ERA14FA163

NTSB accident investigation · Dehavilland DHC-1 · Vonore, TN · March 23, 2014

Accident · FatalField investigationFinal report
Date
March 23, 2014, 13:30 local (17:30 UTC)
Place
Vonore, TN
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N540FMDehavilland DHC-1
Defining event
Enroute-cruise: VFR encounter with IMC
Weather
Day
Status
Completed · report January 27, 2015
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Lycoming Engines
FAA report
20140323005269A
Case key
88957

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

The pilot’s continued visual flight rules flight into instrument meteorological conditions, which resulted in controlled flight into terrain.

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.

Ceiling/visibility/precip: obscurationEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionDehavilland DHC-1: 1 caseAll aircraft: 45 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

On the morning of the accident, the pilot contacted a flight service station for a weather briefing for a visual flight rules (VFR) flight from Wisconsin to Georgia. The briefer told the pilot that VFR flight was not recommended from southern Kentucky through Tennessee and into north Georgia. He also stated that there was an Airmet for mountain obscuration for the same area until 1400. Toward the conclusion of the briefing, the pilot indicated that he would probably spend the night in Kentucky. The pilot flew to Indiana, refueled, and departed about 1209. When the pilot did not arrive at his destination, a search was initiated, and the wreckage was found in mountainous terrain in the Cherokee National Forest. The aircraft heading at impact was toward the northwest (his destination was to the southeast). Damage to broken trees within the wreckage debris path was indicative of a near-level aircraft attitude at impact. Although the pilot had extensive experience in the accident airplane and was an airline pilot with a major air carrier, the airplane was not equipped for flight in instrument conditions. No distress calls were received from the pilot before the accident. An examination of the airframe and engine did not reveal evidence of a preexisting mechanical malfunction or failure. Although no eyewitnesses to the accident were found, one local resident reported that the mountain tops were obscured at the time of the accident. It is likely that the pilot attempted to cross the mountains below the cloud cover and, after he realized that he could not continue in visual conditions, he attempted to exit the weather, and the airplane impacted the mountain.

Factual narrative

The low wing, tailwheel landing gear, tandem cockpit airplane was a Dehavilland model DHC-1 (Super Chipmunk) that was manufactured in 1947. It was powered by a Lycoming IO-540-D4A5 engine, rated at 260 horsepower and was equipped with a Whirl Wind 400C three-bladed constant speed propeller. The maintenance logbook noted the engine serial number as "EXPERIMENTAL." The airplane was not certified for flight under instrument flight rules. The tachometer time recorded at the accident site was 1859.0 hours, which corresponded to a total aircraft time of 3,609.7 hours. The last annual inspection on the airframe, engine, and propeller occurred on March 1, 2014 at an airframe total time of 3,603.6 hours. On March 23, 2014, about 1330 eastern daylight time (EDT), a Dehavilland DHC-1, N540FM, impacted mountainous terrain near Vonore, Tennessee. The airline transport pilot was fatally injured and the airplane sustained substantial damage. The airplane was operated by the pilot. Day, visual meteorological conditions prevailed for the personal flight, and no flight plan was filed. The flight originated from French Lick Municipal Airport (FRH), French Lick, Indiana, and was destined for Franklin County Airport (18A), Canon, Georgia. On the morning of the accident, at 0639, the pilot telephoned Lockheed Martin Flight Service and requested a visual flight rules weather briefing from Watertown, Wisconsin to Augusta, Georgia, for altitudes between 3,000 and 6,000 feet above mean sea level (msl). The briefer responded that there was "…a lot of weather…" and also reported that, from southern Kentucky to his destination, there was "some uh severe weather going there." Regarding instrument flight conditions, the briefer told the pilot that visual flight rules (VFR) flight was not recommended from southern Kentucky through Tennessee and into north Georgia. He also stated that there was an Airmet for mountain obscuration for the same portion of his flight until 1400. Toward the conclusion of the briefing, the pilot responded to the briefer, "Looks like I'm probably only gonna get get down to Kentucky and spend the night." According to personnel at FRH, the pilot landed at FRH about 1039 and purchased 30.8 gallons of 100 low lead aviation gasoline. The flight departed FRH at 1209. When the pilot did not arrive at his destination, a Federal Aviation Administration Alert Notice (ALNOT) was issued. The wreckage was located during the morning of March 24, 2014. The wreckage was found on the side of a mountainous slope within the boundary of the Cherokee National Forest in Tennessee, at coordinates 35.465833, -84.010278. The elevation at the accident site was about 2,222 feet msl and about 100 feet below a ridgeline. There were no known witnesses to the accident. A postmortem examination of the pilot was performed at the Office of the Medical Examiner, Regional Forensic Center, at The University of Tennessee, Knoxville, Tennessee on March 25, 2014. The autopsy report notedthe cause of death as "Multiple blunt force injuries." Forensic toxicology testing was performed on specimens of the pilot by the Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The CAMI toxicology report indicated negative for carbon monoxide, ethanol, and drugs. Testing for cyanide was not performed. The closest weather observation facility to the accident site was McGhee Tyson Airport (TYS), Alcoa, Tennessee, located about 20 nautical miles north of the accident site. The airport elevation was about 981 feet msl. The TYS 1324 surface weather observation (about 6 minutes prior to the accident) included scattered clouds at 1,700 feet AGL, ceiling broken at 5,000 feet, wind variable at 5 knots, visibility 10 statute miles or greater, temperature 9°Celcius (C), dew point 5°C, and altimeter setting 30.13 inches of mercury. The TYS 1336 surface weather observation (about 6 minutes after to the accident) included a scattered clouds at 1,900 feet AGL, ceiling broken at 2,800 feet, ceiling broken at 5,000 feet, wind from 320 degrees at 5 knots, visibility 10 statute miles or greater, temperature 10°C, dew point 4°C, and altimeter setting 30.13 inches of mercury. A local area resident reported that he was in Robbinsville, North Carolina during the afternoon of the accident. Robbinsville was located about 13 nautical miles southeast of the accident site. When asked about the weather conditions, he recalled that the weather was "bad" that afternoon. He stated that there was heavy fog and it was raining in the mountains. These conditions prevailed until about 1530 to 1600 on March 23. The tops of the mountains were not visible during that time. A staff meteorologist with the NTSB examined the weather conditions around and including the accident site. He reported the following. Visible satellite imagery from 1345 identified a band of overcast cloud cover stretching along a portion of the Tennessee-North Carolina border that included the accident site. Infrared imagery indicated cloud top temperatures for this band in the area of the accident location were approximately -1°C. When considering a North American Mesoscale (NAM) model sounding for 1400 EDT above the accident location, this temperature probably corresponded to cloud top height of about 5,400 feet above msl, which is consistent with the moisture profile depicted in the NAM sounding. It should be noted, however, that due to the presence of a temperature inversion above this level, -1°C also corresponded to a level of 7,800 feet above msl, although the NAM sounding profile does not support clouds at this height. The NAM model sounding identified a saturated layer centered at 3,400 feet above msl, and analysis by the Rawinsonde Observation Program suggested a broken cloud layer existed as low as about 2,650 feet above msl. Regional weather radars could not "see" low enough to capture precipitation conditions near the surface at theaccident location. There were no pilot reports publically available at altitudes of 8,000 feet above msl or lower for the accident region in Tennessee or North Carolina. The pilot, age 59, held an airline transport pilot certificate with ratings for airplane multi-engine land, airplane single engine land, and flight engineer. He possessed an FAA class I medical certificate dated November 4, 2013. He reported 16,000 hours total flight time including 500 hours in the last six months prior to his latest medical certificate application. He was required to have glasses available for near vision. On May 16, 2011, the pilot was arrested for driving under the influence (DUI) of alcohol with a portable breath test alcohol level of 0.126%. According to the FAA, this was the pilot's only alcohol conviction with no evidence of alcohol dependence or abuse and the pilot was found eligible for medical certification. He was cautioned that further alcohol offenses or evidence of alcohol abuse may require re-evaluation of his medical certification. According to FAA registration records, the pilot purchased the airplane in July, 1991. A pilot logbook was found within the wreckage. The first entry in the logbook was October, 2006 and his flights in the accident airplane continued in a consistent manner until the last entry, dated March 11, 2014. According to the logbook notations, many of the flights in the accident airplane were for cross county, airshows, and airshow practice. At the time of the accident, the pilot was employed as a chief pilot for Delta Air Lines. The wreckage was found upright, and the debris path was oriented on a heading of about 300 degrees. Damage to broken trees within the wreckage debris path was indicative of a near-level aircraft attitude at impact. There was no evidence of fire noted. The engine controls were found in the "full forward" positions. All major structural components were found within the area of the main wreckage. The pilot was found strapped into the rear cockpit seat and was wearing a parachute at the time of the accident; it was not deployed. The wreckage was recovered to a storage facility at Springfield, Tennessee for examination. The empennage remained attached to the fuselage. The left and right horizontal stabilizers were cut from the airframe by recovery personnel. The leading edges of the horizontal stabilizers exhibited leading edge damage and crush in the aft direction. The elevators remained attached to the stabilizers. The rudder remained attached to the vertical stabilizer and the assembly was cut from the airframe by recovery personnel. Control cable continuity was established from the elevator and rudder to the cockpit controls. The both wings were crushed in a forward-to-aft direction from impact forces. The leading edges exhibited signatures consistent with impact with trees in a near horizontal attitude. The outboard sections of both wings were severed; however, all structural components were accountedfor. The outboard sections of both ailerons remained attached to the outboard wing sections. Both wing flaps were accounted for. Due to a general fragmentation of the wings, aileron control continuity could not be established to the cockpit controls. All recovered aileron cable sections were either attached to their control surfaces, broken with overstress signatures, or cut by recovery personnel. Both wing fuel tanks were ruptured and no residual fuel was found. Both fuel tank caps were secure. The engine was rotated manually by turning the propeller. Continuity of the crankshaft to the rear gears and to the valve train was confirmed. Compression and suction were observed on all six cylinders. No indication of pre-impact anomaly or malfunction of the engine was observed. A label reading "Poplar Grove Airmotive" was affixed to the top of one of the crankcase halves. A Lycoming Engines data plate was not affixed to the engine. The propeller remained attached to the engine. The propeller spinner was crushed and partially separated from the propeller. Investigators marked the propeller blades "A," "B," and "C" to facilitate their examination. The propeller blade marked "C" was splintered and broken off at about 2/3 span. The blade marked "B" was splintered and broken off at about 1/2 span. The blade marked "A" was splintered beginning near the hub and broken off about 10 inches outboard of the hub. The propeller governor remained attached to the engine and the propeller governor control cable remained attached to the governor control arm. The arm was observed near the full increase rpm position. The governor was removed from the engine and the oil screen was found unobstructed. The fuel injector servo was fractured across the throttle bore and separated from the engine. The induction air box was crushed. The throttle, mixture, and alternate air controls were separated and their pre-impact positions could not be determined. The fuel regulator section was disassembled and no damage to the diaphragms and internal components was noted. The servo fuel inlet screen was absent of debris. The fuel flow divider remained attached to the engine and no damage was noted. It was removed and disassembled. No damage to the diaphragm or internal components was noted. The fuel injector nozzles were removed and observed to be unobstructed. The engine driven fuel pump remained attached to the engine and was impact damaged. It was removed and disassembled. No damage to the diaphragms or valves was noted. The spark plug electrodes exhibited gray coloration and normal wear as compared to a Champion inspection chart. The #2 bottom spark plug was impact-damaged. Oil was observed inside the engine. The oil suction screen was removed and was observed to be absent of debris. The oil filter was impact damaged and was not examined. The oil cooler and oil cooler hoses remained attached to the engine. The oil cooler exhibited impact damage.

Aircraft

Registration
N540FM
Reported as
Dehavilland DHC-1
Category
Airplane
Serial number
189
Built
1947
Airframe hours
3,609
Engine
Lycoming IO-540-D4A5, 260 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Maroney James L
Registered owner
Maroney James L
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Annual · March 1, 2014 · 6 hours before
Departed
FRH · French Lick, IN
Destination
18A · Canon, GA

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
59
Injuries
Fatal
Certificates
Airline transport, Flight engineer
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
February 15, 2014
Seat
Rear
Restraint
5-point
Toxicology
Performed
Flight hours
16,000 total

Weather

Conditions
Day
Wind
320° at 5 knots
Visibility
10 statute miles
Lowest ceiling
2,800 ft broken
Temperature
50 °F, dew point 39 °F
Altimeter
30.12 inHg
Observed at
TYS, 20 nm away

Docket · 32

The files NTSB released with the investigation on January 13, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 30.3 MB in all.

FAA Formal Accident Package ExcerptsItem 1 · .PDF · 569 KBWeather StudyItem 2 · .PDF · 380 KBRecord of Conversation - TolsonItem 3 · .PDF · 53 KBCorrespondence with FRH Airport ManagerItem 4 · .PDF · 124 KBFuel RecordItem 5 · .PDF · 155 KBExcerpt – Airframe LogbookItem 6 · .PDF · 189 KBExcerpt – Engine LogbookItem 7 · .PDF · 193 KBCertification of Party RepresentativeItem 8 · .PDF · 190 KBRelease of Wreckage NTSB Form 6120.15Item 9 · .PDF · 207 KBToxicology ReportItem 10 · .PDF · 113 KBPhoto 1 - Main Wreckage (Photo Courtesy of Knox County Sheriff)Item 11 · .PDF · 2.2 MBPhoto 2 - Main Wreckage (Photo Courtesy of Knox County Sheriff)Item 12 · .PDF · 3.2 MBPhoto 3 - Main Wreckage (Photo Courtesy of Knox County Sheriff)Item 13 · .PDF · 2.2 MBPhoto 4 - Top Aft Fuselage and Empennage (Photo Courtesy of Knox County Sheriff)Item 14 · .PDF · 2.4 MBPhoto 5 - Empennage (Photo Courtesy of Knox County Sheriff)Item 15 · .PDF · 2.2 MBPhoto 6 - Damage to Tops of Trees (Photo Courtesy of Knox County Sheriff)Item 16 · .PDF · 2.8 MBPhoto 7 - Left Side Fuselage and Left Wing Inboard SectionItem 17 · .PDF · 841 KBPhoto 8 - Outboard Section of Left WingItem 18 · .PDF · 753 KBPhoto 9 - Left Wing FragmentsItem 19 · .PDF · 789 KBPhoto 10 - Right Side of Fuselage and Right Wing Inboard SectionItem 20 · .PDF · 785 KBPhoto 11 - Outboard Section of Right WingItem 21 · .PDF · 741 KBPhoto 12 - Right Wing Fragments and Right Main Landing GearItem 22 · .PDF · 917 KBPhoto 13 - Cockpit Engine ControlsItem 23 · .PDF · 801 KBPhoto 14 - Aft Empennage and TailwheelItem 24 · .PDF · 775 KBPhoto 15 - Left Horizontal Stabilizer and ElevatorItem 25 · .PDF · 862 KBPhoto 16 - Right Horizontal Stabilizer and ElevatorItem 26 · .PDF · 751 KBPhoto 17 - Vertical Stabilizer and RudderItem 27 · .PDF · 734 KBPhoto 18 - Engine and PropellerItem 28 · .PDF · 947 KBPhoto 19 - Engine and PropellerItem 29 · .PDF · 1.0 MBPhoto 20 - Fuel ServoItem 30 · .PDF · 924 KBPhoto 21 - Engine Spark PlugsItem 31 · .PDF · 834 KBPhoto 22 - Engine Fuel Injector NozzlesItem 32 · .PDF · 706 KB

FAA reports on this event · 1

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