ERA12FA345

NTSB accident investigation · Shepard Jimmy D JR Pitts S1D · Port Richey, FL · May 21, 2012

Accident · FatalField investigationFinal report
Date
May 21, 2012, 12:10 local (16:10 UTC)
Place
Port Richey, FL
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N360MWShepard Jimmy D JR Pitts S1D
Defining event
Maneuvering-aerobatics: Low altitude operation/event
Weather
Visual (VMC) · Day
Status
Completed · report June 19, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA Tampa FSDO, Lycoming Engines
FAA report
20120521008189A
Case key
83705

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 pilot's decision to conduct aerobatic flight at a low altitude, which resulted in a collision with the water.

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.

Terrain: waterEnvironmental issues › Physical environment · Contributed to outcomeShepard Jimmy D JR PITTS S1D: 1 caseAll aircraft: 97 cases
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Incorrect use/operationShepard Jimmy D JR PITTS S1D: 1 caseAll aircraft: 1,310 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

Several witnesses reported that the pilot was conducting aerobatic maneuvers over the Gulf of Mexico. The airplane initiated a loop between 300 to 500 feet above the water. At the top of the loop, while inverted, the airplane started the descent; however, the airplane was too low to recover. The airplane collided with the water in a nose-down, left-wing-low attitude. There was no noticeable change in engine noise during the accident sequence. Examination of the airframe, flight controls, engine assembly and accessories revealed no anomalies. According to the pilot’s wife, for the 4 days leading up to the accident, the pilot had symptoms of a cold and was prescribed Amoxicillin, an antibiotic which treats infections.On the day of the accident, the pilot did not complain of or was not known to have any issues with light headedness or dizziness. Based on this information the pilot did not appear to have a medical condition that would have contributed to the accident and witness accounts indicated the pilot was maneuvering the airplane until impact with the water. According to the operating rules section of 14 Code of Federal Regustions Part 91, which defines the restrictions on aerobatics, no person may operate an aircraft in aerobatic flight below an altitude of 1,500 feet above the surface.

Factual narrative

***This report was modified on May 8, 2013. Please see the docket for this accident to view the original report.*** HISTORY OF FLIGHT On May 21, 2012, at 1210 eastern daylight time, an experimental, amateur-built Pitts S1D, N360MW, was substantially damaged when it impacted the waters of the Gulf of Mexico while conducting aerobatic maneuvers about 200 to 400 yards from the shoreline near Port Richey, Florida. The airline transport pilot was fatally injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight, which departed Hidden Lake Airport (FA40), New Port Richey, Florida, at 1145. According to the pilot’s father-in-law, the pilot was conducting aerobatic maneuvers over the Gulf of Mexico, while his family observed from a nearby park. During the demonstration, the witness watched as the pilot performed aileron rolls, wingovers, loops, and stalls. Immediately prior to the accident, the pilot initiated a loop at an altitude between 300 and 500 feet above the water. Upon reaching the apex of the loop, while the airplane was inverted, the airplane began to descend, and the witness observed that the airplane did not appear to have sufficient altitude to recover from the maneuver. The witness believed that the pilot may have attempted to recover from the maneuver before the airplane impacted the water in a nose down, left wing low attitude. The witness also reported that there was no discernible change in the sound of the engine at any point during the accident sequence. Another witness stated that he was wade fishing in the Gulf of Mexico at Brasher Park. The accident airplane had been conducting aerobatic maneuvers over the water. When he first observed the airplane, the pilot conducted several aileron rolls, stalls and loops at a higher altitude prior to the last loop, which the pilot initiated between 200 to 300 feet. He observed the airplane pitch up into a loop and start back down. There was no change in engine noise until the airplane started to pull out of the maneuver and there was a "pop" sound. The airplane collided with the water in a nose down, left wing low attitude. It floated for a short time before it started to sink. According to the pilot's wife, on the day of the accident, the pilot did not stay in the "box" as he normally did. She also added that the pilot normally flew crisp maneuvers and that his flying was kind of sloppy on the day of the accident. PERSONNEL INFORMATION The pilot, age 33, held an airline transport pilot (ATP) certificate with multiple ratings including airplane single-engine land and multi-engine land, with type ratings in the Boeing 737/757/767, Lear Jet 60, and Raytheon 390S. The pilot also held a flight instructor certificate with ratings for airplane single-engine, airplane multi-engine, and instrument airplane. According to Federal AviationAdministration (FAA) and pilot records, the pilot had accrued 3,359 total flight hours. Between August 10, 2011 and April 24, 2012, the pilot logged 45 hours of experience in the accident airplane make and model, 8 hours of which, was logged as dual instruction in aerobatics. The pilot’s most recent Federal Aviation Administration first-class medical certificate was issued on July 5, 2011, with no waivers or restrictions. AIRCRAFT INFORMATION The accident aircraft was a single–seat aerobatic biplane of conventional tube and fabric construction. It was equipped with a flat M6 aero foil section and upper and lower wing ailerons The airplane was powered by a non-certificated, experimental, 180 horsepower, Lycoming IO-360, with a Christen inverted oil system, a non- certificated fuel injection servo, a non- certificated fuel flow divider, a non-certificated right ignition system, and non-certificated alternator. No engine data plate was installed on the engine block. The left engine crank case half was marked L-3086-36. Lycoming records indicate that engine serial number left the factory on March 4, 1960, and was shipped to Beech Airplane Corporation as an O-360-A1A, 180 horsepower engine. In addition, Lycoming does not have any record that the engine had been returned to the factory for service. The FAA experimental operating limitations and special airworthiness certificate were issued on June 23, 1986 for N360DS. The registration for the airplane was later changed to N360MW. The last annual inspection was completed on June 24, 2011. At the time of the inspection, the airplane had accumulated 513.3 total hours of operation, and the engine had accumulated 2166.7 total hours of operation. METEOROLOGICAL INFORMATION The Tampa International Airport (TPA), Tampa, Florida, 1253 surface weather observation, located 21 nautical miles southeast of the accident site was: wind from 250 degrees at 8 knots, visibility 10 miles, clear skies, temperature 30 degrees Celsius, dew point 12 degrees Celsius, and altimeter setting of 30.01 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane came to rest on the sea floor in the Gulf of Mexico, west of Brasher Park in Port Richey, Florida. Examination revealed that it had come to rest upright in 4 feet of water on a magnetic heading of 334 degrees. Post accident examination of the airplane revealed the propeller assembly remained attached to the propeller crankshaft flange. The propeller spinner was damaged and separated from the spinner bulkhead. The forward spinner bulkhead and rear spinner bulkheads were pushed aft and exhibited deformation opposite the direction of rotation. One propeller blade was bent aft 10 degrees, 18 inches inboard of the propeller blade tip, and the other propeller blade was not damaged. The engine was partially disassembled and crankshaft and valve train continuity was verified by rotating the drive train by turning the crankshaft flange. Suction and compression was obtained onall cylinders. Valve train continuity was observed through all cylinder rocker arms and the accessory drive gears were observed to rotate. All cylinders were examined using a lighted bore scope and no anomalies were noted. The throttle was in the full open position and the mixture was full rich. The fuel selector valve was on. The tachometer indicated 240.6 hours. The altimeter indicated 300 feet and 29.99 inches of mercury. The “G” meter was set for 1 G. One indicator hand of the G meter indicated negative 5Gs and the other hand of the G meter indicated positive 12Gs which were the maximum readings. The upper right wing separated at the wing root and the two inboard ribs were separated. The rear wing spar was broken. The upper aileron remained attached to all attachment points and was not damaged. The right wing strut remained attached to the bottom of the wing. The bottom right wing separated at the wing root and was fragmented. Both the front and rear spars were broken. The right wing strut was not attached to the top of the bottom right wing. The bottom aileron remained attached at all attachment points and was damaged. The flying wires were attached. The upper left wing separated at the wing root and the two inboard ribs were separated. The rear wing spar was broken. The upper aileron remained attached at all attachment points and was not damaged. The left wing strut remained attached to the bottom of the left wing. The bottom left wing separated at the wing root and was fragmented. Both the front and rear spars were broken. The left wing strut was not attached to the top of the left wing. The bottom left aileron remained attached at all attachment points and was not damaged. The flying wires were intact. The fuselage from the pilot seat aft was intact and the vertical fin was attached and not damaged. The left and right horizontal stabilizers were intact and not damaged. Both elevator control surfaces were attached and undamaged. The elevator trim tab was deflected in the full up (nose down) position. Control continuity of the airplane was traced from the cockpit area to each of the flight control surfaces, with no anomalies noted. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the remains of the pilot by the Medical Examiner District Six, Largo, Florida, as authorized by the Pinellas County Coroner. The cause of death was listed as blunt trauma. The FAA Civil Aerospace Medical Institute (CAMI) performed forensic toxicology on specimens from the pilot with negative results for drugs and alcohol. In an interview with a CAMI medical doctor, the wife of the pilot stated that her husband experienced a fainting episode while on a business trip about two years prior to the accident and that he had suffered a possible broken nose. A review of the pilot's FAA medical records failed to identify any documentation relating to the fainting incident or any other condition that would facilitate symptoms related to losing consciousness.According to the wife of the pilot, on the four days leading up to the accident, the pilot had symptoms of a cold and at one point, was relieved from his occupational flying duties due to left eye pain. The pilot consulted a family care clinic where he received a diagnosis of bronchitis and a chest x-ray that did not indicate any abnormal conditions. He was prescribed 875 milligrams of Amoxicillin, an antibiotic which treats infections, and sent home where he later mowed his yard. The next day was spent at brunch, at the beach with family, and welding cosmetic items onto his airplane. The pilot's wife stated that on the day of the accident, the pilot did not complain of or was not known to have any issues with light headedness or dizziness. ADDITIONAL INFORMATION According to the FAA, aerobatic flight is defined as an intentional maneuver involving an abrupt change in an aircraft’s attitude, an abnormal attitude, or abnormal acceleration, not necessary for normal flight. According to the operating rules section of 14 CFR Part 91 which defines the restrictions on aerobatics, no person may operate an aircraft in aerobatic flight below an altitude of 1,500 feet above the surface.

Aircraft

Registration
N360MW
Reported as
Shepard Jimmy D JR Pitts S1D
Category
Airplane, amateur-built
Serial number
062957DS
Airframe hours
513
Engine
Lycoming IO-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
John P. Donnenfield
Registered owner
John P. Donnenfield
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Annual · June 24, 2011
Departed
FA40 · New Port Richey, FL
Destination
FA40 · New Port Richey, FL

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
33
Injuries
Fatal
Certificates
Airline transport, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Front
Toxicology
Performed
Flight hours
3,359 total · 45 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
86 °F, dew point 54 °F
Altimeter
30.01 inHg
Observed at
TPA, 21 nm away

Docket · 35

The files NTSB released with the investigation on April 26, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 62.9 MB in all.

Supplement aItem 1 · .PDF · 120 KBSupplement bItem 2 · .PDF · 157 KBRecord of Conversation M LundeItem 3 · .PDF · 200 KBRecord of Conversation VanpeltItem 4 · .PDF · 125 KBFAA CAMI Deceased Pilot Wife InterviewItem 5 · .PDF · 149 KBExtract Engine LogbookItem 6 · .PDF · 4.1 MBExtract Aircraft LogbookItem 7 · .PDF · 540 KBExtract Propeller LogbookItem 8 · .PDF · 1.4 MBFuel ReceiptsItem 9 · .PDF · 356 KBPilot Fuel LogItem 10 · .PDF · 121 KBAircraft RegistrationItem 11 · .PDF · 112 KBSpecial Airworthiness CertificateItem 12 · .PDF · 108 KBExperimental Operating LimitationsItem 13 · .PDF · 184 KBWeatherItem 14 · .PDF · 65 KBPort Richey Police ReportItem 15 · .PDF · 3.0 MBWeight and BalanceItem 16 · .PDF · 140 KBWreckage ReleaseItem 17 · .PDF · 145 KBWreckage Release Aircraft and Pilot Log BooksItem 18 · .PDF · 91 KBExtract Pilot LogbookItem 19 · .PDF · 1.5 MBToxicology ReportItem 20 · .PDF · 104 KBParty FormItem 21 · .PDF · 176 KBOn Scene Wreckage Summary.Item 22 · .PDF · 19 KBPhoto 1 Front view of airplane at rest. Photo NTSBItem 23 · .PDF · 3.8 MBPhoto 2 Front view of airplane at rest. Photo NTSBItem 24 · .PDF · 4.2 MBPhoto 3 Right side view of airplane. Photo NTSBItem 25 · .PDF · 4.1 MBPhoto 4 Left rear view of airplane. Photo NTSBItem 26 · .PDF · 4.1 MBPhoto 5 Left side view of airplane. Photo NTSBItem 27 · .PDF · 3.8 MBPhoto 6 Left front side view. Photo NTSBItem 28 · .PDF · 4.0 MBPhoto 7 View of aircraft during recovery at Brasher Park. Photo NTSBItem 29 · .PDF · 6.2 MBPhoto 8 View of fragmented engine cowling. Photo NTSBItem 30 · .PDF · 6.0 MBPhoto 9 View of instrument panel and cabin area. Photo NTSBItem 31 · .PDF · 3.1 MBPhoto 10 View of upper wing fuel cap. Photo NTSBItem 32 · .PDF · 2.9 MBPhoto 11 View of propeller Assembly. Photo NTSBItem 33 · .PDF · 4.0 MBPhoto 12 View of engine assembly during examination. Photo NTSBItem 34 · .PDF · 3.9 MBOriginal Factual Report with RevisionsItem 35 · .PDF · 25 KB

FAA reports on this event · 1

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