Aviation Accident Summaries

Aviation Accident Summary CEN14FA024

Boerne, TX, USA

Aircraft #1

N11RC

BELLANCA 14-19-3A

Analysis

The pilot was returning to his home airport. A review of radar data showed the accident airplane in a straight-line descent from cruise flight at a rate of nearly 2,900 ft per minute. The descent resulted in a loss of 8,100 ft in less than 3 minutes until the airplane disappeared from radar in the vicinity of the accident site. Disassembly of the airplane's cabin heat shroud, which provided heated air to the cabin, revealed evidence of cracks and holes in the muffler wall and exhaust gas penetration into the interior of the shroud. According to the autopsy report, the pilot died as a result of thermal injuries and smoke inhalation, with soot present in the upper airway and 37% carbon monoxide found in his blood postmortem. Based on the lack of soot in the lower airway and the elevated carbon monoxide levels, the majority of the carbon monoxide in the pilot's blood was likely from inhalation during the flight at levels that would have impaired his ability to safely fly the airplane. Although cetirizine, also known as Zyrtec® (used to temporarily relieve allergy symptoms and could cause drowsiness), was also detected in the pilot's urine and blood, the detected level indicated that impairment from the drug was unlikely.

Factual Information

HISTORY OF FLIGHT On October 27, 2013, about 1740 central daylight time, a Bellanca 14-19-3A, N11RC, collided with power lines and trees near Boerne, Texas. The pilot, the sole occupant on board, was fatally injured. The airplane was destroyed by impact forces and an ensuing fire. A family cat sustained extensive thermal injuries but survived the accident. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight originated from Elton Hensley Memorial Airport (KFTT), Fulton, Missouri, about 1230, and was en route to San Geronimo Airpark (8T8), San Antonio, Texas. According to the pilot's wife, her husband had flown to Columbia, Missouri, three days before the accident. She travelled by commercial air carrier and joined him there to see their son play in a University of Missouri football game. After breakfast on the morning of the accident, the pilot flew his wife's nephew and son's girlfriend from Columbia to KFTT. There, the airplane was refueled and the pilot departed KFTT for 8T8. His wife returned home by commercial air carrier because she reportedly disliked flying in small airplanes. According to Federal Aviation Administration (FAA) radar data, a target appeared on San Antonio (SAT) Approach Control radar at 1700, squawking a mode C visual flight rules transponder code of 1200. The pilot was not in radio contact with approach control. The target's course was about 188?, a direct course to 8T8. Its altitude was 10,200 feet and its ground speed was 128 knots. The target continued at a constant airspeed with only slight variations in altitude. The target then began a straight-line descent of nearly 2,900 feet per minute --- a loss of 8,100 feet in 2 minutes, 47 seconds. Airspeed varied from 136 to 154 knots. The descent continued until the target disappeared from radar at 1740 in the vicinity of the accident site, east of Boerne. The first 9-1-1 call was received by the Boerne Police Department at 1741. CREW INFORMATION According to FAA documents, the 47-year-old pilot held a private pilot certificate with an airplane single-engine land rating. He was not instrument rated. He also held an airframe and powerplant (A&P) certificate with inspector authorization (IA) privileges. His third class airman medical certificate, dated November 16, 2012, contained no restrictions or limitations. At the time of this medical certification, the pilot estimated his total flight time to be 630 hours, with 45 hours accrued in the previous six months. A partial copy of the pilot's logbook was made available for review. The copy contained entries from December 17, 2005, to May 12, 2012. According to this document, the pilot purchased N11RC in Versailles (3V5), Missouri, on December 17, 2005. He and his instructor ferried the airplane from 3V5 to 8T8. On December 22, 2005, the instructor gave the pilot a 1.5 hour high performance checkout that included a biennial flight review. The pilot was given additional flight reviews on February 7, 2007; February 5, 2010, and February 18, 2012. Between December 17, 2005, and May 12, 2012, the pilot logged 129.3 hours in the Bellanca 14-19-3A. His total logged time was 630.3 hours. No further flights were logged after May 12, 2012. AIRCRAFT INFORMATION N11RC (serial number 4279), a model 14-19-3, converted to a model -3A, was manufactured by the Bellanca Aircraft Company of Plainview, Texas, and was issued a Certificate of Airworthiness on January 19, 1966. It was equipped with a Continental IO-490-F1 engine (serial number CS-1335732-8-F), rated at 260 horsepower, driving a Hartzell 3-blade, all-metal, constant speed propeller (model no. HC-C2YF-1B, serial number AN229). The serial numbers for the propeller blades were 8468A-4, B26812, and B26803. According to the aircraft maintenance records, the last annual and 100-hour inspections were accomplished on November 17, 2012. At that time, the airframe and engine had accrued 2,812.35 and 1,978.55 hours, respectively. The engine had accumulated 382.55 hours since its last major overhaul, which was completed on October 29, 1997. The ELT battery was also inspected and was current at the time of the accident. The pitot-static system and transponder Mode C calibration checks were performed on October 20, 2012. The airplane was certified for IFR flight at the time of the accident. METEOROLOGICAL INFORMATION The following weather was recorded by San Antonio International Airport's Automated Surface Observing Systems (ASOS), located 22 miles south-southeast of the accident site: 1651 CDT: Wind, 160° at 9 knots; visibility, 10 miles; ceiling, 2,400 feet broken; temperature, 26° C. (Celsius); dew point, 14° C.; altimeter setting, 30.20 inches of mercury. 1751 CDT: Wind, 120° at 12 knots; visibility, 10 miles; ceiling, 5,000 feet broken; temperature, 26° C.; dew point, 19° C.; altimeter setting, 30.00 inches of mercury. WRECKAGE AND IMPACT INFORMATION Both an FAA aviation safety inspector and a National Transportation Safety Board (NTSB) air safety investigator examined the wreckage at the accident site. The elevation of the crash site was 1,419 feet above mean sea level (msl). The initial impact was a 20-foot tall oak tree, about 14 inches in diameter and 80 feet to the north of the centerline of Highway 46. The left wing spar, flap, landing gear trunnion, and numerous smaller parts lay on the ground near the tree. Wreckage was strewn on a magnetic heading of 185°. The airplane then stuck power lines 32 feet above the ground, and broke three poles – one pole to the west and two poles to the east – about midspan. The airplane dragged the power line across Highway 46. There were perpendicular scrapes on the pavement. The scrape across the roadway centerline was approximately ½-inch deep and the scrapes on the south edge of the road were about ½ to 1 inch deep. The airplane continued south into more trees and struck a 4-foot tall fence, passing beneath a set of 3-phase high voltage power lines 42 feet above the ground. The airplane went through a narrow clearing beneath the wires, and struck more trees beyond the clearing. A small area of charred vegetation, containing the horizontal stabilizer and attached elevator and vertical stabilizer and attached rudder, was found at the beginning of this clearing. A large burnt area was noted past the clearing. Within this burned area was the twisted right main fuel tank. About 30 feet beyond, on the edge of the right-of-way, were the right wing, aileron, and landing gear trunnion. Slight sooting was noted around the filler port. About 30 feet beyond, or about 300 feet from Highway 46 centerline, was the completely charred fuselage laying on its right side. Melted remnants of the auxiliary fuel tank were in the rear fuselage. The tubular frame was intact and all the outer fabric had been burned. The left main tank was found intact and unburnt. No hydraulic deformation was noted. No fuel was noted inside the tank. The left wing was relatively untouched by the fire, but the right wing and fuselage had been consumed by fire. The right wing tank and auxiliary tank both bore hydraulic deformation signatures and had been breached. The engine hard points were broken but remain attached to the engine mounts. The engine, with the propeller still attached, was located 19 feet south of the fuselage, sitting upright or a magnetic heading of 180°. The propeller flange did not appear to be displaced. One blade was bent 30° forward. The other blade was bent 30° forward and bent 90° aft. No chordwise scratching or leading-edge damage was noted on either blade. No propeller strike marks were noted in the trees, on the ground, or on the highway pavement. Examination of the wooden wing structure and other components revealed no evidence of water damage, delamination, insect invasion, or rot. Rudder and elevator control continuity was established between the cockpit control bar and the control arms in the empennage. Aileron control continuity was established between the bicycle chain forward of the yoke to the wing clevis ends in the wing root. The total wreckage path is estimated to be 300 feet in length, with an additional 19 feet to the separated engine and propeller. MEDICAL AND PATHOLOGICAL INFORMATION According to the autopsy report, death was attributed to "thermal burns and smoke inhalation, with possible blunt force trauma," and the manner of death was listed as "accident." The report indicated soot was present in the upper airway, and blood carboxyhemoglobin concentration was 30 per cent. A toxicology scan performed by FAA Civil Aeromedical institute revealed 37 per cent carbon monoxide in blood. No cyanide was detected. Cetirizine, also known as Zyrtec® (used to temporarily relieve allergy symptoms and could cause drowsiness), was detected in urine and blood. Mioxidil, an antihypertension and hair growth compound, was detected in urine but not blood. No ethanol was detected in vitreous. The autopsy and toxicology reports and interview summary were reviewed by NTSB's medical officer. According to his report, severe burns were identified but it could not be determined if the skull fractures and brain injuries were due to blunt force trauma or thermal injury. No natural disease was identified. Examination of the airways identified moderate soot within the mucus of the upper airways, larynx and trachea but no evidence of soot deposition in the large and small airways of the lungs. TESTS AND RESEARCH The damaged fuel selector valve was removed from the accident site and sent to Alexandria Aircraft, LLC, the current type certificate holder for Bellanca Aircraft. They determined that the fuel selector was positioned on the left main tank. On March 24, 2014, the engine was examined at Teledyne Continental Motors in Mobile, Alabama, under the auspices of NTSB. There was no evidence of engine failure, and no anomalies or discrepancies were noted. The exhaust system was disassembled and examined. Impact damage was noted to the inner muffler tube, which was almost completely separated. All heat transfer pins, on the outside of the muffler tube and on the inside of the cabin heat shroud, were present and intact. The outer surface of the cabin heat shroud showed evidence of thermal damage to the paint and slight thermal warping to the metal. The thermal evidence seen on the outside of the shroud corresponded to several cracks and holes observed on the muffler wall. There was also evidence on the cabin heat side of the muffler that exhaust gases had been penetrating the interior of the cabin heat shroud which provides heated air to the aircraft cabin.

Probable Cause and Findings

A defective exhaust system that allowed carbon monoxide to enter the cabin and impair the pilot, rendering him unable to control the airplane.

 

Source: NTSB Aviation Accident Database

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