# NTSB CEN21FA345: Piper J3C-65, N42522, Hartford, WI, July 31, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: July 31, 2021, 11:30 local (16:30 UTC) - Place: Hartford, WI - Coordinates: 43.350781, -88.400281 - Nearby events: https://openairdocs.org/map.md?lat=43.3508&lon=-88.4003&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA-MKE FSDO - NTSB case key (mKey): 103599 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21FA345 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103599/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103599 - Page: https://openairdocs.org/ntsb/CEN21FA345 ## Probable cause The flight crew’s exceedance of the airplane’s critical angle of attack during a simulated engine failure during initial climb after takeoff, which led to an aerodynamic stall/spin and loss of control. Contributing to the severity of the occupants’ injuries was the airplane’s lack of shoulder harnesses. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Piper J3C-65, 8 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7100510), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Piper J3C-65, 4 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7100510), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Flight crew (probable cause); cases with it: [Piper J3C-65, 43 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7100510), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Equipment/furnishings: flight compartment equipment](https://openairdocs.org/ntsb-findings/01022510): Aircraft › Aircraft systems · Not installed/available; cases with it: [Piper J3C-65, 3 cases](https://openairdocs.org/ntsb-findings/01022510/cases.md?model=7100510), [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [Piper J3C-65, 1 case](https://openairdocs.org/ntsb-events/600/sequence.md?model=7100510), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper J3C-65, 21 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7100510), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot receiving instruction reported that they had performed about 10 practice takeoffs and landings before the accident takeoff. On the accident takeoff, when the airplane reached an altitude of 400-500 ft above ground level (agl), the instructor said, “engine failure, turn around for 09”. The pilot receiving instruction later reported that it was unclear from the instructor’s statement whether it was an actual or a simulated engine failure. Both pilots were on the flight controls at the time and started a turn when the airplane entered a “graveyard spin”. The pilot receiving instruction remembered about 1 to 2 seconds of the spin and had no further recollection of the accident. Examination of the flight controls and engine did not reveal any preimpact anomalies that would preclude normal operation. Based on the surviving pilot’s description and the airplane damage signatures, the airplane was in a nose-low, left-wing low attitude at impact. It is likely that the airplane entered an inadvertent stall/spin when the critical angle of attack was exceeded. The surviving pilot was not sure if the airplane’s engine had actually lost power or if the flight instructor was simulating an engine emergency. The lack of engine-related mechanical anomalies and the pilot training purpose of the flight suggest that it was likely a simulated emergency scenario initiated by the flight instructor. The airplane was not equipped with shoulder harnesses and only lap seat belts were installed. Regulations did not require shoulder harnesses to be installed at the time it was manufactured. However, at the time of the accident, several manufacturers offered shoulder harnesses kits that could be retrofitted to the airplane under supplemental type certificate. The investigation determined that the injuries to the occupants were consistent with the use of only lap seat belts. The availability of shoulder harnesses would likely have reduced the severity of the injuries. ## Factual narrative On July 31, 2021, about 1130 central daylight time, a Piper J3C-65 airplane, N42522, was substantially damaged when it was involved in an accident near Hartford, Wisconsin. The flight instructor was fatally injured and the pilot receiving instruction was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot receiving instruction reported that they were practicing takeoffs and landings from runway 27 at the Hartford Municipal Airport (HXF) and had performed about 10 before the accident occurred. On the accident takeoff, when the airplane reached 400-500 ft agl, the instructor said, “engine failure, turn around for 09”. The instructor did not state if it was an actual or simulated engine failure. Both pilots were on the controls at this time and started a turn for runway 9 when the airplane entered a “graveyard spin.” He remembered about 1 to 2 seconds of the spin and had no further recollection of the accident. The airplane impacted a bean field about 1,100 ft west of the departure end of runway 27. Based on airframe damage signatures, the airplane impacted in a left-wing low, nose low attitude, with the airplane coming to rest about 35 ft west of the initial impact point. A postaccident examination of the airplane confirmed flight control system continuity from the cockpit controls to all control surfaces. There were no separations in any of the flight control cables. The left-wing spars were broken at the wing root, but the remainder of the wing was predominately intact. Both left lift struts were bent and remained attached at the fuselage and wing. The right wing remained attached to the fuselage with little damage. Both right lift struts were bent and remained attached to the fuselage and wing. The forward lower fuselage at the firewall was pushed rearward. The engine remained attached to the fuselage. One propeller blade was bent aft and under the engine, and the crankshaft was partially separated just aft of the propeller flange. Examination of the engine confirmed internal continuity, and both magnetos provided a spark on all spark plug leads. All spark plugs were examined, and no anomalies were noted. The front of the cabin area was crushed rearward and upward at the firewall, but the deformation was limited to the area where the front pilot would have placed their feet. The top of the instrument panel was bent forward, consistent with the front pilot impacting it during the accident sequence. The flight instructor in the front seat suffered fatal injuries attributed to blunt force trauma to the head by the medical examiner. The student pilot in the rear seat sustained serious head and torso injuries, including loss of consciousness, lumbar and rib fractures, and broken ulna and radius. When originally manufactured, the airplane was equipped with lap seat belts but did not have shoulder harnesses installed and no shoulder harnesses had been retrofitted to theairplane. A National Transportation Safety Board survival factors specialist used anthropometric data, photographic evidence, manufacturer drawings, and measurements taken from the accident scene to determine the occupant trajectories in the event of an accident both with and without shoulder harnesses installed. The study showed that both occupants were likely to impact their head and upper torso on structures located within the airplane’s cabin when restrained only by a lap belt. The addition of an upper torso restraint (shoulder harness) would likely have lessened the severity of the injuries by altering the body trajectories such that impact forces with objects within the cabin were eliminated or lessened. Effective July 18, 1977, Section 23.785 of 14 CFR Part 23 required all normal aircraft, for which application for type certificate was made on or after July 18, 1977, to have approved upper torso harnesses for each front seat. Section 14 CFR Part 91.205(b)(14) required all small civil airplanes manufactured after December 12, 1986, to have an approved upper torso harness for all seats. However, aircraft that were manufactured before that date were not required to have an upper torso restraint installed. In 1981 the NTSB initiated a multi-part general aviation crashworthiness program (NTSB Safety Report SR8301). The NTSB examined accidents and their effects on the occupants and airplane structure for the purpose of upgrading occupant protection design standards. In the second report in this program (NTSB Safety Report SR8501), the NTSB found that 20 percent of the fatally injured occupants in those accidents could have survived with upper torso harnesses (assuming the seatbelts were fastened properly) and 88 percent of the serious injuries could have significantly less severe injuries with the use of upper torso harnesses. The NTSB concluded that upper torso harness use was the most effective way of reducing fatalities and serious injuries in general aviation accidents. As a result of the program the NTSB issued safety recommendation A-85-124 recommending the FAA issue an advisory circular to provide information on crash survivability aspects of small aircraft. In March 1987, Technical Standard Order (TSO) C114, “Torso Restraint Systems,” was issued by the FAA. The TSO prescribed the minimum performance standards that upper torso harness restraint systems must meet to be identified with a TSO marking. Then on September 19, 2000, the FAA issued policy statement number ACE-00-23.561-01, “Methods of Approval of Retrofit Shoulder Harness Installation in Small Airplanes.” This provided guidance to make it easier to retrofit shoulder harnesses in certificated aircraft by making it a “minor change” if the following criteria were met: The aircraft was manufactured before July 19, 1978, for front seats and Dec. 12, 1986, for rear seats. TSO-C114 belts were used. No drilling or welding had been performed. The mechanic doing the install consultedAdvisory Circular 43.13-2A, Chapter 9, for information on restraint systems, effective restraint angles, attachment methods, and other details of installation. The installing mechanic made an entry in the aircraft's maintenance log. If drilling or welding was required, then a supplemental type certificate or field approval was required to make the modification. At the time of this accident several manufacturers offered shoulder harness kits that could be retrofit to the accident airplane under supplemental type certificate. ## Aircraft - Registration: [N42522](https://openairdocs.org/aircraft/N42522), registered now, S/N 14795 (OpenAirDocs) - Reported make and model: PIPER J3C-65 - Registry model: [Piper J3C-65](https://openairdocs.org/model/piper-j3c-65) (registry code 7100510) (OpenAirDocs) - Category: Airplane - Serial number: 14795 - Year built: 1945 - Airframe hours: 5295 - Engines: Continental C90-8 90 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Cub Air Flight LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 22, 2021 - Airport: HXF, Hartford Muni, runway 09/27, 3,401 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 21; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine sea, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: front; restraint: lap only; toxicology performed; flight hours: 388 total, 122 in this make and model, 299 as pilot in command, 93 in the last 90 days, 47 in the last 30 days - Pilot; age 18; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: rear; restraint: lap only ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 5 knots, gusting 8 - Visibility: 10 statute miles - Temperature: 73 °F, dew point 61 °F - Altimeter: 30.02 inHg - Observed at: KETB, 12 nm away - METAR: METAR KETB 311635Z AUTO 26005G08KT 10SM SCT028 SCT037 23/16 A3002 RMK AO2= ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20210731012259A](https://openairdocs.org/incident/20210731012259A), Jul 31, 2021: Piper J3C-65, Hartford, WI, Substantial damage, 1 fatal. On 07/31/2021 at approximately 1130 CST while practicing take-off's and landings at Hartford, WI. (Hxf), a Piper J3 cub, N42522 lost power and landed in a… ## Docket (11 files) The files NTSB released with the investigation on April 26, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103599. 12.8 MB in all. - CEN21FA345 specialist restraint study (item 1, PDF, 14 pages, 12 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15203219&FileExtension=pdf&FileName=CEN21FA345%20Specialist%20Restraint%20Study-Rel.pdf - CEN21FA345 sf attachment 1 injury chart (item 2, PDF, 2 pages, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15203375&FileExtension=pdf&FileName=CEN21FA345%20SF%20Attachment%201%20Injury%20Chart-Rel.pdf - CEN21FA345 sf attachment 2 firefighter narrative (item 3, PDF, 3 pages, 2 photos, 277 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15202472&FileExtension=pdf&FileName=CEN21FA345%20SF%20Attachment%202%20Firefighter%20Narrative-Rel.pdf - Medical factual (item 4, PDF, 4 pages, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15209886&FileExtension=pdf&FileName=CEN21FA345_Hartford_WI_Medical_Factual_FINAL_030823-Rel.pdf - Toxicological report (item 5, PDF, 1 page, 416 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15216273&FileExtension=pdf&FileName=2021_127_001_Redacted-Rel.pdf - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 6, PDF, 9 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15216195&FileExtension=pdf&FileName=6120-unlocked_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 1 page, 732 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15215874&FileExtension=pdf&FileName=CCF_000011_Redacted-Rel.pdf - Record of conversation with rear seat pilot (item 8, PDF, 1 page, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15216106&FileExtension=pdf&FileName=ROC%20with%20rear%20seat%20pilot-Rel.pdf - Sheriff's report (item 9, PDF, 18 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15217129&FileExtension=pdf&FileName=Sheriff%20report%20combined_redacted-Rel.pdf - Photographs (item 10, PDF, 8 pages, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15217080&FileExtension=pdf&FileName=Docket%20Photo%20array-Rel.pdf - Aircraft examination summary (item 11, PDF, 8 pages, 6 photos, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15333594&FileExtension=pdf&FileName=Examination%20Summary%20-%20Report-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.