ERA20FA088

NTSB accident investigation · Aeropro CZ A220 · Grafton, WV · January 27, 2020

Accident · FatalClass 3 · FieldFinal report
Date
January 27, 2020, 12:54 local (17:54 UTC)
Place
Grafton, WV
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N214KAeropro CZ A220
Defining event
Enroute-climb to cruise: VFR encounter with IMC
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/ FSDO, Rotax Aircraft Engines
FAA report
20200127000269A
Case key
100871

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 decision to continue a visual flight rules flight into instrument meteorological conditions and conditions favorable for airframe icing, which resulted in a loss of control of the airplane.

Findings · 4

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.

Aircraft capability: instrument flight capabilityAircraft › Aircraft oper/perf/capability · Capability exceededAeropro CZ A220: 1 caseAll aircraft: 10 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedAeropro CZ A220: 1 caseAll aircraft: 1,269 casesProbable cause
Ceiling/visibility/precipEnvironmental issues › Conditions/weather/phenomena · Effect on operationAeropro CZ A220: 1 caseAll aircraft: 65 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 pilot took delivery of his newly assembled special light sport airplane a few days before the accident and received about 5 hours of instruction in the airplane. On the morning of the accident, he departed on the cross-country flight to his home airport after indicating to the mechanic and flight instructor who assisted with the airplane’s delivery and transition training that he was going to “scud run.” After stopping for fuel en route, the pilot departed to continue the flight. According to automatic dependent surveillance-broadcast data, for the first 5 minutes after takeoff, the airplane appeared to be performing a normal en route to cruise climb, but, when the airplane reached about 3,000 ft mean sea level (msl), the climb rate increased considerably. For the next 2 to 3 minutes, the airplane climbed at an accelerated rate, its groundspeed slowed, and the course heading deviated to the left and right. During the final 10-15 seconds of data, the airplane completed a 180°, rapidly descending left turn. The final reported position showed the airplane at 4,300 ft msl, about 1/4 mile from the accident site. The condition and orientation of the wreckage indicated that the airplane impacted terrain in a steep and rapid descent. The wreckage was heavily fragmented and further damaged by a postcrash fire. Examination of the wreckage did not reveal evidence of a preimpact mechanical malfunction. Remnants of the whole airframe parachute system were not identifiable; whether the pilot attempted to activate the system could not be determined based on the available information. Review of weather conditions indicated that the airplane likely entered an overcast cloud layer and instrument meteorological conditions around 3,000 ft msl and remained in those conditions for the entire climb to a maximum altitude of about 5,500 ft msl. In the cloud layer, conditions were conducive to the development of light-to-moderate rime airframe icing. The overcast layer of clouds likely had tops near 11,500 ft msl, so it is unlikely that the pilot entered visual flight rules (VFR) conditions above the cloud layer. Several weather observations and forecasts available to the pilot before departure called for these conditions. Although there was no evidence that the pilot obtained an official weather briefing, statements made by the pilot on the morning of the accident indicated that he was aware of the poor weather conditions and that he intended to continue VFR flight to his destination regardless of the forecast conditions. The pilot was instrument rated and current; however, the airplane was neither certified nor equipped for flight in instrument or icing conditions. It is likely that the pilot was attempting to maintain control of the airplane in instrument meteorological conditions after accumulating structural icing that degraded the aerodynamic characteristics of the airplane. In addition, the pilot may have experienced erroneous flight instrument indications dueto an icing-induced pitot-static system blockage. These factors indicate that the pilot likely lost control of the airplane after his continued VFR flight into instrument meteorological and icing conditions and subsequently entered a steep descent and spiral from which he did not recover.

Factual narrative

According to the FAA Airmen’s Information Manual (AIM), the following references are provided for light and moderate airframe icing intensities: Light. The rate of accumulation may create a problem if flight is prolonged in this environment (over 1 hour). Occasional use of deicing/anti-icing equipment removes/prevents accumulation. It does not present a problem if the deicing/anti-icing equipment is used. Moderate. The rate of accumulation is such that even short encounters become potentially hazardous and use of deicing/anti-icing equipment or flight diversion is necessary. The AIM also defined clear and rime inflight icing: Rime Ice. A rough, milky, opaque ice formed by the rapid freezing of supercooled drops/droplets after they strike the aircraft. The rapid freezing results in air being trapped, giving the ice its opaque appearance and making it porous and brittle. Rime ice typically accretes along the stagnation line of an airfoil and is more regular in shape and conformal to the airfoil than glaze ice. It is the ice shape, rather than the clarity or color of the ice, which is most likely to be accurately assessed from the cockpit. Clear Ice or Glaze Ice. Ice, sometimes clear and smooth, but usually containing some air pockets, which results in a lumpy translucent appearance. Glaze ice results from supercooled drops/droplets striking a surface but not freezing rapidly on contact. Glaze ice is denser, harder, and sometimes more transparent than rime ice. Factors, which favor glaze formation, are those that favor slow dissipation of the heat of fusion (i.e., slight supercooling and rapid accretion). With larger accretions, the ice shape typically includes “horns” protruding from unprotected leading edge surfaces. It is the ice shape, rather than the clarity or color of the ice, which is most likely to be accurately assessed from the cockpit. The terms “clear” and “glaze” have been used for essentially the same type of ice accretion, although some reserve “clear” for thinner accretions which lack horns and conform to the airfoil. FAA Advisory Circular 61-134 states: Operating in marginal VFR/IMC conditions is more commonly known as scud running…some pilots, including some with instrument ratings, continue to fly VFR in conditions less than that specified for VFR. The result is often a CFIT accident when the pilot tries to continue flying or maneuvering beneath a lowering ceiling and hits an obstacle or terrain or impacts water. According to FAA airworthiness records, the 2-seat, single-engine, high-wing special light sport airplane was issued a special airworthiness certificate on January 23, 2020. It was powered by a Rotax 912 ULS 100-horsepower engine and was equipped with a BRS Aerospace Whole Aircraft Rescue Parachute System. According to a bill of sale and registration application, the pilot purchased and registered the airplane on January 23, 2020. The operating limitations in the Pilot’s Operating Handbook (POH) provided a warningagainst flight into instrument and icing conditions. (see Figure 4.) Figure 4: A warning excerpt from the POH. The POH stated that the aerodynamic stall speed was 43 mph (37 knots) with flaps down, and 49 mph (42 knots) with flaps up. It also provided an additional warning that stated, “The stall speed mentioned above are with wings level. Once any angle of bank (e.g. turn) is encountered the stall speed is significantly increasing. Example: angle of bank 60° ……. VS = 73 MPH [63 knots].” A review of the POH found that the airplane was not equipped with any anti-ice or de-ice equipment, including pitot heat. On January 27, 2020, at 1254 eastern standard time, an Aeropro CZ A220 airplane, N214K, was destroyed when it was involved in an accident near Grafton, West Virginia. The private pilot was fatally injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. According to Federal Aviation Administration (FAA) airworthiness and registration records, the pilot purchased the newly assembled airplane on January 23, 2020. The mechanic who completed the airplane’s final assembly reported that the pilot arrived at Shawnee Field Airport (1I3), Bloomfield, Indiana, on January 25, 2020, to begin taking delivery of the airplane. He reported that the pilot completed multiple training flights with a flight instructor the day before the accident. The mechanic further reported that, on the morning of the accident, the pilot planned to begin his trip toward his home in Massachusetts. He added that the pilot told him that he would be “scud running” most the morning in order to “clear some miles.” The instructor who flew with the pilot over the weekend reported that, “I was afraid he [the pilot] was going to try to scud run,” because the pilot stated to him on the morning of the accident, he was going to “scud run.” The mechanic and flight instructor reported that the pilot departed from 1I3 for the cross-country flight about 0900. They both added that, at the time of his departure from 1I3, low ceilings and visibility with fog persisted in the area. According to fixed-based operator (FBO) employees and fuel receipt records, the airplane arrived at North Central West Virginia Airport (CKB), Clarksburg, West Virginia, shortly before 1230. The pilot requested to fuel the airplane himself and he subsequently added a total of 16 gallons of 100 low-lead aviation fuel divided between both wing fuel tanks. He informed the FBO employees that he was headed to Massachusetts; however, he did not provide any specific intermediate destination. Before departing, he showed the airplane’s parachute system to one of the employees. The other employee reported that the pilot, prior to departing, stated, “your weather is bad.” Review of FAA air traffic control (ATC) communications revealed that the pilot was given clearance by a CKB tower controller to taxi and subsequently depart runway 21 under visual flight rules (VFR).The pilot departed the area to the northeast, a frequency change was approved, and there were no further communications with ATC. Review of FAA automatic dependent surveillance-broadcast (ADS-B) tracking data revealed that the airplane departed runway 21 at 1246 and proceeded to climb to about 3,000 ft mean sea level (msl) on a northeast heading for 4 minutes. The airplane leveled off for about 1 minute, then re-entered a climb at an increased rate. For the next three minutes, the airplane continued to climb, its groundspeed slowed significantly, and the airplane’s course began to deviate to the left and right. In the final minute of the flight, the airplane reached a maximum altitude of about 5,500 ft msl, and then descended about 600 ft before climbing to 5,100 ft. Subsequently, the flight track showed the airplane complete a 180° rapidly descending left turn. The final data point was at 1254:16, which depicted the airplane about .25 nautical mile from the accident site heading south, at 4,300 ft msl. Figure 1 provides an overview of the final few minutes of the flight. Figure 1: Overview of the ADS-B flight track for the final few minutes of the flight. Figure 2 provides a three-dimensional view of the ADS-B data for the final minute of the flight. Figure 2: A three-dimensional view of the ADS-B flight track for the final minute of the flight. Figure 3 is a chart of the reported altitude and groundspeed for the entire flight. The source of this data is from L3 Harris OPSVUE. Figure 3: A chart of the reported altitude and groundspeed for the entire flight. The route of flight and accident site were located immediately northeast of a stationary front and behind a trough in an area of general low pressure. Weather observations near the route of flight about the time of the accident indicated marginal VFR conditions and instrument flight rules (IFR) conditions. The 1253 recorded weather observation at CKB (the departure airport), which was located about 10 miles southwest of the accident site at an elevation of 1,224 ft, included a broken ceiling at 1,800 ft above ground level (agl), an overcast ceiling at 2,300 ft agl, 10 statute miles visibility, wind 260° at 6 knots, temperature was 4°C, dew point -2°C, and an altimeter setting of 29.83 inches of Hg. The 1253 recorded weather observation at Morgantown Municipal Airport (MGW), Morgantown, West Virginia, which was located about 16 miles north of the accident site at an elevation of 1,244 ft, included an overcast ceiling of 2,100 ft agl, 10 statute miles visibility, wind 280° at 7 knots, temperature 3°C, dew point -2°C, and an altimeter setting of 29.82 inches of Hg. The 1255 recorded weather observation at Garrett County Airport (2G4), Oakland, Maryland, approximately 34 miles northeast of the accident site at an elevation of 2,933 ft, included, ceiling overcast at 600 ft agl, wind from 260° at 10 knots gusting to 16 knots, wind from 242° variable 302°, 10 miles or more visibility, temperature-2°C, dew point -3°C, altimeter 29.72 inches of Hg. According to a High-Resolution Rapid Refresh (HRRR) numerical model performed for the area surrounding the accident site, a cloud layer existed from about 2,600 ft msl through 11,500 ft msl. The freezing level was about 1,800 ft msl, which supported conditions conducive to structural airframe icing in the clouds with a mixture of clear to rime type icing at moderate intensities. The model also identified possible mountain wave turbulence in the clouds. According to Leidos Flight Service, there was no record that the pilot received a weather briefing or filed flight plans on the day of the accident. Forecast weather products that would have been available to the pilot included a terminal aerodrome forecast (TAF) and AIRMETs calling for overcast clouds, IFR conditions, moderate icing, and mountain obscuration conditions. A review of the pilot's logbook revealed the pilot had logged 967 total hours of flight experience, of which 5.3 hours were instructional hours in the accident airplane recorded the day before the accident. The pilot logged 25 and 8 hours in the past 90 and 30 days, respectively. From August 8, 2019, to January 26, 2020, the pilot had logged 7 hours of actual instrument fight time and accumulated 16 instrument approaches. His most recent flight review was completed on September 8, 2018. Several pages of the pilot’s logbook were damaged by the postcrash fire and were not legible. The instructor who completed the 5.3 hours of initial training in the accident airplane with the pilot reported that the pilot performed “just fine” in their flights, which included takeoffs, landings, maneuvering, and simulated instrument conditions. He recalled stating to the pilot, that the airplane “would be very difficult” to fly in clouds. The instructor believed that the airplane’s flight manual stated that the airplane must be flown only under day visual flight rules conditions. He could not recall having any conversation with the pilot about the whole airframe parachute system installed on the airplane. The initial impact point coincided with a 100-ft-tall tree, about 110 ft from the main wreckage. The angle of descent from the top of the tree where the airplane first collided to the main wreckage was about -55° and oriented on a 175° true heading. The accident site elevation was about 1,480 ft msl. Figure 5 provides an overview of the accident site. Figure 5: Overview of the accident site (NTSB Photo). All major components of the airplane were found near the main wreckage. Flight control continuity could not be established due to the highly fragmented wreckage and postcrash fire that consumed most of the fuselage; however, fragments of each flight control surface, forward and rear wing spars, and wingtips were located with the main wreckage. The cockpit, instrument panel, seats, and fuselage were largely consumed by the postcrash fire. A fragmented and fire-damaged airspeed indicator was foundindicating about 40 mph (35 knots). The main fuel shutoff valve was found selected to an on/open position. A search performed at the accident site and again at the recovery facility was unable to identify any remnants of the BRS parachute system. The engine was located with the main wreckage, partially embedded in the ground. It sustained heavy impact damage; the No. 2 cylinder was found about 5 ft from the remainder of the engine. The propeller hub had fragmented into several pieces and all three propeller blades were located near the main wreckage. All spark plugs were located and each sustained impact and fire damage. They exhibited normal combustion signatures. Both carburetors were displaced from their respective intake manifolds and were heavily fragmented. Internal examination of each cylinder’s rocker arms, valves, and valve springs revealed no evidence of preimpact anomalies.

Aircraft

Registration
N214K
Reported as
Aeropro CZ A220 (NO SERIES)
Category
Airplane
Serial number
57819
Built
2020
Airframe hours
8
Engine
Rotax 912 ULS, 100 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
Condition · December 26, 2019 · 8 hours before
Departed
CKB · Clarksburg, WV
Equipment
Electronic primary flight display, Electronic flight bag or handheld device, Airframe parachute, ADS-B

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
67
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
September 8, 2018
Seat
Left
Toxicology
Performed
Flight hours
967 total · 5.3 in this make and model · 25 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Instrument (IMC) · Day
Wind
260° at 6 knots
Visibility
10 statute miles
Lowest ceiling
1,800 ft broken
Temperature
39 °F, dew point 28 °F
Altimeter
29.82 inHg
Icing
Unknown
Turbulence
Unknown
Observed at
CKB, 10 nm away

Docket · 15

The files NTSB released with the investigation on November 30, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 23.5 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.