ERA18FA230

NTSB accident investigation · Aeronca 7AC · Hanson, MA · August 24, 2018

Accident · FatalField investigationFinal report
Date
August 24, 2018, 15:35 local (19:35 UTC)
Place
Hanson, MA
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N65HMAeronca 7AC
Defining event
Initial climb: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 20, 2020
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20180824012229A
Case key
98152

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

A loss of engine power due to carburetor icing, the pilot's decision to turn back to the runway shortly after takeoff, and his failure to maintain airspeed during the turn, which resulted in an exceedance of the airplane's critical angle of attack, and subsequent aerodynamic stall.

Findings · 6

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 · PilotAeronca 7AC: 43 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedAeronca 7AC: 7 casesAll aircraft: 990 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedAeronca 7AC: 10 casesAll aircraft: 1,681 casesProbable cause
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Effect on operationAeronca 7AC: 5 casesAll aircraft: 435 casesProbable cause
Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeAeronca 7AC: 5 casesAll aircraft: 435 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

The commercial pilot and passenger were departing on a local personal flight in the single-engine airplane. Review of airport security video showed the airplane level off about 100 ft above ground level as it passed the departure end of the runway. The airplane then entered a left turn and descended to ground contact. Damage to the propeller blades was consistent with a lack of engine power at the time of impact; however, examination of the wreckage revealed no evidence of preimpact mechanical anomalies that would have prevented normal engine operation. Based on the temperature and dew point about the time of the accident, the conditions were favorable for serious carburetor icing at a glide power setting. Video showed that the airplane operated on the ground at an idle engine power setting for about 7 minutes before takeoff, and it is probable that carburetor ice formed during this time, subsequently resulting in the loss of engine power during the initial climb. Following the loss of power, the pilot attempted to turn back to the runway with insufficient altitude and, during the turn, failed to maintain airspeed, resulting in an exceedance of the airplane's critical angle of attack, an aerodynamic stall/spin, and impact with terrain.

Factual narrative

FAA Special Airworthiness Information Bulletin (CE-09-35) – Carburetor Icing Prevention, stated that: …pilots should be aware that carburetor icing doesn't just occur in freezing conditions, it can occur at temperatures well above freezing temperatures when there is visible moisture or high humidity. Icing can occur in the carburetor at temperatures above freezing because vaporization of fuel, combined with the expansion of air as it flows through the carburetor, (Venturi Effect) causes sudden cooling, sometimes by a significant amount within a fraction of a second. Carburetor ice can be detected by a drop in rpm in fixed pitch propeller airplanes and a drop in manifold pressure in constant speed propeller airplanes. In both types, usually there will be a roughness in engine operation. According to FAA records, the airplane was manufactured in 1946. It was equipped with a Continental Motors Inc. C90 series, 90-horsepower engine that drove a fixed-pitch propeller. According to airplane maintenance logbooks, an annual inspection was completed on October 1, 2017, at a total time of 1,521.4 hours and a tachometer time of 3,215.1 hours. Following the accident, the tachometer indicated 3,325.1 hours. The airplane was flown the day before the accident by the owner's son and the accident pilot. The owner's son reported that there were no anomalies with the airplane during their flight, which lasted about an hour. He stated that he usually applied carburetor heat while operating the engine at idle power on the ground because of the "carburetor icing possibilities." The engine operating instructions stated that, during the pretakeoff ground test (engine run-up), the carburetor heat control should be moved "to full HOT position, and observe decrease in engine speed if air heater and control are operating properly. [Then] return control to full COLD position." The instructions noted, "under some conditions, ice may form in the carburetor during ground test. It must be eliminated before takeoff." Cranland Airport was a public, nontower-controlled airport located 3 miles southeast of Hanson, Massachusetts. The airport was equipped with an asphalt runway designated as 18/36, which was 1,760 ft long by 60 ft wide. The airport elevation was 71 ft above mean sea level (msl); the airport was surrounded by cranberry bogs, ponds, and wooded terrain. On August 24, 2018, around 1535 eastern daylight time, an Aeronca 7AC Champion, N65HM, was substantially damaged when it impacted terrain shortly after takeoff from Cranland Airport (28M), Hanson, Massachusetts. The commercial pilot was fatally injured and the passenger was seriously injured. The airplane was privately owned and was being operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight, which was originating at the time of the accident. A review of airport security video showed the airplane about 100ft above ground level as it passed the departure end of the runway during takeoff. The airplane was not climbing and began to bank to the left; the left turn continued as the airplane descended behind trees and impacted terrain. The video also indicated that the airplane operated at idle engine power on the ground for about 7 minutes before beginning the takeoff roll. First responders reported that the airplane came to rest in a nose-down, near-vertical position and that they had to move the airplane in order to perform rescue operations. The passenger stated to a first responder that the airplane "stalled." The Office of the Medical Examiner, Boston, Massachusetts, performed an autopsy on the pilot. The autopsy report indicated that the cause of death was multiple blunt force injuries. Toxicology testing of the pilot was performed at the FAA Forensic Sciences Laboratory. Fluid and tissue specimens tested negative for ethanol. Ketamine, norketamine, midazolam, lorazepam, and morphine were all detected in the blood and liver. In addition, fentanyl was detected in the blood. All detected medications were consistent with emergency medical treatment after the accident. The 1552 recorded weather observation at Plymouth Municipal Airport (PYM), Plymouth, Massachusetts, about 8 miles southeast of the accident location, included wind from 210° at 9 knots, 10 miles visibility, clear skies, temperature 27°C, dew point 12°C; and an altimeter setting of 30.20 inches of mercury. The carburetor icing probability chart from FAA Special Airworthiness Information Bulletin (SAIB): CE-09-35 Carburetor Icing Prevention, showed a probability of serious icing at glide power at the temperature and dew point reported at the time of the accident. According to Federal Aviation Administration (FAA) records, the pilot held a commercial pilot certificate with ratings for rotorcraft-helicopter, instrument helicopter, and private pilot privileges for airplane single-engine land and sea. The pilot was issued a first-class FAA medical certificate on October 10, 2017, with no limitations. According to the pilot's logbook, he had accumulated 195.7 hours of civilian flight experience, of which 4 hours were in the accident airplane in the previous 3 years. An exemplar airplane with a Continental Motors Inc. C90 engine was started and the fuel selector was moved to the OFF position. The engine operated for 31 seconds before the engine lost total power without sputtering. The airplane was restarted and operated at idle power for about 5 minutes. After that time, the engine was shut down and condensation was noted on the carburetor and intake of the engine. At the time of the test, the ambient temperature was 28°C and the dew point was 15°C, which showed a probability of serious icing at glide power on the Carburetor Icing Probability Chart. The airplane impacted a bog 470 ft east of the departure end of runway 18. The main wreckage was located at an elevation of 59 ft msl. Allcomponents of the airplane were located in the vicinity of the wreckage. The nose section was impact crushed aft. Flight control continuity was confirmed from the flight controls in the cockpit to all flight control surfaces. The carburetor heat control was in the OFF position. The leading edges of the right and left wings were impact crushed along the entire span of each wing. A fuel sample was taken from both fuel tanks and the samples tested negative for water contamination. The empennage and aft flight control surfaces remained intact and attached to the fuselage. The airplane was not equipped with a stall warning system or angle of attack indicator. The engine remained attached to the airframe and the propeller remained attached to the engine. One propeller blade was bent slightly aft and the other blade remained straight. Engine crankshaft continuity was confirmed from the propeller flange to the accessory section. All cylinders remained attached to the crankcase and thumb compression and suction was observed on all cylinders when the propeller was rotated through the entire range of motion. The rocker box covers were removed and no anomalies were noted with the valve springs and rocker arms. Valvetrain continuity was confirmed when the propeller was rotated by hand. The carburetor hot air inlet was impact crushed aft. Carburetor heat control continuity was confirmed from the airbox to the cockpit, and the control was cut to facilitate further examination. The control could not be moved as a result of impact damage. The carburetor was removed and disassembled. The gasket was examined with no anomalies noted. The float assembly remained intact with no anomalies noted. The butterfly valve and fuel pump operated when the throttle arm was moved by hand. The needle and seat remained in place. The carburetor bowl was examined and contained brownish fluid similar to the water in the bog; the fluid smelled similar to 100LL aviation fuel. The left and right magnetos were removed. When each magneto was rotated by hand, spark was observed on all towers. The top spark plugs were removed. The spark plugs were in "normal" condition when compared to the Champion Check a Plug Chart, with the exception of the No. 2 top spark plug, which exhibited "normal-worn out" condition.

Aircraft

Registration
N65HM
Reported as
Aeronca 7AC (No Series)
Category
Airplane
Serial number
7AC-3708
Built
1946
Airframe hours
1,631.4
Engine
Continental Motors C90-12F, 95 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 1, 2017 · 110 hours before
Departed
28M · Hanson, MA
Destination
28M · Hanson, MA
Airport
28M · Cranland, runway 18, 1,760 × 60 ft, asphalt
Equipment
None

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
33
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Helicopter
Medical
Class 1, Without waivers/limitations
Last flight review
April 19, 2016
Seat
Front
Restraint
3-point
Toxicology
Performed
Flight hours
195 total · 4 in this make and model · 116 as pilot in command · 4.5 in the last 90 days · 4.5 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 54 °F
Altimeter
30.20 inHg
Observed at
PYM, 8 nm away

Docket · 12

The files NTSB released with the investigation on March 17, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 28.2 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.

Other investigations on N65HM · 1

Matched to the same aircraft by N-number and date.