MIA08LA023

NTSB accident investigation · Porter Glen Aventura II · Rockledge, FL · December 1, 2007

Accident · Serious injuriesLimited investigationFinal report
Date
December 1, 2007, 12:54 local (17:54 UTC)
Place
Rockledge, FL
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N79GPPorter Glen Aventura II
Weather
Visual (VMC) · Day
Status
Completed · report March 5, 2009
Report
Approved by Office Director
Parties
Rotax, FAA/FSDO
Case key
67186

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The failure of the pilot to maintain airspeed during climbout, resulting in an aerodynamic stall and uncontrolled descent. Contributing to the severity of the pilot's injuries was the inadequate manufacture of the shoulder harness restraint cables.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightTakeoff - initial climb
Airspeed - not maintainedPilot in commandCause
Stall - inadvertentPilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground
Material inadequate,improperKit manufacturerFactor
Misc eqpt/furnishings,shoulder harness - failure,total

Analysis

Following maintenance to the amateur-built airplane, including the manufacture and installation of shoulder harness cables and a condition inspection, the airplane was test flown by the facility general manager on two separate flights lasting a total of one hour. The only discrepancies reported by the general manager related to the airplane's brakes and noise in the headset. While the pilot has no independent recollection of the accident flight, a pilot-rated witness who was outside on the airport reported that his attention was drawn to the accident airplane when he heard a normal sounding engine run-up being performed. He watched the airplane take off, becoming airborne at the midpoint of the runway. The initial takeoff climb appeared normal, then approximately 1.5 seconds later, at an estimated 75 feet above ground level (agl), the left wing dropped or "bobbled." The airplane rolled to the right, then climbed to 100 to 150 feet agl. The right wing raised, the nose pitched up 15 degrees, which was more than a normal pitch attitude, and then the airplane "shuddered" and stalled to the left. The airplane impacted terrain in a left-wing-low attitude. During the impact sequence, the pilot's shoulder harness cable failed prematurely due to improper manufacturing, contributing to his serious head injuries. No evidence of preimpact failure or malfunction was identified for either the flight controls or engine.

Factual narrative

History of flight

On December 1, 2007, about 1254 eastern standard time, an amateur-built Porter Glen Aventura II, N79GP, registered to and operated by a private individual, experienced an in-flight loss of control and collided with terrain shortly after takeoff from Rockledge Airport (21FA), Rockledge, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the personal local flight conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The airplane was substantially damaged and the commercial-certificated pilot, the sole occupant, sustained serious injuries. The flight was originating at the time of the accident.

The pilot reported that he has no independent recollection of the accident flight. A pilot-rated witness who was outside on the airport reported his attention was drawn to the accident airplane when he heard a normal sounding engine run-up being performed. He watched the airplane takeoff from runway 36, and reported that the airplane became airborne at the midpoint of the runway. The initial takeoff climb appeared normal, then approximately 1.5 seconds later while flying at an estimated 75 feet above ground level (agl), the left wing dropped, or "bobbled." The airplane rolled to the right, then climbed to 100 to 150 feet agl. The right wing raised, the nose pitched up 15 degrees, which was more than a normal pitch attitude, and then the airplane "shuddered," and stalled to the left. At that time he heard the engine rpm increase, which in his 4,000 hours in the accident make of airplane was consistent with cavitation of the propeller. The airplane impacted in a left wing low attitude, and once on-scene, he noted the airplane was inverted, and fuel was leaking from a fuel line at the top of the engine. Further damage was done to the right wing in an effort to rescue the pilot. The witness further stated that the engine sounded "perfect" from the application of takeoff power to the point where the airplane stalled.

The pilot's wife who also witnessed the accident reported that approximately 200 feet agl into the takeoff climb, the left wing dropped and the airplane turned and impacted the ground nose first.

Personnel information

The pilot, age 77, holds an airline transport pilot certificate with an airplane multi-engine land rating. He also holds a commercial pilot certificate with airplane single engine land and sea ratings, issued July 24, 1999. He holds a second class medical certificate issued November 6, 2007, with a limitation to wear corrective lenses. In a National Transportation Safety Board Form 6120.1 submitted by the pilot, he annotated that his last flight review in accordance with (IAW) 14 CFR Part 61.56 was on July 25, 2007, and that he possessed 22,000 total flight hours, with 3 hours in the accident airplane make and model in the previous 90 days.

Aircraft information

The amateur-built airplane was manufactured in 2000, as model Aventura II, and was designated serial number AP2A0079. It was powered by a Rotax 582 65-horsepower engine and equipped with a 3-bladed Warp Drive square tip propeller. The exterior of the airplane was marked with "N306TC"; however, Federal Aviation Administration (FAA) records indicate the accident pilot/owner requested a change to "N79GP."

The pilot purchased the airplane in Mississippi on August 10, 2007, and transported it the next day by trailer to the kit manufacturer's factory for extensive work and a condition inspection. The airplane's maintenance records were reportedly left with the facility when the airplane was taken there. At the time the airplane was brought to the facility, the airplane was not equipped with shoulder harnesses; it was only equipped with automotive lapbelts. The lapbelts were replaced and shoulder harnesses were installed during the time the airplane was at the kit manufacturer's facility.

According to the general manager of the facility that worked on the airplane, the maintenance records could not be located; however, he reported the condition inspection was signed off as being completed on either November 29, or the morning of November 30, 2007. After the condition inspection was signed off, the maintenance department released the airplane for a maintenance test flight.

Meteorological information

A surface observation weather report taken at Patrick Air Force Base (COF), Cocoa Beach, Florida, at 1255, or approximately 1 minute before the accident indicates the wind was from 040 degrees at 9 knots, the visibility was 7 statute miles, broken clouds existed at 2,700 feet. The temperature and dew point were 25 and 21 Celsius respectively, and the altimeter setting was 30.22 inches of mercury. The accident site was located approximately 7 nautical miles and 304 degrees from COF.

Airport information

21FA is a private airport with one runway designated 18/36, which is 2,010 feet in length and 45 feet wide.

Wreckage and impact information

The airplane crashed in a residential area located approximately .27 nautical mile north-northwest from the approach end of runway 36.

Examination of the accident site by FAA personnel revealed the empennage was nearly vertical and displaced to the right. The nose and right wing were contacting the ground. A slight amount of fuel leakage was noted; the remaining fuel amount in the 18 gallon fuel tank was calculated to be approximately 3 gallons. During rescue of the pilot, the right wing was further damaged.

Examination of the airplane following recovery by Safety Board personnel revealed both wings were separated, and the hull was fragmented to the location of the flightcrew seats. Flight control continuity was confirmed for roll, pitch, and yaw. The elevator trim cable was connected at the trim tab and continuous to the cockpit control. The solid steel wire of the elevator trim cable was bent near the attach point at the trim tab. Safety Board review of pictures taken immediately before takeoff revealed the elevator trim tab was positioned slight tab trailing edge down. Examination of the pilot's restraint system revealed the webbing of both shoulder harnesses and the webbing of one side of the lapbelt were cut during the rescue process. A cable that secured the pilot's shoulder harness to structure was separated from a thimble at the shoulder harness end of the cable. The shoulder harness cable assembly was retained for further examination. The engine was removed from the airframe, placed on a test stand, and found to operate normally.

Examination of the cockpit revealed the master and both ignition switches were in the on position. The primer was fully in, and the throttle was full forward.

Medical and pathological information

The pilot sustained serious injuries to his head, with little bruising around his shoulders. He also suffered a broken wrist. There were no broken bones in his legs.

Tests and research

The airplane was test flown by the kit manufacturer's facility general manager the day before the accident following sign off of the condition inspection. A total of two separate flights lasting a total flight time of approximately 1.0 hour were performed. The general manager reported to the Safety Board a discrepancy with the brakes and a sound in the headset from the strobes were noted. No discrepancies were noted with the engine or flight controls.

Following the flights by the general manager, he briefed the accident pilot about the flight controls, instruments, and was given a cockpit familiarization. After the ground instruction, the airplane was then flown by the accident pilot and the general manager who performed the first takeoff. After takeoff, the accident pilot took the controls and performed slow flight, power-off stalls, and checked the landing gear and flaps. The accident pilot returned for landing and performed a full-stop taxi back landing for a subsequent departure. After departu

Aircraft

Registration
N79GP
Reported as
Porter Glen Aventura II
Category
Airplane, amateur-built
Serial number
AP2A0079
Airframe hours
142.2
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Clark Thomas P
Registered owner
Clark Thomas P
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · November 29, 2008 · 1 hours before
Departed
21FA · Rockledge, FL
Destination
21FA
Airport
21FA · Rockledge Airport, runway 36, 2,010 × 45 ft, asphalt

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
77
Injuries
Serious
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
July 25, 2007
Seat
Left
Flight hours
22,000 total · 20 in the last 90 days · 3 in the last 30 days · 3 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
40° at 9 knots
Visibility
7 statute miles
Lowest ceiling
2,700 ft broken
Temperature
77 °F, dew point 70 °F
Altimeter
30.21 inHg
Observed at
COF, 7 nm away

Docket · 21

The files NTSB released with the investigation on February 4, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.7 MB in all.

Materials Laboratory 15 - Factual Report 08-091Item 1 · .PDF · 6.0 MBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 2 · .PDF · 421 KBWeather Reports and RecordsItem 3 · .PDF · 58 KBFAA Inspector StatementItem 4 · .PDF · 41 KBReports from Parties to the Investigation-RotaxItem 5 · .PDF · 99 KBDocuments from Kevin ColeItem 6 · .PDF · 1.5 MBRecord of NTSB ConversationsItem 7 · .PDF · 609 KBRecord of Conversation with Arthur GiessmanItem 8 · .PDF · 56 KBRecord of Pilot InterviewItem 9 · .PDF · 52 KBE-mail to and Response from Loos and Company, Inc.Item 10 · .PDF · 35 KBStatement of Party Representatives to NTSB InvestigationItem 11 · .PDF · 48 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 12 · .PDF · 404 KBPhoto 1: Digital Picture Provided to NTSB. View of the Airplane Before Takeoff.Item 13 · .PDF · 2.9 MBPhoto 2: Digital Picture Provided to NTSB. View of the Airplane Before Takeoff.Item 14 · .PDF · 69 KBPhoto 3: Digital Picture Provided to NTSB. View of the Airplane at the Accident Site.Item 15 · .PDF · 67 KBPhoto 4: NTSB Digital Picture. View of the Airplane First Viewed by NTSB.Item 16 · .PDF · 391 KBPhoto 5: NTSB Digital Picture. View of the Engine Assembly.Item 17 · .PDF · 386 KBPhoto 6: NTSB Digital Picture. View of the Shoulder Harness Cable Attach Point at the Structure.Item 18 · .PDF · 369 KBPhoto 7: NTSB Digital Picture. View of the Pilot and Co-Pilot Shoulder Harness Cables.Item 19 · .PDF · 336 KBPhoto 8: NTSB Digital Picture. View of the Pilot Shoulder Harness Cable Attach Point at the Shoulder Harness.Item 20 · .PDF · 395 KBPhoto 9: NTSB Digital Picture. View of the Engine Operational Testing.Item 21 · .PDF · 381 KB