CEN10FA107

NTSB accident investigation · Costruzioni Aeronautiche Tecna P2002 · Waxahachie, TX · January 23, 2010

Accident · FatalField investigationFinal report
Date
January 23, 2010, 11:58 local (17:58 UTC)
Place
Waxahachie, TX
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N145AGCostruzioni Aeronautiche Tecna P2002
Defining event
Maneuvering: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report February 6, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
ANSV - Agenzia Nazionale per la Sicurezza del Volo, FAA Dallas FSDO, Tecnam
FAA report
20100123026579A
Case key
75297

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

A loss of aircraft control while maneuvering for undetermined reasons.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedCostruzioni Aeronautiche Tecna P2002 SIERRA: 1 caseAll aircraft: 1,269 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedCostruzioni Aeronautiche Tecna P2002 SIERRA: 2 casesAll aircraft: 2,247 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

According to radar data, the airplane climbed to an initial altitude of about 2,700 feet mean sea level on a southerly heading. Over the span of the flight, the airplane reversed course toward the north, reversed course again to the south, and then reversed course a third time to the north. Several witnesses observed the accident airplane in a spin approximately 800 feet above the ground. Ground scars and damage to the airplane were consistent with a 70-degree nose down attitude at the time of impact. A postaccident examination of the airframe, airplane systems, and engine revealed no mechanical anomalies that would have precluded normal operation; however, a mechanic’s work light was discovered in the tail section of the airplane. Score marks on the body of the work light were consistent with the work light having been jammed in the tail of the airplane underneath the stabilator control tube. Due to the distortion of the wreckage components, it was not possible to establish if the work light interfered with proper movement of the stabilator control tube.

Factual narrative

HISTORY OF FLIGHT On January 23, 2010, at 1158 central standard time, a Costruzioni Aeronautiche Tecnam P2002 Sierra special light sport airplane, N145AG, was substantially damaged when it impacted terrain following an uncontrolled descent near Waxahachie, Texas. The certified flight instructor (CFI) and student pilot sustained fatal injuries. The airplane was owned by U S Aviation Group, LLC, and was operated by CRP Future Pilots Flight School, Inc. Visual meteorological conditions prevailed at the time of the accident and a flight plan had not been filed for the 14 Code of Federal Regulations Part 91 instructional flight. The flight departed the Dallas Executive Airport (RBD), Dallas, Texas, at 1139. One witness observed the airplane in “slow vertical spin” approximately 800 feet above the ground. The airplane made one and a half to two turns before it disappeared behind a row of trees. Another witness observed the airplane pointed nose down and moving in a circular motion “like the blades of a ceiling fan”. Radar data, provided by the Federal Aviation Administration (FAA), identified and depicted the accident flight from the time of departure until the time of the accident. The airplane climbed to an initial altitude of about 2,700 feet mean sea level (msl) on a southerly heading. Over the span of the flight, the airplane reversed course towards the north, reversed course again to the south, and then reversed course a third time to the north. The last recorded position of the airplane was at 1158. PERSONNEL INFORMATION Certified Flight Instructor The CFI, age 36, held a commercial pilot certificate with airplane single and multiengine land, and instrument airplane ratings. In addition, he held a flight instructor certificate with airplane single and multiengine, and instrument airplane privileges. He was issued a first class airman medical certificate, without limitations, on January 13, 2010. A review of the CFI’s logbook indicated that he had logged 1,162 hours of flight experience; 59 of which were logged in the same make and model as the accident airplane. Student Pilot The student pilot, age 15, did not hold a student pilot certificate or an airman medical certificate. A review of the student pilot’s logbook indicated that he had logged 3.3 hours of flight experience; all of which had been flown in the same make and model as the accident airplane. AIRCRAFT INFORMATION The two-seat, low-wing, fixed-gear airplane, serial number (s/n) 316, was manufactured in 2007. It was powered by a Rotax 912 ULS 100-hp engine and equipped with a GT Tonini model GT-2/173/VRR-FW 101 SRTC fixed-pitch wood and composite propeller. A review of the aircraft maintenance records indicated that the FAA had issued a special airworthiness certificate for light sport airplane on May 12, 2008 at an aircraft total time of 3.3 hours. Another logbook entry showed that a “conformity” inspection had been completed on June 14, 2009 at a total airframe time of 75.3 hours.At the accident scene the hobbs meter was observed as 00117.77 hours. The airplane had flown about 114.4 hours since the initial condition inspection, and about 42.4 hours since the June 14, 2009 inspection. METEOROLOGICAL INFORMATION The closest official weather observation station was Mid-Way Regional Airport, Midlothian, Texas (JWY), located 3 nautical miles (nm) southwest of the accident site. The elevation of the weather observation station was 713 feet msl. The routine aviation weather report (METAR) for JWY, issued at 1204, reported, calm wind, visibility of 10 miles, overcast clouds at 7,000 feet above ground level (agl), temperature 16 degrees Celsius (C), dew point temperature 7 degrees C, with an altimeter setting of 29.57 inches of mercury. FLIGHT RECORDERS The airplane was equipped with an Advanced Flight Systems AF-3400EF cockpit display capable of displaying Electronic Flight Instrument System (EFIS) information to the pilot. The unit contained an Attitude/Heading Reference System (AHRS) to provide the pilot with attitude and heading information and an internal Air Data System (ADS) to provide the pilot with altitude and airspeed information. The unit also had the capability to store flight data. The AFS-3400EF recording contained approximately 14 hours of data over 20 power cycles. The accident flight was the last flight of the recording and its duration was approximately 25 minutes. A review of the data points over the last minute of the flight showed the airplane was northbound and at an average altitude around 2,300 feet msl with recorded airspeeds ranging from a maximum of 52.9 knots to the minimum of 39.5 knots. A data point at 1157:44 showed the airplane was at an altitude of 2,260 feet msl, or about 1,625 feet agl, with an airspeed of 39.5 knots, when it began to bank to the left and pitch nose down. The last data point at 1157:59 showed the airplane was descending through an altitude of 1,240 feet msl, or about 605 feet agl, in a 33.4 degree bank to the left and a nose down pitch of 45.27 degrees. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was located in a flat open farm field approximately 3 miles northeast of JWY. The wreckage was oriented on a heading of 190 degrees. The elevation of the accident site was estimated from map data to be 635 feet msl. The main wreckage consisted of the left and right wing, empennage, fuselage, engine and propeller. The airplane came to rest in an approximate 40-degree nose down attitude. The cockpit canopy separated from the airframe and was located about 15 feet forward of the main wreckage. The engine was partially embedded in the ground directly beneath the wreckage. The propeller hub remained attached to the engine. One blade had fractured but remained attached to the hub. The other blade had separated from the hub and was observed about five feet forward of the main wreckage. Both wings exhibited aft accordion crushing along their leading edges and there were correspondingimpact scars on the ground. The forward portion of the fuselage was crushed aft, reducing the occupiable space in the cabin. The instrument panel was fragmented and partially separated. The fuselage aft of the cabin exhibited forward to aft accordion crushing and remained attached to the empennage. Both wings remained attached to the fuselage except that the left wing aft spar attach point was broken off at the bolt hole. The left and right ailerons remained attached and control continuity to both ailerons was confirmed. The left wing flap was hanging loose at a 45-degree angle with the flap pushrod attach point separated from the flap inboard rib. The right flap was retracted and remained attached. The stabilator, vertical tail, and rudder remained attached to the empennage which was bent over the top portion of the fuselage. The stabilator trim tab and the electric actuator were observed in the neutral position. Rudder control continuity was confirmed. Stabilator control continuity was confirmed from the stabilator to the forward clevis end at the center control yoke. A red battery operated work light was observed in the rear fuselage area underneath the stabilator control tube and just aft of the half length flange. The clevis rod end was broken at the forward end of the stabilator control tube in the threaded portion. The bearing potion of the clevis rod end was still secured in the center control yoke. In the cabin area, the control yoke assembly and the left and right control sticks were observed to be deformed, but still intact with the aileron control cables attached. The auto pilot pitch and trim servo actuators had free motion of the control arms. The actuators measured an arm turning radius of 2-1/16 inches from center of the servo to the rod end attach center point, this allowed 4-1/4 inches of linear movement of the push rods at the pitch and roll servo in a 180-degree arc. The aileron roll servo attach point below the right control stick at the aileron cable attach bolt had a total linear movement of 3 inches while the pitch servo rod end attach point at the top of the mixing assembly measured 1-3/16 inches of linear movement. With mechanical connections to the servos disconnected, and with no electrical power applied, the servos had 360 degrees of free rotation. An examination of the engine was performed. No preimpact damage was noted. During partial disassembly the impact damaged engine’s internal ignition coil, internal alternator, and trigger coil were found jamming the flywheel hub and preventing rotation. After removing the propeller hub, gear reduction housing and the trigger coil, the propeller shaft had a full 360 degrees of free rotation. All gears and keepers where found in their respective positions. The valve train for each cylinder moved through each of the four cycles with normal mechanical continuity. Thumb compression was confirmed to all cylinders. All spark plugs exhibited normal wear when compared to theChampion Check-A-Plug comparison card. The left and right carburetors were inspected; all control arms and cables were found attached and in place. The right carburetor bowl was damaged and no fuel was noted in the bowl. The left carburetor bowl contained approximately 3/16 of an inch of fuel. A small amount of fine, black debris was noted in both carburetor bowls that appeared to be the same material as the carburetor floats. Portions of the stabilator control tube, bottom piece of fuselage tail section including stabilator control tube pass-through plate mounting braces, stabilator control tube pass-through plate, rubber grommet, and the work light were removed and sent to the Safety Board materials laboratory for examination. MEDICAL AND PATHOLOGICAL INFORMATION Certified Flight Instructor The Southwestern Institute of Forensic Sciences, Dallas, Texas, performed the autopsy on the certified flight instructor on January 24, 2010. The autopsy concluded that the cause of death was the result of “multiple blunt force injuries” and the report listed the specific injuries. The FAA’s Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy. Results were negative for carbon monoxide, cyanide, and ethanol. Testing of the blood revealed 0.159 ug/ml diphenhydramine. Diphenhydramine is a sedating antihistamine which is commonly used in the treatment of allergies and the common cold. Student Pilot The Southwestern Institute of Forensic Sciences, Dallas, Texas, performed the autopsy on the student pilot on January 24, 2010. The autopsy concluded that the cause of death was the result of “multiple blunt force injuries” and the report listed the specific injuries. The FAA’s Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, performed toxicological tests on specimens that were collected during the autopsy. Results were negative for all tests conducted. TESTS AND RESEARCH Safety Board materials laboratory staff examined portions of wreckage which had been removed from the airplane. The stabilator control tube was bent and buckled at two places along its length. The forward clevis rod was fractured and separated. The fracture features and thread damage indicate that the rod end fractured in ductile overstress due to downward cantilever bending. The forward control mixing unit had three areas of bending overstress fracture. A bend in the linkage was also indicated. The half length flange pass-through plate was bent in the forward direction. The edge of the hole in the pass-through plate was deformed in a manner consistent with forward sliding contact with the stabilator control tube. The rubber grommet in the half length flange pass-through plate hole, had a radial through-thickness cut in the wall. The radial cut in the grommet was consistent with the application of lateral force applied between the stabilator control tube and the pass-through plate. The surface of thestabilator push pull tube had a thin, greasy residue in the area of the pass-through plate. In this same area, the surface of the stabilator control tube exhibited features consistent with scoring and galling. Excrescence features due to galling were consistent with forward sliding contact between the stabilator control tube and the edge of the pass-through plate hole. The black transfer marks present on the inner bottom surface of the fuselage tail section were consistent with marks made by the rubber handle grip on the work light. Due to the distortion of the wreckage components, it was not possible to establish if the work light interfered with proper movement of the stabilator control tube.

Aircraft

Registration
N145AG
Reported as
Costruzioni Aeronautiche Tecna P2002 (SIERRA)
Category
Airplane
Serial number
316
Airframe hours
117
Engine
Rotax 912 ULS, 100 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Crp Future Pilots Flight School Inc
Registered owner
U S Aviation Group LLC
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
Condition · May 12, 2008 · 114 hours before
Departed
RBD · Dallas, TX
Destination
RBD · Dallas, TX

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
36
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right
Toxicology
Performed
Flight hours
1,162 total · 59 in this make and model · 1,038 as pilot in command · 10 in the last 90 days · 1 in the last 30 days · 0 in the last 24 hours
Role
Student pilot
Age
15
Injuries
Fatal
Seat
Left
Toxicology
Performed
Flight hours
3 total · 3 in this make and model · 1 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
7,000 ft overcast
Temperature
61 °F, dew point 45 °F
Altimeter
29.56 inHg
Observed at
JWY, 3 nm away

Docket · 29

The files NTSB released with the investigation on December 14, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 33.7 MB in all.

Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 1 · .PDF · 22 KBRecord of Pilot Logbook ReviewItem 2 · .PDF · 55 KBWitness StatementsItem 3 · .PDF · 1.9 MBStatement from CFI - BandyItem 4 · .PDF · 20 KBRecord of Mechanic InterviewsItem 5 · .PDF · 76 KBStatement from Mechanic - ProbstItem 6 · .PDF · 8 KBAircraft Maintenance LogsItem 7 · .PDF · 8.8 MBWeight and Balance Revision - Flight ManualItem 8 · .PDF · 88 KBFlight Manual - Page 45 (Stall Speeds)Item 9 · .PDF · 131 KBMaterials Laboratory factual Report 10-122 (with 13 embedded images)Item 10 · .PDF · 6.1 MBCockpit Display(s) - Recorded Flight Data - Specialist's Factual ReportItem 11 · .PDF · 648 KBCockpit Display(s) - Recorded Flight Data - Attachment 1 Tabular Data - (CSV Format)Item 12 · .CSV · 23 KBMapsItem 13 · .PDF · 331 KBWeather DataItem 14 · .PDF · 129 KBATC Partial TranscriptItem 15 · .PDF · 109 KBDimensional View of the Inside of Tail AreaItem 16 · .PDF · 82 KBPhoto 1 - Precrash photo (Internet photo from www.airport-data.com)Item 17 · .PDF · 315 KBPhoto 2 - Wide view from the left front (FAA Photo)Item 18 · .PDF · 755 KBPhoto 3 - View from the left side (Tecnam Photo)Item 19 · .PDF · 844 KBPhoto 4 - Close view from the rear (Police Photo)Item 20 · .PDF · 494 KBPhoto 5 - Propeller (NTSB Photo)Item 21 · .PDF · 99 KBPhoto 6 - Engine before partial disassembly (NTSB Photo)Item 22 · .PDF · 233 KBPhoto 7 - View of the Inside of Tail Area (Tecnam Photo)Item 23 · .PDF · 472 KBPhoto 8 - View of Inside of Tail Area Near the Half Length Flange (Tecnam Photo)Item 24 · .PDF · 493 KBATC Radar Replay of a 1200 Transponder Target from 1140 until 1158 CST (WMV File)Item 25 · WMV · 9.8 MBTecnam Report number 2002/60A - Spinning Flight Test ReportItem 26 · .PDF · 721 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 27 · .PDF · 627 KBToxicological Report - CFIItem 28 · .PDF · 127 KBToxicological Report - StudentItem 29 · .PDF · 126 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.