# NTSB ERA14FA445: North American T 28C, N531KG, Alton, VA, September 19, 2014 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 19, 2014, 17:10 local (21:10 UTC) - Place: Alton, VA - Coordinates: 36.558612, -79.207496 - Nearby events: https://openairdocs.org/map.md?lat=36.5586&lon=-79.2075&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Abrupt maneuver](https://openairdocs.org/ntsb-events/270) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report November 17, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 90107 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14FA445 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90107/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90107 - Page: https://openairdocs.org/ntsb/ERA14FA445 ## Probable cause The pilot’s failure to maintain altitude while performing low-level aerobatic maneuvers, which resulted in collision with terrain. Contributing to the accident was the pilot’s improper decision to attempt aerobatics at such a low altitude. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [North American T-28C, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=6402507), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [North American T-28C, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=6402507), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [North American T-28C, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=6402507), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Abrupt maneuver](https://openairdocs.org/ntsb-events/270) (defining event); cases with it: [North American T-28C, 1 case](https://openairdocs.org/ntsb-events/270/sequence.md?model=6402507), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md) - [Maneuvering-aerobatics: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [North American T-28C, 4 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=6402507), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis A witness, who was a friend of the pilot, was at an automobile racing facility and received a text message from the pilot that the airplane would fly over in 6 minutes. The accident airplane then performed a low pass over the area, reversed direction, and initiated a barrel roll during the second pass. Although the airplane started to climb before the barrel roll, video evidence indicates that it was only 100 feet above ground level, which was not high enough to complete the maneuver. The airplane subsequently collided with trees and terrain. Examination of the wreckage did not reveal any preimpact mechanical malfunctions that would have precluded normal operation. ## Factual narrative Review of Federal Aviation Regulation 91.303 revealed: "No person may operate an aircraft in aerobatic flight - … (b) Over an open air assembly of persons… (e) Below an altitude of 1,500 feet above the surface…" The two-seat tandem, low-wing, retractable tricycle gear airplane, serial number 140531, was manufactured in 1954. It was equipped with a Wright R-1820, 1,425-horsepower engine and a three-blade constant speed propeller. The airplane maintenance logbooks were not recovered; however, an invoice revealed that an annual inspection was completed on the airplane on December 6, 2013. On September 19, 2014, about 1710 eastern daylight time, an experimental North American T-28C, N531KG, operated by a private individual, was destroyed when it impacted a kudzu field, while performing aerobatics near Alton, Virginia. The private pilot and passenger were fatally injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the flight that departed Easton Airport (ESN), Easton Maryland, about 1600. No flight plan was filed for the planned flight to Danville Regional Airport (DAN), Danville, Virginia. A witness, who was a friend of the pilot, was at a racing facility with a motorcycle racing team that the pilot owned. The witness added that he received a text message from the pilot that the pilot would be there in 6 minutes. The accident airplane then performed a low pass over the area, reversed direction, and initiated a barrel roll during the second pass. The witness stated that the airplane started to climb before the barrel roll, but it wasn't enough and he knew the airplane would not have enough altitude to complete the maneuver. The airplane subsequently collided with trees and terrain. A second witness recorded a video of the maneuver, which was forwarded to the NTSB Vehicle Recorder Laboratory, Washington, D.C. The video confirmed the witnesses' statements and revealed that the airplane attempted a barrel roll about 100 feet above ground level and then disappeared behind a treeline. An autopsy was performed on the pilot on September 20, 2014, by the State of Virginia Office of the Chief Medical Examiner, Richmond, Virginia. The cause of death was noted as "Blunt force injuries of head." Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. The results were negative for carbon monoxide, alcohol, and drugs. The accident site was located about 6 miles east of DAN. The recorded weather at DAN, at 1653, was: wind 040 degrees at 8 knots; visibility 10 miles; broken ceiling at 11,000 feet; temperature 21 degrees C; dewpoint 17 degrees C; altimeter 30.22 inches Hg. The pilot held a private pilot certificate with ratings for airplane single-engine land and airplane multiengine land. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued onOctober 5, 2011. At that time, he reported a total flight experience of 1,410 hours. The pilot's logbook was not recovered. A debris path was observed, initiating with the propeller, and extending approximately 300 feet on a magnetic heading about 320 degrees. The three propeller blades remained attached to the hub and the hub had separated from the engine. The blades were twisted and bent aft, with one blade exhibiting leading edge gouges. A flight control cable was located about 200 feet along the debris path and it exhibited damage consistent with overload. The left flap was located about 250 feet along the debris path. An aileron cable was separated consistent with overload and resting on top of the left flap The right elevator was located about 275 feet along the debris path and the right flap was located about 290 feet along the debris path. An aileron cable was separated consistent with overload and resting on top of the right flap. The left wing and engine were located at the end of the debris path, to the left of the cockpit. The left wing and cockpit sustained heat damage from a postcrash fire. The left wing also exhibited impact damage and the left aileron remained attached. The landing gear had separated from the left wing. The engine was resting on the propeller flange and several of the cylinders sustained impact damage. The cockpit and empennage were resting on the right wing. The left horizontal stabilizer, left elevator, and rudder remained attached to the empennage. Elevator, elevator trim, and rudder control cable continuity were confirmed from the control surfaces to the mid-cockpit area. Aileron control continuity could not be confirmed due to the fragmentation and disposition of the wreckage. Review of the cockpit revealed that the propeller and mixture control were in the full forward position. The throttle lever was midrange. The pilot's five-point harness remained buckled and the belts were cut by rescue personnel. ## Aircraft - Registration: [N531KG](https://openairdocs.org/deregistered/N531KG-2018-03-30), registration cancelled 2018-03-30, S/N 140531, built 1954 (OpenAirDocs) - Reported make and model: NORTH AMERICAN T 28C - Registry model: [North American T-28C](https://openairdocs.org/model/north-american-t-28c) (registry code 6402507) (OpenAirDocs) - Registry engine: [Wright R-1820-86](https://openairdocs.org/engine/wright-r-1820-86) (registry code 67200, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 140531 - Year built: 1954 - Engines: WRIGHT R-1820 1425 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Couch Jon - Registered owner: Couch Jon - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, December 6, 2013 - Departed: ESN, Easton, MD - Destination: DAN, Danville, VA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; medical: class 3, with waivers/limitations; seat: front; restraint: 5-point; toxicology performed; flight hours: 1,410 total, 999,999 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 40° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 11,000 ft broken - Temperature: 70 °F, dew point 63 °F - Altimeter: 30.21 inHg - Observed at: DAN, 6 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 20140919017429A](https://openairdocs.org/incident/20140919017429A), Sep 19, 2014: North American T-28C, Alton, VA, Destroyed, 2 fatal. Aircraft was seen performing a low pass over Virginia international raceway. The aircraft reversed direction, and initiated a barrel roll during a second low… ## Docket (9 files) The files NTSB released with the investigation on November 5, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90107. 2.1 MB in all. - Interview Summary (item 1, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418504&FileExtension=.PDF&FileName=Interview%20Summary-Master.PDF - Maintenance Invoice (item 2, .PDF, 469 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418505&FileExtension=.PDF&FileName=Maintenance%20Invoice-Redacted.PDF - Weather Report (item 3, .PDF, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418506&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Witness Video of Accident Sequence (item 4, .PDF, 6 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418507&FileExtension=.PDF&FileName=Witness%20Video%20of%20Accident%20Sequence-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 5, .PDF, 332 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418509&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicology Report (item 6, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418508&FileExtension=.PDF&FileName=Toxicology%20Report-Master.PDF - Photo 1 - Propeller (item 7, .PDF, 362 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418510&FileExtension=.PDF&FileName=Photo%201%20-%20Propeller-Master.PDF - Photo 2 - Engine (item 8, .PDF, 343 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418511&FileExtension=.PDF&FileName=Photo%202%20-%20Engine-Master.PDF - Photo 3 - Main Wreckage (item 9, .PDF, 313 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418512&FileExtension=.PDF&FileName=Photo%203%20-%20Main%20Wreckage-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.