CEN10FA448

NTSB accident investigation · American Champion Aircraft Cor 7GCBC · Midlothian, TX · July 31, 2010

Accident · FatalField investigationFinal report
Date
July 30, 2010, 19:55 local (Jul 31, 2010, 00:55 UTC)
Place
Midlothian, TX
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N5027GAmerican Champion Aircraft Cor 7GCBC
Defining event
Maneuvering: Miscellaneous/other
Weather
Visual (VMC) · Day
Status
Completed · report October 4, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
Lycoming Engines, FAA Dallas FSDO
FAA report
20100730041369A
Case key
76804

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

The flight instructor’s incapacitation due to preexisting but unrecognized coronary disease, and the student pilot’s distraction and inability to recover the airplane from a stall/spin at low altitude.

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.

Impairment/incapacitation: cardiovascularPersonnel issues › Physical · Instructor/check pilotBellanca 7GCBC: 1 caseAll aircraft: 69 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedBellanca 7GCBC: 3 casesAll aircraft: 1,269 casesProbable cause
Attention/monitoring: attentionPersonnel issues › Psychological · Student/instructed pilotBellanca 7GCBC: 2 casesAll aircraft: 226 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

The flight instructor and student pilot were conducting local area flight training before departing on a night cross-country flight. The airplane was southbound on the south end of the airport when several witnesses observed the airplane flying erratically at low altitude. The witnesses observed that, after several maneuvers, the airplane was in a turn when it suddenly entered an almost vertical spiral into the ground. Postaccident examination of the airplane revealed no preaccident mechanical malfunctions or failures that would have precluded normal operations. An autopsy of the instructor revealed severe atherosclerosis of the right coronary artery with superimposed fresh-recent thrombus, suggesting an acute myocardial infarction (heart attack). The instructor’s most recent application for a second-class medical certificate noted “no” to all under “Medical History” including heart or vascular trouble. There was no indication that the instructor was aware of his heart disease. Such an acute event may have led to incapacitation of the instructor and distracted of the student pilot to the point of a loss of airplane control.

Factual narrative

HISTORY OF FLIGHT On July 30, 2010, about 2000 central daylight time, an American Champion Aircraft Corp., 7GCBC, N5027G, registered to private individuals and operated by Big Q Aviation, impacted terrain in the vicinity of Mid-Way Regional Airport (JWY), Midlothian, Texas. The certified flight instructor (CFI) and student pilot were fatally injured. The airplane was substantially damaged. Visual meteorological conditions (VMC) prevailed and no flight plan was filed for the Title 14 Code of Federal Regulations Part 91 instructional flight. The flight originated from JWY about 1955. The CFI and student pilot, were doing local area traffic pattern flights prior to departing the area for a night cross country flight instructional flight. Two witnesses driving eastbound on the highway west of the impact location, observed the southbound airplane initiating a left hand turn below 250 feet above ground level (AGL). One of the witnesses stated, the airplane was going very slow when the airplane completed the turn, the nose dropped down and the airplane entered a shallow dive and recovered to climb up to about 300 feet AGL. The airplane then entered another flat turn. During the turn, the airplane turned more sharply and started to dive again and went into a wings level nose down attitude. The witnesses were then less than a half-mile from the impact location when the airplane pulled up sharply, and the airplane entered an almost vertical spiral into the ground. Another witness about 1,500 feet northeast from the impact location observed the airplane flying much lower than normal. The airplane continued to descend and began a left turn which steepened and the airplane then suddenly headed straight down and impacted terrain. PERSONNEL INFORMATION The 64-year-old CFI, held an airline transport pilot certificate with ratings for airplane multiengine land and instrument airplane. In addition, his certificate included commercial pilot privileges with ratings for airplane single-engine land and glider. He held a flight instructor certificate with ratings for airplane single and multiengine land, and instrument airplane. He also held an aircraft dispatcher certificate. The CFI held a second-class medical certificate issued on July 8, 2010, with the restriction, "Must wear corrective lenses." The CFI’s last flight review was completed on April 29, 2010. A recovered insurance form dated July, 2010, indicated the CFI reported he had 16,000 total flight hours with 2,500 of those hours in conventional gear equipped airplanes. In addition, the CFI indicated he had 3,500 hours as a flight instructor. The 37-year old student pilot was issued a second-class medical certificate dated February 25, 2010, with the restriction, "Holder shall wear corrective lenses." The back side of the student pilot’s certificate was endorsed for solo flight in 7GCBC aircraft on May 2, 2010, and was endorsed for solo cross country flight in 7GCBC aircraft on May 17, 2010. The last entryrecorded in the student pilot's logbook on July 29, 2010 revealed he then had accumulated 23.4 hours total time in all airplanes with all of that experience in the accident airplane. The logbook contained entries for 18.2 hours of dual instruction and 5.2 hours of solo flight. AIRCRAFT INFORMATION: The airplane was a single-engine, high wing, tail wheel airplane with aerobatic capability. The airplane serial number 1174-79 was manufactured in 1979, and it was powered by a Lycoming O-320-A2B, 150 horsepower engine driving a two bladed fixed pitch metal propeller. Review of the airplane log books revealed the last annual inspection was conducted on December 5, 2009, and the total time on the engine and airframe was 2,330 hours. The last 100-hour inspection was conducted on June 5, 2010, at a total time of 2,432 hours. The aircraft total time at the time of the accident was estimated as 2,495 hours. METEOROLOGICAL INFORMATION At 1945, the automated surface weather observation at JWY reported wind from 170 degrees at 9 knots, visibility 10 miles, clear skies, temperature 33 degrees Celsius, dew point temperature 18 degrees Celsius, and an altimeter setting of 29.89 inches of Mercury. U.S. Naval Observatory data shows that on July 30, 2010, sunset occurred at 2027, and the end of civil twilight occurred at 2054. WRECKAGE AND IMPACT INFORMATION The main wreckage was located on the west side of a private unpaved road about one mile south of JWY. An impact crater was located on the east side of the road and about 20 feet from the main wreckage. A ground scar to the east of the impact crater corresponded to a ground impact with the right wing. A hand held compass showed that the main wreckage was located about 300 degrees from the impact crater. A trail of debris led from the impact crater to the main wreckage. The airplane was resting upright and the damaged fuselage was oriented to about 70 degrees. The right wing was partially separated and folded aft over the top of the right side of the empennage. The left wing was in place and sustained aft crushing along the leading edge. The cabin area had been impact compressed and reduced in size by approximately 40 percent. The engine was impact driven into the area of the front seat. The leading edges of both wings sustained aft crushing damage from the wing root, extending outboard to the wing tips. Both fuel tanks were ruptured. A portion of wing skin from the fuel tank area of both wings was removed and hydraulic deformation was observed on both fuel tanks. The ailerons were damaged and remained attached at all hinge points. The flaps were damaged and remained attached at all hinge points. The vertical fin, rudder assembly were not damaged. The right horizontal stabilizer and elevator were not damaged. The left horizontal stabilizer and left elevator were damaged. The left trim tab remained attached to the left elevator. Control cable continuity was verified throughout the airframe, and it was noted thatthe rear seat throttle handle was observed impact locked in the fully closed position. The position of the front seat throttle handle could not be determined because of impact damage. The separated propeller was observed resting adjacent to the impact crater. One blade displayed an approximate two degree aft bend at six inches out from the blade tip and the other blade displayed a gradual ten degree aft bend approximately six inches out from the propeller hub. The back of both propeller blades displayed rotational scoring and leading edge polishing. The face of both propeller blades were unblemished. Crush angles evident on the propeller spinner were consistent with a near vertical impact. The engine remained partially attached to the fuselage and engine mounts. It was removed and examined. The exhaust system was impact crushed. The exhaust system was removed, along with the magnetos, rocker covers, spark plugs, and the vacuum pump. The crankshaft was rotated by hand and thumb suction and compression were obtained on all cylinders. Valve action was observed at all rockers, and the accessory gears were observed rotating. Mechanical continuity was observed throughout the engine. All cylinders were inspected using a lighted borescope and accelerated wear was observed on all of the cylinder walls. The oil suction screen was removed and examined. It was noted that approximately five percent of the screen was obstructed with particles that had the appearance of carbon flakes and ferrous metal. The carburetor was impact broken off of the engine. It was recovered and the inlet fuel screen was removed and examined, it was observed unremarkable. The carburetor was destroyed and no testing was done on the unit. No fuel was observed at the engine examination. The gascolator was removed and the screen was examined, it was observed unremarkable. Both magnetos were rotated by hand and both furnished spark at all outlet points as required. An unmeasured amount of oil displaying an extended service life was observed in the oil sump. An approximately four inch fracture was observed on the upper right front of the crankcase that began at the crankshaft flange and continued longitudinally aft. Both magnetos were removed from the engine and rotated by hand. Spark was furnished at all outlet points. All eight spark plugs were removed and examined. They all exhibited wear and color consistent with normal combustion when compared to the Champion Spark Plug Wear Chart. No preimpact mechanical malfunctions or failures of the aircraft or engine were found that would have precluded normal operation. A Garmin global positioning system (GPS) receiver was retrieved from the wreckage and sent to the NTSB Vehicle Recorder Laboratory for download. The GPS data was reviewed and the accident flight was not recorded. MEDICAL AND PATHOLOGICAL INFORMATION The Institute of Forensic Sciences, Medical Examiner, Dallas, Texas, conducted the autopsy on the CFI on July 31, 2010. The causeof death was blunt force injuries. The autopsy of the CFI also revealed severe atherosclerosis of the right coronary artery with superimposed fresh-recent thrombus suggesting an acute myocardial infarction (heart attack). The CFI’s most recent application for a second-class medical certificate noted “no” to all under “Medical History” including heart or vascular trouble. There was no indication that the CFI was aware of his heart disease. The Bioaeronautical Research Science Laboratory, Federal Aviation Administration (FAA), Oklahoma City, Oklahoma performed a postmortem toxicology of specimens from the CFI. The report stated that the test results were negative for carbon monoxide, cyanide, ethanol, and listed drugs. The Institute of Forensic Sciences, Medical Examiner, Dallas, Texas, conducted the autopsy on the student pilot on July 31, 2010. The cause of death was multiple blunt force injuries. The Bioaeronautical Research Science Laboratory, FAA, Oklahoma City, Oklahoma performed a postmortem toxicology of specimens from the student pilot. The report stated that the test results were negative for carbon monoxide, cyanide, ethanol, and listed drugs. ADDITIONAL INFORMATION: Review of performance data in the airplane flight manual revealed the airplane will stall at 43 knots or 50 mph. Refueling facility records at JWY showed that the airplane had most recently been serviced with 16.6 gallons of 100LL aviation gasoline. Following the accident, management persons at JWY quarantined the fuel facility and personally supervised fuel quality testing of the 100LL refueler. Samples taken from both the hose and the tank sump were clean and showed no debris, water, or other contamination. First responders said that a strong smell of fuel was noted around the wreckage immediately after the accident. Another person, who was not a witness to the accident, stated he was rated as an airline transport pilot and had flown with the CFI on several occasions and did not believe that the CFI would ever allow an airplane to stall/spin. He also stated that the CFI instructed aircraft control and stall awareness as a principle.

Aircraft

Registration
N5027G
Reported as
American Champion Aircraft Cor 7GCBC
Category
Airplane
Serial number
1174-79
Airframe hours
2,432
Engine
Lycoming O320, 150 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Big Q Aviation, doing business as Big Q Aviation
Registered owner
Peter Setian And Carol L Walker
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 5, 2010 · 63 hours before
Departed
JWY · Midlothian, TX
Destination
JWY · Midlothian, TX
Airport
JWY · Mid-Way Regional Airport, runway 18, 4,999 × 75 ft, asphalt

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
64
Injuries
Fatal
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
April 29, 2010
Seat
Rear
Toxicology
Performed
Flight hours
16,000 total · 500 in this make and model
Role
Student pilot
Age
37
Injuries
Fatal
Certificate
Student
Airplane ratings
Single-engine land
Medical
Class 2, With waivers/limitations
Last flight review
May 2, 2010
Seat
Front
Toxicology
Performed
Flight hours
33 total · 33 in this make and model · 8 as pilot in command · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 64 °F
Altimeter
29.88 inHg
Observed at
JWY, 1 nm away

Docket · 23

The files NTSB released with the investigation on August 24, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 25.2 MB in all.

Summary of On-scene Examination of Airframe and EngineItem 1 · .PDF · 59 KBWitness StatementsItem 2 · .PDF · 389 KBWaxahachie Police ReportItem 3 · .PDF · 611 KBPilot Operating Manual (Selected Pages)Item 4 · .PDF · 2.4 MBWeather SummaryItem 5 · .PDF · 313 KBCertified Flight Instructors Recent Pilot Experience as Reported on an Insurance Pilot History FormItem 6 · .PDF · 1.1 MBStudent Pilot Log Book and Medical CertificateItem 7 · .PDF · 13.2 MBGlobal Positioning System Device - Specialist's Factual ReportItem 8 · .PDF · 14 KBPhoto 1 - West facing view of the impact crater and the main wreckage (NTSB Photo)Item 9 · .PDF · 59 KBPhoto 2 - View of the main wreckage as seen from the east (NTSB Photo)Item 10 · .PDF · 602 KBPhoto 3 - Wreckage and impact crater as viewed from the southeast (NTSB Photo)Item 11 · .PDF · 269 KBPhoto 4 - Close-up view of propeller (FAA Photo)Item 12 · .PDF · 698 KBPhoto 5 - Close-up view of the engine and forward cockpit area (Lycoming Photo)Item 13 · .PDF · 420 KBPhoto 6 - Engine and forward cockpit area as viewed from the left front (NTSB Photo)Item 14 · .PDF · 449 KBPhoto 7 - Wreckage as viewed from the left rear (Lycoming Photo)Item 15 · .PDF · 551 KBPhoto 8 - Wreckage as viewed from the right rear (Lycoming Photo)Item 16 · .PDF · 485 KBPhoto 9 - Engine as viewed from the front (NTSB Photo)Item 17 · .PDF · 650 KBPhoto 10 - Engine as viewed from the left side (NTSB Photo)Item 18 · .PDF · 739 KBToxicology - Certified Flight InstructorItem 19 · .PDF · 126 KBToxicology - Student PilotItem 20 · .PDF · 139 KBStatement of Party Representatives to NTSB InvestigationItem 21 · .PDF · 1.1 MBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 22 · .PDF · 585 KBRelease of Aircraft Wreckage - Receipt for Returned Garmin GPSMAP 96CItem 23 · .PDF · 232 KB

FAA reports on this event · 1

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