ERA17FA115

NTSB accident investigation · Ryan Navion · Westhampton Beach, NY · February 26, 2017

Accident · FatalField investigationFinal report
Date
February 26, 2017, 11:40 local (16:40 UTC)
Place
Westhampton Beach, NY
Injuries
2 fatal, 1 serious
Damage
Destroyed
Phase of flight
Approach
Aircraft
N4529KRyan Navion
Defining event
Approach-VFR go-around: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report July 16, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Continental Motors, FAA/FSDO
FAA report
20170226018819A
Case key
94775

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 NTSB’s determination of the probable cause, and any contributing factors.

The flight instructor's exceedance of the critical angle of attack during a go-around, which resulted in an aerodynamic stall/spin. Contributing to the accident was the flight instructor's failure to familiarize himself with the flight characteristics of the unfamiliar airplane before conducting the flight review.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The commercial pilot, who was the owner of the airplane, was receiving a flight review from an instructor who was not familiar with the airplane make and model. The pilot stated that they did not discuss the potential differences between the accident airplane and the airplanes the instructor typically flew before the flight. After departing, they flew to a nearby airport to perform touch-and-go landings. The pilot was performing the first approach for landing in gusty wind conditions. About 100 ft above the runway, the flight instructor took control of the airplane. The airplane landed hard and bounced back into the air. The pilot applied full engine power in an attempt to avoid a stall when the flight instructor yelled, "hands off the yoke." The airplane subsequently experienced an aerodynamic stall/spin and impacted terrain. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation. The pilot stated that the design of the accident airplane resulted in a "sight picture" during the landing approach that appeared "very steep." He also stated that, although slipping with the wing flaps fully extended is prohibited in many airplanes, such a maneuver is not prohibited in the accident airplane. The pilot opined that the abnormal sight picture observed during the landing approach and his slipping of the airplane with the flaps extended may have caused the instructor to "[feel] the need to take control of the aircraft at such a critical point in flight." Federal Aviation Administration Advisory Circular (AC) 61-98D provides information for pilots and flight instructors to use when complying with the requirements of the flight review. The AC states that, before giving a flight review in an unfamiliar aircraft, an instructor should obtain recent flight experience in that aircraft or sufficient knowledge of its limitations, characteristics, and performance. Although the reason that the instructor took control of the airplane could not be determined, it is likely that he felt the pilot was performing an unsafe maneuver that required intervention; however, it is possible that he interpreted the pilot's actions as unsafe due to his lack of familiarity with the airplane and its operating characteristics. During the subsequent go-around following the bounced landing, the instructor exceeded the airplane's critical angle of attack, which resulted in an aerodynamic stall and spin.

Factual narrative

The factual narrative1,466 words

On February 26, 2017, about 1140 eastern standard time, a Ryan Navion F airplane, N4529K, impacted trees and terrain during takeoff from Francis S. Gabreski Airport (FOK), Westhampton Beach, New York. The flight instructor and passenger were fatally injured. The commercial pilot was seriously injured. The airplane was consumed by fire and destroyed. The airplane was owned and operated by the commercial pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the instructional flight, which originated from Republic Airport (FRG), Farmingdale, New York.According to the commercial pilot, he contacted the flight instructor with whom he typically flew to schedule a flight review. The instructor was unavailable and arranged for another instructor to conduct the review. The pilot stated that the flight instructor asked if he wanted to use a Cessna 172 for the flight review and that the instructor did not have any experience in Navion airplanes. The pilot declined, as he felt more comfortable flying his own airplane. They did not discuss any differences in the airplanes before the flight review. The pilot stated that he informed the instructor that he was not qualified to act as pilot-in-command, as he was not current, and that the instructor would be pilot-in-command for the flight. The flight departed FRG for FOK to perform touch-and-go landings. During the flight, the pilots performed positive exchanges of the flight controls, using the phrases, "my aircraft," and "your aircraft" when accepting or relinquishing the controls, respectively. The pilot was flying the airplane during the approach for landing to runway 33 at FOK. He stated that the wind was "gusty" so he "carried some extra power" and performed a slip maneuver during the approach. The pilot said that, about 100 ft above the runway, the instructor stated, "my airplane," grabbed the control yoke, and abruptly pulled back on the yoke. The pilot relinquished control and the airplane landed hard on the runway, then bounced back into the air. The pilot subsequently applied full engine power to avoid a stall, and the instructor yelled, "hands off the yoke." The pilot could not recall whether his hands were on the yoke at the time but did relinquish the controls to the instructor. The pilot stated that the airplane then entered a spin and collided with the trees and terrain. Control tower personnel stated that, during the airplane's initial climb after the landing, they saw it bank to the right to such a degree that they could see the bottom of the airplane. One of the controllers stated that the airplane seemed to "correct itself" briefly, then banked hard to the right again, colliding with treetops and coming to rest in the trees about 700 ft right of the runway. The controller estimated that the airplane was between 100 and 200 ft above ground level before it descended into trees. In a postaccidentinterview, the pilot stated that the design of the accident airplane provided a "sight picture" during an approach for landing that typically appeared "very steep." He stated that the sight picture of landing the accident airplane was "totally different" from the Piper Dakota (a PA-28 variant) airplane that he also flew. He also stated that, although many airplanes prohibit slips when the wing flaps are fully extended, such a maneuver is not prohibited in the accident airplane. The pilot opined that the sight picture observed during the landing approach and his slipping of the airplane with the flaps extended may have caused the instructor to "[feel] the need to take control of the aircraft at such a critical point in flight." PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot held a commercial pilot certificate with a rating for airplane single-engine land. He held an FAA second-class medical certificate, issued October 27, 2015. At the time of the medical examination, the commercial pilot reported 857 total hours of flight experience. According to the pilot, he had 962 total hours of flight experience and 500 hours of flight experience in the make and model of the accident airplane at the time of the accident. According to FAA records, the flight instructor held a commercial pilot certificate and a flight instructor certificate. He held an FAA third-class medical certificate, issued March 29, 2016. At the time of the medical examination, the flight instructor reported 1,000 total hours of flight experience. Review of the flight instructor's logbook revealed that he had 1,061.5 total hours of flight experience and 159.1 total hours of experience as a flight instructor at the time of the accident. Most of his instruction was given in Piper PA-28 and Cessna 172 airplanes. AIRCRAFT INFORMATION The four-seat, low-wing, retractable-gear airplane was manufactured in 1951. It was powered by a Continental TSIO-520, 285-horsepower engine, equipped with a three-blade McCauley propeller. Review of maintenance records revealed that the airplane's most recent annual inspection was completed on August 18, 2016. At that time, the airframe had accumulated about 4,550 total hours of operation and the engine had accumulated 1,257 hours since major overhaul. METEOROLOGICAL INFORMATION The 1153 recorded weather at FOK included wind from 310° at 21 knots gusting to 27 knots, visibility 10 statute miles, few clouds at 5,000 ft, temperature 5°C, dew point temperature -9°C, and an altimeter setting of 29.97 inches of mercury. Remarks included peak wind from 290° at 28 knots, at 1109. WRECKAGE AND IMPACT INFORMATION The airplane came to rest on a heading of 157° magnetic at 66 ft mean sea level. A debris path extended about 75 ft from the initial tree impact to the wreckage site on a heading about 030° magnetic. The outboard 6 ft of the right wing was fractured and located 75 ft from the main wreckage, toward the initial impactpoint. Its leading edge exhibited a 2-ft deep concave impression consistent with tree contact. The wing flaps were retracted, and the landing gear was extended. The left main landing gear was folded under the left wing, the right main landing gear was down and locked, and the nose gear was folded under the fuselage. The fuel selector was found in the main fuel tank position. The instrument panel and cabin area were all destroyed by fire. The three-blade McCauley propeller separated from the engine and was located about 30 ft from the main wreckage. The propeller blades exhibited rotational scoring, leading edge gouges, and "S" bending. Valve train continuity was observed through the engine by rotating the crankshaft. Thumb compression was attained on cylinder Nos. 2, 4, and 6. Limited thumb compression was noted on cylinder No. 5. The No. 5 cylinder head was impact-fractured on the rocker arm side. The intake valve springs were separated and the intake valve was inside the cylinder. Piston movement was confirmed on all six cylinders. The spark plugs were light gray in color and their electrodes were intact. The magnetos were intact and no slipping was noted. The ignition harnesses were intact; however, they were fire-damaged on the left side. The magnetos were removed and rotated. Both magnetos generated sparks to the ignition leads. All fuel lines were connected except for the vapor return line, which was fractured at the pump. The throttle valve was in the full open position. The throttle lever was fractured. The mixture lever was in the full rich position. The throttle-mixture-propeller cables were all intact and attached to the levers. The cockpit controls were melted. The manifold valve was clean and clear of debris. The fuel metering unit had some small debris on the screen. The outlet and return fittings were fractured. The fuel pump drive fitting was intact and rotated smoothly. The oil pan had a small puncture hole in the bottom of the pan. There was no oil in the engine; however, there was oil on the ground under the engine. MEDICAL AND PATHOLOGICAL INFORMATION The Office of the Medical Examiner, Suffolk County, New York, performed an autopsy on the flight instructor. The report listed the cause of death as unspecified blunt force trauma. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the flight instructor. The results were negative for drugs and alcohol. ADDITIONAL INFORMATION FAA Advisory Circular 61-98D provides information for certificated pilots and flight instructors to use in complying with the flight review required by 14 CFR 61. Paragraph 4.2.5 states: Instructors should also consider their own experience and qualifications in a given M/M [make and model] aircraft prior to giving a review in that model.… For aircraft in which the flight instructor is not current or with which he or she is not familiar, he or she should obtain recent flightexperience or sufficient knowledge of aircraft limitations, characteristics, and performance before conducting the review.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N4529K
Reported as
Ryan Navion (F)
Category
Airplane
Serial number
NAV-4-2338-B
Built
1951
Airframe hours
4,547
Engine
Continental TSIO-520-UB4A, 300 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 18, 2016
Departed
FOK · Westhampton Beach, NY
Destination
FOK · Westhampton Beach, NY
Airport
FOK · Francis S Gabreski, runway 33, 5,003 × 150 ft, asphalt
Equipment
Auto-pilot, Angle of attack indicator, Stall warning system, Electronic primary flight display, Electronic multifunction display

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
61
Injuries
Serious
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
June 30, 2014
Seat
Left
Restraint
3-point
Flight hours
962 total · 500 in this make and model · 737 as pilot in command · 30 in the last 90 days · 9 in the last 30 days · 0 in the last 24 hours
Role
Flight instructor
Age
64
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Right
Restraint
3-point
Toxicology
Performed
Flight hours
1,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
310° at 21 knots, gusting 27
Visibility
10 statute miles
Lowest ceiling
None
Temperature
41 °F, dew point 16 °F
Altimeter
29.96 inHg
Observed at
FOK

Docket · 9

The files NTSB released with the investigation on June 12, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.7 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.