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On April 11, 2005, at 1308 eastern daylight time, a Cessna 152, N24779, was substantially damaged when it impacted a field near Williamsburg, Ohio. The certificated flight instructor (CFI) and student pilot were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local instructional flight conducted under 14 CFR Part 91.
According to another company CFI, prior to takeoff, the accident pilots were discussing "hood work and spin training." The flight departed Clermont County Airport (I69), Batavia, Ohio, about 1230, and proceeded to a practice area approximately 10 miles east of the airport. A witness, who was driving in his car about the time of the accident, observed the accident airplane "falling out of the sky...nose first," and did not appear to have any power. Another witness, who was standing near her residence, heard engine noise oscillate about three times, followed by no engine noise at all. The witness looked up and observed the accident airplane spiraling downward. A third witness was standing near her mailbox, and observed the accident airplane spiraling downward. The witnesses could not confirm the direction of rotation as the airplane was spiraling.
Review of radar data provided by the Federal Aviation Administration (FAA), revealed a target displaying a 1200 transponder code, traveling south at 4,000 feet msl. The target began a right turn toward north about 1306:38, and began to descend about 1307:25. The last target was recorded at 1308:01, at a position about 1/8-mile from the accident site. The last target indicated an altitude of 2,100 feet msl.
The accident occurred during the hours of daylight; located about 39 degrees, 01.12 minutes north latitude, and 84 degrees, 00.24 minutes west longitude.
The CFI held a commercial pilot certificate and flight instructor certificate, with ratings for single engine land and instrument airplane. He had a total flight experience of approximately 468 hours, of which, about 88 hours were in the same make and model as the accident airplane. Additionally, he had approximately 192 hours of experience as a flight instructor.
The flight instructor's most recent FAA third class medical certificate was issued on September 12, 2002.
The student pilot held a student pilot certificate. He had a total flight experience of approximately 47 hours, of which, about 2 hours were in the same make and model as the accident airplane.
The student pilot's most recent FAA first class medical certificate was issued on October 5, 2004.
The airplane was manufactured in 1977. It's most recent annual inspection was performed on February 11, 2005. At that time, the airplane had accumulated approximately 10,681 hours of operation. The airplane accumulated approximately 38 hours of operation from the time of the last inspection, until the accident.
The reported weather at Lunken Field (LUK), Cincinnati, Ohio, at 1253, was: wind variable at 5 knots; visibility 10 miles; sky clear; temperature 81 degrees F; dew point 46 degrees F; altimeter 29.99 inches Hg.
The wreckage was examined on April 11 and 12, 2005, and all major components of the airplane were accounted for at the scene. The wreckage was intact, oriented about a 100-degree heading, and resting upright in a field. The field elevation at the accident site was approximately 915 feet above sea level. There was no observed debris path or horizontal ground scars at the accident site.
No fuel was found in the two fuel tanks. However, both tanks had ruptured, and fueling records indicated that the airplane was completely fueled prior to takeoff. With the exception of the left aileron, flight control continuity was confirmed from all control surfaces to the cockpit area. Flight control continuity was confirmed from the left aileron bellcrank to the cockpit area. The bellcrank rod arm was separated from the left aileron, consistent with overstress. An FAA inspector stated that emergency personnel had to cut control cables and manipulate the wreckage to recover the pilots. The elevator trim jackscrew corresponded to an approximate 8-degree nose-down setting, and the elevator trim cable was separated near the cockpit area consistent with a cut.
The right wing exhibited compression damage, and the damage was more severe near the leading edge. The right flap was found retracted, and the right aileron was approximately neutral. The left wing also exhibited compression damage, and the damage was more severe near the leading edge. The left flap was found retracted, and the left aileron was approximately neutral.
The cockpit area was crushed, a portion of the fuel selector lever was separated, and the selector was found in the "ON" position. The flap switch was found near the 10-degree extension position, and the flap indicator was in the flaps retracted position. The mixture control was found in the lean position, the throttle control was full throttle, and the ignition key was selected to "BOTH." The carburetor heat selector was found in the mid-range position. Both seatbelts and shoulder harnesses were fastened, and were cut by emergency personnel.
The tachometer needle was observed near the 1,000-rpm position. The altimeter face was found separated from the unit; the needle indicated 1,300 feet, and 30.00 was displayed in the Kollsman window. The attitude indicator displayed an approximate 90-degree left bank, and 10-degree nose-up attitude. The directional gyro indicated approximately 100 degrees. The airspeed indicator needle had separated, and was not recovered. The face of the turn coordinator had separated from the unit, and was found near the 90-degree right bank position. The vertical speed indicator was not recovered.
The propeller remained attached to the engine. One propeller blade was bent forward near the tip, and the other blade was bent aft. Minor rotational damage was observed on the blades. The spark plugs, propeller, and valve covers were removed from the engine for inspection. Oil was present throughout the engine and in the oil filter. The spark plugs appeared light gray in color, and their electrodes were intact. The propeller flange was rotated by hand, using a crowbar. Camshaft, crankshaft, and valve train continuity in the engine were confirmed. Thumb compression was obtained on all cylinders. The right magneto was partially separated from the engine. When the right magneto was rotated by hand, it produced spark at all leads. The left magneto remained attached to the engine, and produced spark at all leads while the crankshaft was rotated by hand. The vacuum pump remained attached to the engine. The vacuum pump was disassembled, and the rotor was observed fractured. The oil filter was examined, and no metallic contamination was noted. Fuel was recovered from the carburetor, and was consistent in odor and color to 100 low lead aviation gasoline. The carburetor fuel screen was absent of debris.
The empennage was found separated from the airplane, and resting upright. The empennage was buckled on the left side, and the rudder was deflected full left. The Ohio State Police photographed the wreckage prior to its manipulation by emergency personnel. The photographs revealed that the empennage remained partially attached to the airplane, and the rudder was deflected full left. Further examination of the rudder revealed that it was jammed beyond its full left travel limit. The rudder bumper had traveled over and beyond the rudder stop, and had locked behind it. Further examination of the two rudder bumpers revealed that they were installed inverted.
MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy was performed on the pilots by the Brown County Coroner's Office, Mount Orab, Ohio.
Toxicological testing was conducted on the pilots at the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma.
History of Rudder Bumpers
In a correctly installed system, the rudder bumper assemblies consisted of two brackets; with one bracket attached to the left side of the rudder horn, and one bracket attached to the right side of the rudder horn. Each bracket had a lip at one end, which contacted their respective rudder stop (bolt). When the rudder traveled to its full left limit, the right side bracket would contact the right stop, preventing further travel. When the rudder traveled to its full right limit, the left side bracket would contact the stop, preventing further travel.
Review of airplane maintenance records revealed that there was no specific mention of the rudder bumpers during the 28-year history of the airplane. There were some records of work performed near the rudder bumpers:
On March 7, 1988, the rudder cables were removed and replaced.
On August 25, 1991, the lower rudder fairing was replaced.
On August 1, 1998, the left hand aft rudder cable fairlead was replaced.
On November 30, 2000, the rudder cables attach point bushing was removed and replaced.
On October 17, 2002, the aft left rudder cable was removed and replaced.
The airplane was last painted on August 29, 1997. The paint on the inverted rudder bumpers was consistent with that paint job. The investigation could not determine if the rudder bumpers were inverted at the time of production, or if they had been inverted during the maintenance history of the airplane.
On January 22, 2001, Cessna Aircraft Company issued Service Bulletin SEB01-1, and designated it mandatory. The purpose of the service bulletin was to provide an enhanced rudder stop, bumper, doubler and attachment hardware designed to assist in preventing the possibility of the rudder overriding the stop bolt during full left or right operation of the rudder. Specifically, the new rudder stop was much larger than the original rudder stop. The service bulletin had not been complied with on the accident airplane, and under 14 CFR Part 91, was not required to be complied with.
On October 10, 2003, Transport Canada issued Airworthiness Directive (AD) CF-2000-20R2, which made the service bulletin mandatory for all applicable Canadian registered airplanes.
At the time of the accident, the FAA had no similar AD. During the course of the accident investigation, the FAA began procedures to issue a similar AD. The AD would make the service bulletin mandatory and require a check of the correct orientation of the rudder bumpers.
The wreckage was released to a representative of the owner's insurance company on April 12, 2005.