ERA13LA270

NTSB accident investigation · Maule BEE DEE M-4-210 · Cuttyhunk, MA · June 5, 2013

Accident · FatalLimited investigationFinal report
Date
June 5, 2013, 10:05 local (14:05 UTC)
Place
Cuttyhunk, MA
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N9807MMaule BEE DEE M-4-210
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report June 2, 2014
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, CMI
FAA report
20130605009389A
Case key
87100

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 failure to maintain adequate airspeed after takeoff, which resulted in an aerodynamic stall and loss of airplane control.

Findings · 2

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotMaule BEE DEE M-4-210: 1 caseAll aircraft: 9,295 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedMaule BEE DEE M-4-210: 1 caseAll aircraft: 1,269 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

During the takeoff climb from a private runway, several witnesses heard the airplane's engine "sputtering," but another witness heard the engine "running strong." All heard the impact; however, none observed the airplane on the departure roll or at impact. The airplane was found nose down within a row of trees about 300 feet past the steel pole. Postaccident examination of the runway revealed tire tracks, similar in dimension as the accident airplane's tires, leading from the runway to, and slightly past, a knocked over windsock steel pole. However, the tracks were also similar to those of a vehicle on the property. Further, it could not be determined when the pole was knocked down. Subsequent examination of the airplane revealed a puncture in the right elevator in similar in dimension to the steel pole or a tree branch and long grass in the tailwheel assembly, similar to the grass near the windsock and where the airplane normally parked. Thus, the physical evidence on the airplane and near the windsock pole was inconclusive, and the investigation could not determine if the airplane struck the pole during the takeoff roll or not. Further examination of the airplane revealed that there were no preimpact anomalies noted with the airplane or engine that would have precluded normal operation. Although trace amounts of an orange substance similar in color to lock-tite compound was located within the engine driven fuel pump, it is likely these specks were left in the solvent tank in which the pump was tested and inadvertently were drawn into the engine-driven fuel pump. It is likely that shortly after takeoff, the airplane entered a stalled condition and subsequent spin from which the pilot could not recover due to the low altitude.

Factual narrative

According to fuel records, on May 27, 2013, the airplane was filled with 17.7 gallons of aviation 100LL fuel. According to the fixed base operator, the pilot always requested that the fuel tanks "be topped off." On July 11, 2013, the airplane and engine were examined by the NTSB investigator in charge along with a representative from the FAA and the engine manufacturer at a fixed base operator in New Bedford, Massachusetts. The airframe was examined and flight control continuity was confirmed from the control column and rudder pedals to the associated flight control through the various cable cuts required for recovery. Examination of the underside of the right elevator revealed a puncture that was measured at approximately 1 inch in width and 3 ½ inches in length, the width of the puncture was similar in dimension as the steel pole that was located in the grass adjacent to the windsock. Examination of the instrument panel revealed the airplane had been equipped with a stall warning system which consisted of one red indicator light marked "STALL WARNING," which was located on the upper portion of the instrument panel; however, examination of the light bulb and filament were unable to conclusively determine if the light had been illuminated prior to impact. The engine had remained attached to the airframe by the four engine mount legs and various lines, hoses, and cables. The top sparkplugs were removed and the crankshaft was rotated by hand utilizing the attached propeller. Continuity to the rear accessories was observed and thumb compression was achieved on all cylinders. During hand rotation of the propeller, the magneto impulse couplings engaged and spark was obtained on all six top spark plug leads. The fuel manifold was disassembled and the diaphragm remained intact, the fuel screen was free of debris, and a small amount of blue colored liquid, similar in color and smell as aviation fuel, was noted in the fuel manifold valve cavity. The fuel was tested for water utilizing water finding paste, and the result was negative for water. The engine driven fuel pump was removed, the inlet line was placed in a solvent tank, the pump was rotated utilizing a cordless drill, and the fuel pump discharged solvent from the outlet fitting. The electric fuel boost pump was connected to the airplane's 12-volt battery and the motor operated when electrical power was applied. The examination did not reveal any abnormalities that would have precluded normal operation. For detailed information on the airframe and engine examination, refer to the "Aircraft and Engine Examination Report" located in the public docket associated with this accident. Examination of the engine driven fuel pump by a representative of the pilot's estate revealed an orange colored substance similar to a compound called lock-tite within the pump. Maule M4-210 Airplane Flight Manual (AFM) According to Section II "Procedures" of the AFM stated in part, "Stall Warning Indicator: The electricstall warning system will light a red light on the instrument panel at [sic] approximately seven mph above the stalling speed. It will be inoperative when the master switch is off." However, further review of the manual did not reveal any procedures on how to recover from a stall or a spin, nor did it delineate how much altitude may be lost during recovery from a stall. A review of other Maule AFMs contained information that the typical altitude lost during a stall recovery ranged from 200 to 300 feet as well as a procedure for "Recovery from Inadvertent Spins." The recovery procedure was similar in that they required the pilot to "simultaneously apply full rudder opposite to the direction of rotation and full nose down elevator with ailerons neutral. When the rotation stops neutralize the rudder and elevator, reduce power to idle and ease back on the control wheel as required to smoothly regain level flight…" According to FAA and airplane maintenance records, the airplane was issued an airworthiness certificate on November 5, 1965, and was registered to pilot on May 30, 1995. The airframe had 1,116.2 hours total time in service at the most recent annual inspection that was recorded on November 16, 2012, and at the time of the accident the tachometer indicated 1,164.74 hours. It was equipped with a Continental Motors IO-360-A5B, which was rebuilt on January 31, 1997, by the engine manufacturer and installed on the airframe on June 9, 1997, with an airframe recorded total time in service of 701.33 hours. At the time of the accident the engine had 463.41 total hours since factory rebuild. The engine was equipped with a 2-bladed McCauley Propeller, Model D2A34C67-P. METEOROLOGICAL INFORMATION The 0953 recorded weather observation at Martha's Vineyard Airport (MVY), Vineyard Haven, Massachusetts, included wind at 100 degrees at 5 knots, 10 miles visibility, clear skies, temperature 19 degrees C, dew point 5 degrees C; barometric altimeter 30.19 inches of mercury The departure airport was a privately owned airport known as "The Bluffs." According to Massachusetts Department of Transportation Aeronautics Division records, dated April 8, 2013, it was owned by Ridgeley Farm Limited Partnership and was operated by the pilot of the accident airplane; it was considered a private restricted landing area (PRLA). The runway was a turf runway designated as a runway 11/29. It was a 1,100-foot-long and 70-foot-wide runway that was located 42 feet above mean sea level. It was also 14.6 nautical miles from MVY, the nearest public airport. According to photographs provided by the FAA, the runway was equipped with two wind indicators and no other services were available at the PRLA. On June 5, 2013, about 1005 eastern daylight time, a Maule BEE DEE M-4, N9807M, was substantially damaged when it impacted the ground shortly after takeoff from the pilot's private turf runway near Cuttyhunk, Massachusetts. The certificated private pilot was fatally injured. Day visualmeteorological conditions prevailed and no flight plan was filed. The airplane was registered to and operated by a private individual, and operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Although no eyewitnesses had been located, several individuals reported to the FAA inspector that they heard the engine "sputtering" and then the impact. Another eyewitness reported hearing the engine "running strong," then the engine sound "stopped abruptly," and finally the sound of "rustling" in the trees. An autopsy was performed on the pilot on June 6, 2013, by the Office of the Chief Medical Examiner for the Commonwealth of Massachusetts, Cape Cod, Massachusetts. The autopsy findings included "blunt force trauma," and the report listed the specific injuries. The cause of death was reported as three of the listed injuries. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol was detected in Vitreous fluid, and no drugs were detected in the urine. The pilot, age 70, held a private pilot certificate for airplane single-engine land and instrument airplane, issued April 17, 2004. In addition, a third-class airman medical certificate was issued June 21, 2011, with limitation of "Must Wear Corrective Lenses." According to a Federal Aviation Administration inspector, a review of the pilot's logbook revealed 1,036.7 total flight hours, of which, 421.1 flight hours in the accident aircraft make and model, and 15.2 flight hours were within the preceding 90 days. According to photographs provided by a FAA inspector that responded to the accident, the airplane came to rest against several trees in a nose down, near vertical attitude. The FAA inspector further reported that there were tire tracks, similar in dimension as the accident airplane, located in the grass that boarders the turf runway. The tire tracks led up to a windsock and steel pole that was 1 inch in diameter, which was lying in the grass and the tracks continued a short distance past the windsock. The grass located under the pole was not discolored. The airplane came to rest about 300 feet from the windsock. Examination of the airplane revealed that the wing fuel tanks were intact and contained an undetermined amount of fuel and no water was noted in the fuel sample that was acquired from the tanks. In addition, grass, longer in length than the grass on the runway, was located in the tailwheel assembly.

Aircraft

Registration
N9807M
Reported as
Maule BEE DEE M-4-210
Category
Airplane
Serial number
1040
Airframe hours
1,117
Engine
Cont Motor IO-360-A5B, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 6, 2012
Departed
NONE · Cuttyhunk, MA
Airport
NONE · The Bluffs, runway 11, 1,100 × 70 ft, grass/turf

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
70
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
September 27, 2011
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
1,037 total · 421 in this make and model · 15 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
68 °F, dew point 46 °F
Altimeter
30.19 inHg
Observed at
MVY, 14 nm away

Docket · 19

The files NTSB released with the investigation on May 6, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.8 MB in all.

FAA reports on this event · 1

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