ERA14LA174

NTSB accident investigation · N/A N/A · Patillas, PR · March 26, 2014

Accident · FatalLimited investigationFinal report
Date
March 26, 2014, 17:00 local (21:00 UTC)
Place
Patillas, PR
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
UNREGN/A N/A
Defining event
Approach-VFR pattern base: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report April 27, 2015
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
Case key
88978

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 airplane control during approach for landing, which resulted in a stall/spin.

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotAll aircraft: 9,295 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedAll aircraft: 1,269 casesProbable cause
Maintenance: fabricationPersonnel issues › Task performance · Owner/builderAll aircraft: 30 cases

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.

Loss of control in flightApproach-VFR pattern baseAll aircraft: 5,002 casesDefining event

Analysis

The accident flight was reportedly the pilot's first flight in the unregistered airplane. There were no witnesses to the accident; the airplane was found about 750 ft from the runway threshold on an approximate 45-degree angle from the runway. Although there were no witnesses or other recorded data available documenting the moments leading up to the accident, the location of the wreckage in relation to the runway suggested that the airplane might have been turning from the base to the final leg of the airport traffic pattern when the accident occurred. The orientation of the wreckage was consistent with the airplane having been in an aerodynamic stall/spin at impact. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or anomalies. Paperwork recovered from the pilot's home indicated that the airplane was based on a commercially available set of plans for an ultralight aircraft and that the pilot used these plans when he constructed the airplane. However, he made modifications that could have resulted in unanticipated adverse handling characteristics. Federal Aviation Administration guidance on amateur-built aircraft recommends developing a flight test plan to detect any hazardous operating characteristics and to determine the airplane's performance and operating envelope; however, no documents were located indicating that the pilot had developed or intended to perform a flight test plan.

Factual narrative

On March 26, 2014, approximately 1700 atlantic standard time, an unregistered airplane was substantially damaged when it impacted the ground while maneuvering for landing at Patillas Airport (X64), Patillas, Puerto Rico. The airline transport pilot/builder was fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight. The flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. According to a Federal Aviation Administration (FAA) inspector, the accident flight was the pilot's first flight in the airplane. The airplane impacted the ground about 750 feet southwest of the runway 10 threshold at X64. There were no witnesses to the accident. Examination of photos from the accident site revealed that the airplane came to rest upright approximately 10 feet from a tree, which displayed several broken branches. The left aileron and the outboard portion of the left wing were separated from the airplane and came to rest under the tree. The cockpit area, right main landing gear, and right wing displayed significant aft crushing and were displaced aft, while the left wing root displayed minor damage and was displaced forward. The vertical and horizontal stabilizers, rudder, and elevators were intact and remained attached to the airframe. The engine remained attached to the airframe, and the two-bladed wooden propeller remained attached to the engine. One blade was fractured aft near the propeller hub, and was splintered and bent beneath the engine. The second blade was intact and displayed gouging along its leading edge and a crack emanating inward approximately 3 inches from its tip. Control continuity was established from the cockpit area to all flight control surfaces. The airplane was recovered to a hangar, and examination of the engine was conducted on May 6, 2014. The battery displayed a charge of 12 volts, the fuel tank contained approximately 3 gallons of fuel, and the engine oil level was full. Continuity of the fuel system was established from the fuel tank to the engine, and throttle and fuel mixture control continuity was established from the cockpit to the engine. The top spark plugs were removed, and visual inspection revealed normal wear. Visual inspection of the cylinders further revealed no anomalies. The engine crankshaft was rotated by hand at the propeller, and compression was obtained on all cylinders. The 1656 weather observation at Luis Munoz Marin International Airport (JSJ), San Juan, Puerto Rico, approximately 27 nautical miles north of the accident location, included wind from 50 degrees at 13 knots, 10 miles visibility, few clouds at 4,700 feet, temperature 29 degrees C, dew point 20 degrees C, and an altimeter setting of 30.04 inches of mercury. The airplane was a single-seat, tailwheel-equipped airplane of wood, steel tube, and fabric construction. It was powered by one 4-cylinder reciprocating automobile engine fitted with a wooden propeller.Paperwork recovered from the pilot's home indicated that the airplane's design was based on a commercially-available set of plans for an ultralight aircraft, from which the pilot constructed the airplane with several modifications. No documentation of the airplane and engine's build, modification, maintenance history, or flight test plan were located. The pilot held a commercial pilot certificate with ratings for airplane single- and multi-engine land and instrument airplane, as well as an airline transport pilot certificate with a rating for rotorcraft-helicopter. The pilot also held a repairman experimental aircraft builder certificate, issued in 2004, for a Vans Aircraft RV-8. His most recent FAA second-class medical certificate was issued in November 2013, at which time he reported 3,800 total hours of flight experience. The pilot's logbooks were not located. An autopsy was performed on the pilot by the Institute of Forensic Sciences, San Juan, Puerto Rico. The cause of death was listed as "blunt force trauma." The Federal Aviation Administration Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot, with negative results for carbon monoxide, ethanol, and drugs. FAA Advisory Circular (AC) 90-89A, Amateur-Built Aircraft and Ultralight Flight Testing Handbook, stated, "…test flying an aircraft is a critical undertaking, which should be approached with thorough planning, skill, and common sense." Chapter 1: Preparation, stated, "The most important task for an amateur-builder is to develop a comprehensive flight test plan. This plan should be individually tailored to define the aircraft's specific level of performance. It is therefore important that the entire flight test plan be developed and completed BEFORE the aircraft's first flight. The objective of a flight test plan is to determine the aircraft's controllability throughout all the maneuvers and to detect any hazardous operating characteristics or design features. This data should be used in developing a flight manual that specifies the aircraft's performance and defines its operating envelope." The advisory circular provided further guidance on preparing a plan for each phase of an amateur-built airplane's production. The areas for which guidance was provided included preparing for the airworthiness inspection, weight and balance, taxi test, flight testing, and emergency procedures. The suggested flight testing regimen was separated into 10-hour segments for the 40-plus hour flight testing requirement.

Aircraft

Registration
UNREG
Reported as
N/A N/A
Category
Airplane, amateur-built
Serial number
N/A
Engine
Volkswagen unk, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Emerito Guzman
Registered owner
Emerito Guzman
Airworthiness certificate
None
Departed
X64 · Patillas, PR
Destination
X64 · Patillas, PR
Airport
X64 · Patillas Airport

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
59
Injuries
Fatal
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Single
Toxicology
Performed
Flight hours
3,800 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 13 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 68 °F
Altimeter
30.04 inHg
Observed at
JSJ, 27 nm away

Docket · 6

The files NTSB released with the investigation on March 30, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.5 MB in all.