# NTSB ERA13LA024: Cashmer Philip M Sonex, N198PC, Crossville, TN, October 16, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 16, 2012, 08:20 local (13:20 UTC) - Place: Crossville, TN - Coordinates: 35.95111, -85.084724 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.9511&lon=-85.0847&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: Serious injuries - Injuries: 2 serious - Status: Completed, report June 4, 2013 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 85336 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA024 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85336/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85336 - Page: https://openairdocs.org/ntsb/ERA13LA024 ## Probable cause The pilot’s failure to maintain control of the airplane, which resulted in a low-altitude aerodynamic stall/spin. Contributing to the accident was a loss of engine power for reasons that could not be determined during postaccident examination and the pilot’s decision to depart with a known deficiency. Contributing to the pilot’s injuries was his failure to use the installed restraint system. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cashmer Philip M SONEX, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05630I3), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cashmer Philip M SONEX, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05630I3), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Cashmer Philip M SONEX, 1 case](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=05630I3), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cashmer Philip M SONEX, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=05630I3), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Equipment/furnishings: flight compartment equipment](https://openairdocs.org/ntsb-findings/01022510): Aircraft › Aircraft systems · Not used/operated (probable cause); cases with it: [Cashmer Philip M SONEX, 1 case](https://openairdocs.org/ntsb-findings/01022510/cases.md?model=05630I3), [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: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [Cashmer Philip M SONEX, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=05630I3), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cashmer Philip M SONEX, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05630I3), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cashmer Philip M SONEX, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05630I3), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cashmer Philip M SONEX, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05630I3), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Three days before the accident, a witness heard the airplane’s engine stop while the airplane was taxiing for departure and then restart before the airplane departed uneventfully. On the morning of the accident flight, another witness heard the airplane attempting to depart from the accident airport. During the departure, the engine power reduced suddenly while the airplane was at an altitude of about 15 feet. The airplane then continued to fly at that altitude until reaching the midpoint of the runway, before the engine power again increased, and the airplane began an abrupt climb. Shortly thereafter, another witness reported seeing the airplane in a spin just before it impacted the ground beyond the departure end of the runway. Postaccident examination of the airplane showed damage signatures consistent with the airplane being in a left-turning aerodynamic stall/spin at impact. Additionally, a witness report, the condition of the cockpit canopy, and the postaccident position of the pilot’s restraints suggested that the pilot was likely not wearing the restraints at impact. Examination of the engine revealed no evidence of any obvious mechanical deficiencies. A definitive determination of the engine’s operational state at impact could not be established based on available evidence; however, the manufacturer of the airplane kit advised pilots to discontinue a takeoff if there were any signs of abnormal engine operation and to investigate the cause before attempting another takeoff. ## Factual narrative On October 16, 2012, about 0820 central daylight time, an experimental amateur-built Sonex, N198PC, was substantially damaged when it impacted terrain shortly after takeoff from Crossville Memorial Airport (CSV), Crossville, Tennessee. The certificated private pilot/owner and the passenger were seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which was presumed to be destined for Winter Haven’s Gilbert Airport (GIF), Winter Haven, Florida. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to personnel from a fixed based operator (FBO) located at Martin Campbell Field (1A3), Copperhill, Tennessee, the pilot and passenger arrived in the accident airplane at their facility on October 12. The pilot stated that they were enroute to a fly-in event at CSV, but had to divert to 1A3 due to deteriorating weather conditions. The following morning, the FBO personnel watched as the pilot taxied the airplane for departure and noted that as the airplane approached the runway, the engine “stopped.” The personnel listened as the pilot then re-started the engine, back-taxied down the runway, and departed without further incident. On the morning of the accident flight, a pilot-rated witness observed as the accident airplane attempted to depart from runway 26 at CSV. The witness stated that he heard the airplane’s engine increase in power, and then heard a sudden reduction of power that caused him to turn his attention toward the airplane. He then observed the airplane about 1,000 feet from the approach end of the runway at an altitude of about 15 feet. The airplane continued to fly at that altitude until about the mid-field point, when the engine power again increased and the airplane “climbed abruptly,” before disappearing from view. The witness walked further out on the flight line in an attempt to regain sight of the airplane, but was advised by other individuals on the airport that the airplane had crashed near the departure end of runway 26, outside of the airport perimeter fence. Another witness, who was driving on a road adjacent to the airport, observed the accident airplane in a tail-low attitude before it began to “spin around” about 2 or 3 times. The airplane then impacted the ground, and the witness stopped to contact local authorities and render assistance. Another witness who stopped to render assistance noted that the pilot had been partially ejected from the cockpit, and did not appear to have been wearing any restraints. A Federal Aviation Administration (FAA) inspector examined the wreckage following the accident. According to the inspector, the airplane impacted terrain beyond the departure end of the runway, in a ravine. The left and right wing roots displayed compression buckling at their aft and forward fuselage connection points, respectively. The outboard leading edge of the left wing leading edge displayed aft crushdamage. The propeller was fragmented consistent with ground contact. The fuselage remained intact, with the majority of the damage concentrated within the area of the engine and firewall. A hole approximately 12 inches in diameter was broken through top of the overhead cockpit canopy. The left side of the left seat restraint was found tucked inside a side wall pocket. Continuity of the engine valvetrain and powertrain were confirmed, and rotation of the engine utilizing the starter showed no binding or other faults. Operation of the ignition system to the bottom spark plugs was confirmed, though operation of the top spark plugs could not be confirmed as the required engine speed could not be attained. The spark plugs appeared to be in new condition. Examination of the fuel system showed that fuel was available to the engine, with no anomalies noted. An electronic flight instrument system was recovered from the airplane and forwarded to the NTSB Vehicle Recorder Laboratory for further examination. Power was applied to the intact unit; however, no data were present as the data recording feature had not been enabled. A review of maintenance records revealed that the pilot was also the builder of the experimental amateur-built, kit airplane, which was completed in June 2011. Between that time and October 4, 2012, when the most recent airframe log entry was made, the airplane had accumulated 60 hours of flight time. The airplane’s most recent condition inspection was completed by the pilot in June 2012, at 59 total flight hours. Airman records retained by the FAA showed that the pilot held a private pilot certificate with a rating for airplane single engine land, as well as a repairman experimental aircraft builder certificate for the accident airplane. The pilot’s most recent third-class medical certificate was issued in August 2011, and at that time the pilot reported 525 total hours of flight experience. No further records of the pilot’s flight experience were available for review; however, all of the flight hours recorded in the airframe maintenance log were recorded by the pilot. Crossville Memorial Airport was comprised of a single asphalt runway oriented in an 8/26 configuration. The runway was 5,418 feet long by 100 feet wide. The weather conditions reported at CSV, at 0853, included clear skies, calm winds, temperature 11 degrees Celsius (C), dew point 8 degrees C, and an altimeter setting of 30.04 inches of mercury. Consultation of a carburetor icing probability chart published by the FAA showed that the possibility of serious icing at cruise power settings, and also fell within the range specified for icing in pressure-type carburetors. According to the kit manufacturer’s flight manual, takeoff procedure, “It is important to check full-throttle engine operations early in the take-off run. If there are any signs of rough engine operation or sluggish engine acceleration, discontinue the take-off. Investigate the cause of the poor engineoperation before attempting another take-off.” ## Aircraft - Registration: [N198PC](https://openairdocs.org/deregistered/N198PC-2022-04-09), registration cancelled 2022-04-09, S/N 1101, built 2011 (OpenAirDocs) - Reported make and model: CASHMER PHILIP M SONEX - Registry model: [Cashmer Philip M SONEX](https://openairdocs.org/model/cashmer-philip-m-sonex) (registry code 05630I3) (OpenAirDocs) - Registry engine: [Aeroconver AEROVEE](https://openairdocs.org/engine/aeroconver-aerovee) (registry code 01401, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 1101 - Airframe hours: 59 - Engines: AeroVee 2.0 80 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, June 20, 2012 - Departed: CSV, Crossville, TN - Destination: GIF, Winter Haven, FL - Airport: CSV, Crossville Memorial Airport, runway 26, 5,418 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; flight hours: 565 total, 60 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 52 °F, dew point 46 °F - Altimeter: 30.04 inHg - Observed at: CSV, 1 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 (OpenAirDocs). - [Accident 20121016024259A](https://openairdocs.org/incident/20121016024259A), Oct 16, 2012: Cashmer Philip M SONEX, Crossville, TN, Substantial damage. Pilot records are unavailable due to such serious injury and comatose state. Open brain injury, lost of eye, and severe head trauma. Wife has multiple upper… ## Docket (8 files) The files NTSB released with the investigation on May 3, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85336. 19.2 MB in all. - Witness Statements (item 1, .PDF, 586 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389657&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - FAA Inspector's Statement (item 2, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389649&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Redacted.PDF - Photo 1 - Airplane From Aft (Photo Courtesy of FAA) (item 3, .PDF, 5.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389652&FileExtension=.PDF&FileName=Photo%201%20-%20Airplane%20From%20Aft%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 2 - Airplane From Front (Photo Courtesy of FAA) (item 4, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389653&FileExtension=.PDF&FileName=Photo%202%20-%20Airplane%20From%20Front%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 3 - Airplane From Left (Photo Courtesy of FAA) (item 5, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389655&FileExtension=.PDF&FileName=Photo%203%20-%20Airplane%20From%20Left%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Photo 4 - Airplane From Right (Photo Courtesy of FAA) (item 6, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389656&FileExtension=.PDF&FileName=Photo%204%20-%20Airplane%20From%20Right%20(Photo%20Courtesy%20of%20FAA)-Master.PDF - Airframe Log (item 7, .PDF, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389648&FileExtension=.PDF&FileName=Airframe%20Log-Redacted.PDF - Flight Manual Excerpt (item 8, .PDF, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40389650&FileExtension=.PDF&FileName=Flight%20Manual%20Excerpt-Master.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.