that as they flew along the St. Johns River at an altitude of 1,500 feet, he asked the accident pilot if he was willing to demonstrate "a breakup and re-join" maneuver to the passenger. The accident pilot agreed, and they completed the maneuvers. According to the CJ6 pilot, the two maneuvers began and ended with the airplanes heading east. The CJ6 pilot then suggested a "shackle turn," and again the accident pilot agreed. The intent of the shackle turn maneuver was to reposition the wingman (the accident airplane) from one side of the lead airplane (the CJ6) to the other. The CJ6 pilot stated that when the accident airplane was 800 to 1,000 feet off his left side, the CJ6 began a left turn, and the CJ6 pilot saw the accident airplane pass behind and above him, as expected. Once the accident airplane was 500 to 600 feet to the right of the CJ6, the CJ6 pilot initiated a right turn to resume their previous eastbound heading. This was the last time the CJ6 pilot saw the accident airplane. The CJ6 pilot stated that during the maneuvers, there were additional aircraft using the same air-to-air radio frequency, and that that hindered his communications with the accident airplane. After the shackle turn, the radio congestion increased, and the CJ6 pilot radioed the accident pilot that he planned to depart the area and return to HEG. Since he did not hear a response from the accident pilot, the CJ6 pilot then returned to the maneuvering area. He did not see any "smoke or obvious crash site," or any unusual boat activity (indicative of an accident), and decided that the accident airplane had departed for St. Augustine for lunch and/or fuel. According to one individual on a pleasure boat that was anchored in the St. Johns River, and located approximately 2 miles west of the accident site, she observed two airplanes flying side by side to the south of her, heading east. She then saw the airplanes perform a coordinated banked turn to the north, which placed them approximately over the east bank of the St. Johns River. She looked away, but her husband called her attention back to the airplanes. She then saw the smaller airplane descending, with the nose pointed steeply down, and she described the airplane as "spiraling." She lost sight of the airplane behind the trees, but did not see any smoke or fire. She then saw the larger airplane circle at least once, as if searching for the other airplane. She estimated that the two airplanes were in view for approximately 15 minutes. The witness stated that the weather was "fine," but there were some "low clouds," and she did experience a "quick rain shower" at some point. Another individual, who was on another boat that was moving south on the St. Johns River, also observed the airplanes. He saw the airplanes heading north towards him. He stated that the larger airplane was in the lead, and that the smaller airplane was in trail off the left (witness' right) side of the larger airplane. The airplanes completed a 360-degree turn to their right, which again placed them on a northerly heading. When the airplanes returned to their northerly heading, they were approximately over the eastern shore of the St. John's River. The witness stated that at that point, the larger, lead airplane continued to the north, while the smaller, trailing airplane turned again to the east. Almost immediately following the separation, the smaller airplane conducted a "barrel roll" to the left. The witness was looking approximately east towards the airplane as it was flying away from him, so it appeared to rotate counterclockwise to him. Once the airplane completed the counterclockwise roll, it started and completed a clockwise roll. Immediately thereafter, the airplane entered a "small puffy white cloud." The witness then saw the airplane emerge from the cloud in a nose-down, right wing down attitude The airplane "spiraled" towards the ground, and completed about three full turns At that point, he saw what he described as "the tail snap" or "the back end chase after the nose." He clarified this to mean that the airplane did not break apart, it just began a new pattern of motion. He watched the airplane disappear behind the treeline, but did not see any smoke or fire, or hear any sounds of impact. At 0955 the morning after the accident, the Federal Aviation Administration (FAA) issued a notice that the airplane was missing. At about the same time, several pilots and airplanes from HEG initiated their own search for the missing airplane, based on the CJ6 pilot's information regarding the last known position of the airplane. At least one of these airplanes detected an emergency locator transmitter (ELT) signal, and the wreckage was located shortly thereafter. The accident site was a remote, wooded area with heavy undergrowth, located just west of an abandoned airfield near Switzerland, Florida. PERSONNEL INFORMATION Pilot/Owner FAA records indicated that the pilot held an airline transport pilot certificate with airplane multiengine land and turbojet ratings, and a flight engineer certificate with a turbojet rating. He also held type ratings in B-767, B-757 and CE-500 airplanes. His most recent FAA second-class medical certificate was issued in July 2008, at which time he reported 11,611 total hours of civilian flight experience. His most recent flight review was completed in January 2009. According to the CJ6 pilot, he and the accident pilot had been "squadron mates" in the US Navy. The pilot cataloged the airplane's hour meter values in his personal flight logbook. Examination of the logbook revealed that he flew the airplane four times in October and November 2007, and accumulated about 5 hours in the airplane. He did not fly the airplane again until March 2008; between March and the end of December 2008, he flew 31 flights, and accumulated about 34 hours in the airplane. The pilot's logbook indicated that between January and June 20, 2009, which was the last entry in the logbook, the pilot flew another 30 flights, and accumulated another 37 hours in the airplane. The Florida District 23 Medical Examiner autopsy report indicated that the cause of death was "blunt force trauma," and that alcohol and drug test results were all negative. The Civil Aeromedical Institute (CAMI) toxicology report indicated that tests for carbon monoxide, cyanide, ethanol and all screened drugs were negative. Correlation of on-scene and autopsy report information indicated that the pilot was seated in the left seat at the time of impact. Pilot-rated Passenger FAA records indicated that the passenger held a private pilot certificate with airplane single-engine land and sea ratings, and a commercial certificate with a glider rating. He also held an experimental aircraft builder repairman certificate. The pilot-rated passenger's personal logbook indicated that he had approximately 898 hours of flight experience, and his most recent logged flight was on March 7, 2009, which was also his most recent flight review. His most recent FAA third-class medical certificate was issued in April 2008. The Florida District 23 Medical Examiner autopsy report indicated that the cause of death was "blunt force trauma," and that alcohol and drug test results were all negative. The CAMI toxicology report indicated that tests for carbon monoxide and cyanide were not performed, and that the test for ethanol was negative. The CAMI report stated that amlodipine and diphenhydramine were detected in the liver and urine. AIRCRAFT INFORMATION According to FAA records, the airplane was built in 1992, by someone other than the accident pilot, and it was owned by several other individuals prior to its purchase by the accident pilot. A maintenance records entry dated May 2002 indicated that the prior maintenance records had been "lost," and that the airplane was "disassembled by persons unknown." The accident pilot purchased the airplane in October 2007. At that time, the airplane hour meter registered 737.8 hours. In November 2008, the accident pilot made entries in the maintenance records that certified the airplane's performance, controllability and aerobatic capabilities. The airplane was a two-place side-by-side, low-wing monoplane design that was fabricated primarily of composite materials. Construction plans, kit components, and raw materials were available from the kit manufacturer, Stoddard-Hamilton Aircraft. The accident airplane was equipped with retractable tricycle-style landing gear, and was powered by a Solair/Lycoming IO-320 series engine and a two-bladed, constant-speed Hartzell propeller. The airplane was equipped with two separate fuel tanks. The 10-gallon header tank was located between the cockpit and the engine compartment. The 53-gallon main tank included most of the spanwise wing internal volume forward of the main spar, and a portion of the wing internal volume between the main spar and the rear spar. The fuel selector valve had three positions, "MAIN", "AUX", and "OFF." The airplane was equipped with three fuel fill ports. One fill port for the main tank was located on each wing, and the header tank fill port was located on the top of the fuselage, forward of the windshield. The airplane Owner's Manual (OM) contained information about the operating procedures and performance, but due to the ability of individual builders to vary the equipment and configuration of each airplane, the information provided by the OM was generic in nature. The Introduction section of the OM contained a citation which stated that the manual cannot "serve as a substitute for adequate and competent flight instruction." The OM defined a "NOTE" as "An operating procedure, condition etc., which it is considered essential to emphasize." The OM defined a "WARNING" as any "procedures, practices, etc. which may result in personal injury or loss of life if not carefully followed." Section 2 (Limitations) of the OM stated that the airplane was capable of many aerobatic maneuvers, including loops and rolls, but contained a note which stated that those maneuvers "can be performed" but that "pilot ability and skill will determine whether they can be accomplished safely." The note also stated that pilots should "never attempt any maneuvers below 3000 feet AGL [above ground level]." The section contained a warning which stated that the Glasair was a "high performance aircraft" and that aerobatics were "to be approached with caution and only after prior dual instruction from an expert aerobatic instructor." The Limitations section stated that the Glasair was "prohibited from intentional spins." Section 3 (Emergency Procedures) contained the warning "intentional spins are prohibited." Section 4 (Normal Operating Procedures) stated that stall recovery was "typical of most conventional aircraft" and that stall characteristics were "predictable in both power off and power on stalls." The section contained a note that stated "stall strips are mandatory…to induce the wing roots to stall first" and that without stall strips, "the stall may be unpredictable or erratic." Section 4 of the OM contained a warning that "intentional spins are prohibited" and that "we [the kit manufacturer] strongly recommend that stalls be practiced at 3000 ft. AGL or higher." Another warning in that section stated "do not use the ailerons to keep the wings level in a stall," since that would "more easily cause a spin entry or aggravate spin recovery." METEOROLOGICAL INFORMATION The 1253 recorded weather observation at Jacksonville Naval Air Station (NIP), located approximately 13 miles north of the accident site, included winds from 080 degrees at 14 knots, with gusts to 19 knots, 10 miles visibility, broken cloud layer at 3,200 feet with towering cumulus present, broken cloud layer at 15,000 feet, temperature 30 degrees C, dew point 21 degrees C, and an altimeter setting of 30.19 inches of mercury. The report also noted towering cumulus clouds to the southeast and northeast, with rain showers in the vicinity, to the northeast. WRECKAGE AND IMPACT INFORMATION According to information provided by the FAA inspectors who travelled to the accident scene about 24 hours after the accident, the debris field was approximately 75 feet long, and the vegetation in the area showed minimal disturbance. Tree and ground scars were consistent with a steep descent on an approximate southerly heading. The airplane was highly fragmented. The propeller was separated from the engine. The landing gear positions were consistent with being in the retracted position. Due to the fragmentation and terrain conditions, no reliable information regarding control continuity, instrument indications, power settings or fuel quantity was obtained on scene. There was no evidence of fuel at the scene, and no fire. When the FAA inspectors arrived on scene, the ELT was still transmitting, and the FAA inspectors located the unit and shut it off. A Garmin GPSMap 496 global positioning system (GPS) unit was found in the wreckage and forwarded to the National Transportation Safety Board (NTSB) recorders laboratory for data download. The remainder of the wreckage was recovered to a secure storage facility for examination by the NTSB. ADDITIONAL INFORMATION Fueling History According to the manager of HEG, the pilot was not in the habit of purchasing fuel at HEG. The fuel-servicing records at HEG for the two weeks preceding the accident were examined, and no sales in the pilot's name were discovered. Searches of recent fueling records at several other airports in the vicinity did not reveal any fuel purchases for the accident airplane. No assessment of the airplane's fuel status about the time of the accident was able to be made, but propeller damage was consistent with the engine running at impact. Handheld Global Positioning System (GPS) Data The GPS unit was equipped with non-volatile memory which retained flight track information after the unit was shut down. The specific data storage algorithms were partially user-defined; pilots can increase or decrease the frequency of the data capture (from the initial factory settings) as a function of time, displacement, and other parameters. Based on the data retrieved from the accident GPS, the pilot had altered the GPS data capture algorithm from the factory settings; the result was that the data capture rate was at a low frequency, and only a limited number of data points were available for recovery. The unit recorded three separate flights on the day of the accident. In chronological sequence, these flights were designated as Flight 0 (the earliest flight), Flight 1, and Flight 2 (the accident flight). A total of 10 points compr

Probable Cause and Findings

A loss of control in flight for undetermined reasons. Contributing to the accident was the pilot's performance of aerobatic maneuvers at altitudes lower than those recommended by the kit manufacturer, resulting in insufficient terrain clearance to conduct a recovery.

 

Source: NTSB Aviation Accident Database

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