CHI94FA097

NTSB accident investigation · Piper PA-38-112 · Inman, KS · March 5, 1994

Accident · FatalField investigationFinal report
Date
March 5, 1994, 08:30 local (14:30 UTC)
Place
Inman, KS
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N2495LPiper PA-38-112
Weather
Visual (VMC) · Day
Status
Completed · report July 12, 1995
Report
Approved by Office Director
Safety recommendations
Yes
FAA report
19940305003609A
Case key
9371

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

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Probable cause

An unintentional spin which occurred during the maneuvering phase of a biennial flight review. A factor related to the accident was: the airplane's lateral-directional characteristics at or near the stall speed.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightManeuvering
Stall/spin - inadvertentFlightcrewCause
Insufficient standards/requirementsManufacturerFactor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The purpose of the flight was to provide a biennial flight review for a private pilot with about 100 hours total flight time. Witnesses observed the airplane spin 5 or 6 turns to the left & reported that the airplane stopped rotating just before it struck the ground. The spin is believed to have occurred inadvertently while the private pilot was demonstrating a stall or slow flight. Although the PA-38 has four non-adjustable stall strips, intended to improve its lateral-directional characteristics, its stall/spin accident rate is significantly higher than comparable trainer-type airplanes.

Factual narrative

History of flight

On March 5, 1994, at 0830 central standard time (cst), a Piper PA-38-112, N2495L, registered to Marvin Hall dBa Hutchinson Aviation, of Hutchinson, Kansas, with a commercially certificated flight instructor administering a biennial flight review (flight review) to a private pilot, was destroyed during a collision with the ground and subsequent fire. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 flight was not operating on a flight plan. Both pilots were fatally injured. The flight departed Hutchinson, Kansas, at 0800 cst.

Three witnesses said they observed the airplane during its descent to the ground. Two witnesses observed the airplane in a five or six turn spin to the left. One witness said he saw the spin stop just above the ground, with the airplane's "...nose pulled up slightly, but then back down before it hit."

During the interview the witnesses were asked to show, with a model airplane, what N2495L had been doing during its descent to the ground. Each witness made a motion with the model airplane that replicated a left spin that had an approximate 45 degree nose down attitude.

Personnel information

The logbook for the pilot receiving the flight review was destroyed in the post crash fire. According to Federal Aviation Administration (FAA), the pilot obtained his private pilot certificate on November 27, 1991. The pilot reported he had 50 hours of flight time when he obtained his second class medical certificate on March 20, 1992. The pilot's supervisor said that to his knowledge the pilot was current and had taken annual leave to obtain a biennial flight review before his currency expired.

The flight review recipient's wife stated he had accumulated about 75 to 100 hours of flying time since obtaining his private pilot certificate. She said her husband had told her that his flight check was due before they moved to Des Moines, Iowa, in May 1994. The wife of the flight instructor administering the flight review stated the other pilot had not flown the PA-38 since May 21, 1993, according to company records.

The flight instructor administering the flight review had completed an FAA airman competency flight check according to 14 CFR Part 135.293, .297, and .299 on December 31, 1993. This pilot's number three logbook showed he had a total time of 7,944.9 hours, 1,803.5 hours as a flight instructor, as of January 25, 1994. The logbook began with the entry of August 16, 1985, showing a total flight time of 4,943.2 hours. The first Piper PA-38 (PA-38) logbook entry was made on August 18, 1985. The pilot's total flying time in the PA-38, as found in the number three logbook, was 104.9 hours. Complete pilot logbook records were not made available for review. The NTSB Form 6120.1/2 that was sent to the pilot's wife was not returned. She did say that he had a total time of 745 hours in the Piper PA-38.

The instructor's flight review methodology was revealed during interviews with two pilots and a written statement from a third pilot. One pilot said the instructor had him do approach to landing, and takeoff and departure stalls on headings and in turns. He said that he demonstrated these stalls to the instructor with landing flaps retracted and extended. The second pilot said the instructor asked to see imminent stalls only. His written statement said, "...I proceeded one time to go to a full stall and Marvin quickly detoured that route."

A pilot, training for a flight instructor rating, said the instructor had spun the PA-38 on several occasions during his training. He said the instructor had demonstrated one turn spins to him and that he had performed spins under his direction. The pilot said the instructor had discussed stalls, spin entry, and spin recovery with him during ground training. He said the instructor had told him to avoid getting the airplane into a spiral and that he had to enter the spin forcefully.

Aircraft information

The PA-38 was certified under the Delegated Option Authority granted to manufacturers of aircraft by the FAA. The PA-38 received its airworthiness certificate from the FAA on December 20, 1977. The PA-38 was certified in the utility and normal category by the FAA. This certification allowed it to perform spins when operated in the utility category.

According to the pilots operating handbook (POH), "Normal recoveries may take up to 1 1/2 turns when proper technique is used; improper technique can increase the turns to recover and the resulting altitude loss." The POH continues, "In all spin recoveries the control column should be moved forward briskly, continuing to the full forward stop if necessary. This is vitally important because the steep spin attitude may inhibit pilots from moving the control column forward positively."

The POH says "...one half of the spin [rotation takes]... about one second... . Improper application of recovery controls can increase the number of turns to recover and the resulting altitude loss. Delay of more than about 1-1/2 turns before moving the control wheel forward may result in the aircraft suddenly entering a very fast, steep spin mode which could disorient a pilot. Recovery will be achieved by briskly moving the control wheel fully forward and holding it there while maintaining full recovery rudder." "If such a spin mode is encountered, the increased rate of rotation may result in the recovery taking more turns than usual after the control column has been moved fully forward. A one-turn spin, properly executed, will require 1,000 to 1,500 feet to complete and a six-turn spin will require 2,500 to 3,000 feet to complete."

Three Piper Aircraft Corporation Service Bulletins (Numbers 609, 661 and 800) were issued on the PA-38's control column. Number 609 dealt with ensuring that the control column (tube) was securely welded to the control wheel. This service bulletin was made into a Federal Aviation Administration Airworthiness Directive (AD). Service bulletin numbers 661 and 800 dealt with the binding of the control column when positioned fully aft (full up elevator).

According to N2495L's airframe logbooks, service bulletins 661 and 800 were complied with. Service Bulletin 609, and its accompanying airworthiness directive, did not apply to N2495L.

Wreckage and impact information

N2495L collided with the ground on an approximate magnetic heading of 040 degrees. The first ground scar was oriented on an approximate magnetic heading of 130/310 degrees, measuring about 38 feet. A second ground scar, originating from the midpoint of the first, was about 120 feet long and on a magnetic heading of 345 degrees. The second ground scar led to N2495L's wreckage. The airplane's wreckage heading was 355 degrees magnetic.

The first ground scar varied in depth between two and four inches. It had white paint transferred onto sections of compressed dirt. A piece of curved, green, glass was found at the extreme southeast edge of this ground scar. At the center of this ground scar an elliptically shaped depression measuring about five feet wide and six feet long. It was about seven inches deep at the center. Gouge marks were found in the approximate center of this area. The largest gouge mark matched one of the airplane's propeller blades. Examination of the blade found chordwise scratches, some having the same colored dirt in them as found in the gouge.

The main landing gear legs had separated from the fuselage mounts. One main landing gear was found on top of the left wing at the mid-span position. A second main landing gear leg was found about 100 feet northwest of the first ground scar termination point. The wheel and tire assemblyies were attached to the main landing gear legs. The tires matched ground indentations that were found south of the elliptically shaped ground depression. The ground indenta

Aircraft

Registration
N2495L
Reported as
Piper PA-38-112
Category
Airplane
Serial number
38-79A0734
Engine
Lycoming O-235-L2C, 112 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Registered owner
M. Hall
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Continuous airworthiness · February 23, 1994
Departed
HUT · Hutchinson, KS

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Toxicology
Performed
Flight hours
7,945 total · 105 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
15 statute miles
Lowest ceiling
None
Temperature
37 °F
Altimeter
29.00 inHg
Observed at
HUT, 11 nm away

FAA reports on this event · 1

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