ERA09LA398
ERA09LA398

HISTORY OF FLIGHT

On July 11, 2009, about 1300 eastern daylight time, an experimental amateur-built Barber SHA Glasair RG, N132JB, was destroyed when it impacted terrain while maneuvering near Switzerland, Florida. The certificated airline transport pilot/owner and the commercial pilot-rated passenger were fatally injured. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight.

The pilot/owner of a Nanchang CJ6 stated that he was a friend of the accident pilot, and that they both based their airplanes at Herlong Airport (HEG), Jacksonville, Florida. On the morning of the accident, the two pilots and their airplanes departed HEG and flew south in formation to Haller Airpark (7FL4), Green Cove Springs, Florida, for an Experimental Aircraft Association meeting that started at 1000. After the meeting, the accident pilot departed 7FL4 in the accident airplane, destined for Palatka Municipal Airport (28J), Palatka, Florida, located about 16 miles south of 7FL4. There he picked up his pilot-rated passenger with the intention of returning to HEG. On the northbound return flight, when the accident pilot and his passenger approached 7FL4 from 28J, they joined up in an aerial formation with the CJ6 and two other airplanes for a photo opportunity above 7FL4. After the photo passes, the CJ6 and the accident airplane proceeded north in formation.

The CJ6 pilot reported that as they flew along the St. Johns River at an altitude of 1,500 feet, he asked the accident pilot if he was willing to demonstrate "a breakup and re-join" maneuver to the passenger. The accident pilot agreed, and they completed the maneuvers. According to the CJ6 pilot, the two maneuvers began and ended with the airplanes heading east. The CJ6 pilot then suggested a "shackle turn," and again the accident pilot agreed.

The intent of the shackle turn maneuver was to reposition the wingman (the accident airplane) from one side of the lead airplane (the CJ6) to the other. The CJ6 pilot stated that when the accident airplane was 800 to 1,000 feet off his left side, the CJ6 began a left turn, and the CJ6 pilot saw the accident airplane pass behind and above him, as expected. Once the accident airplane was 500 to 600 feet to the right of the CJ6, the CJ6 pilot initiated a right turn to resume their previous eastbound heading. This was the last time the CJ6 pilot saw the accident airplane.

The CJ6 pilot stated that during the maneuvers, there were additional aircraft using the same air-to-air radio frequency, and that that hindered his communications with the accident airplane. After the shackle turn, the radio congestion increased, and the CJ6 pilot radioed the accident pilot that he planned to depart the area and return to HEG. Since he did not hear a response from the accident pilot, the CJ6 pilot then returned to the maneuvering area. He did not see any "smoke or obvious crash site," or any unusual boat activity (indicative of an accident), and decided that the accident airplane had departed for St. Augustine for lunch and/or fuel.

According to one individual on a pleasure boat that was anchored in the St. Johns River, and located approximately 2 miles west of the accident site, she observed two airplanes flying side by side to the south of her, heading east. She then saw the airplanes perform a coordinated banked turn to the north, which placed them approximately over the east bank of the St. Johns River. She looked away, but her husband called her attention back to the airplanes. She then saw the smaller airplane descending, with the nose pointed steeply down, and she described the airplane as "spiraling." She lost sight of the airplane behind the trees, but did not see any smoke or fire. She then saw the larger airplane circle at least once, as if searching for the other airplane. She estimated that the two airplanes were in view for approximately 15 minutes. The witness stated that the weather was "fine," but there were some "low clouds," and she did experience a "quick rain shower" at some point.

Another individual, who was on another boat that was moving south on the St. Johns River, also observed the airplanes. He saw the airplanes heading north towards him. He stated that the larger airplane was in the lead, and that the smaller airplane was in trail off the left (witness' right) side of the larger airplane. The airplanes completed a 360-degree turn to their right, which again placed them on a northerly heading. When the airplanes returned to their northerly heading, they were approximately over the eastern shore of the St. John's River. The witness stated that at that point, the larger, lead airplane continued to the north, while the smaller, trailing airplane turned again to the east. Almost immediately following the separation, the smaller airplane conducted a "barrel roll" to the left. The witness was looking approximately east towards the airplane as it was flying away from him, so it appeared to rotate counterclockwise to him. Once the airplane completed the counterclockwise roll, it started and completed a clockwise roll.
Immediately thereafter, the airplane entered a "small puffy white cloud." The witness then saw the airplane emerge from the cloud in a nose-down, right wing down attitude
The airplane "spiraled" towards the ground, and completed about three full turns
At that point, he saw what he described as "the tail snap" or "the back end chase after the nose." He clarified this to mean that the airplane did not break apart, it just began a new pattern of motion. He watched the airplane disappear behind the treeline, but did not see any smoke or fire, or hear any sounds of impact.

At 0955 the morning after the accident, the Federal Aviation Administration (FAA) issued a notice that the airplane was missing. At about the same time, several pilots and airplanes from HEG initiated their own search for the missing airplane, based on the CJ6 pilot's information regarding the last known position of the airplane. At least one of these airplanes detected an emergency locator transmitter (ELT) signal, and the wreckage was located shortly thereafter. The accident site was a remote, wooded area with heavy undergrowth, located just west of an abandoned airfield near Switzerland, Florida.


PERSONNEL INFORMATION

Pilot/Owner

FAA records indicated that the pilot held an airline transport pilot certificate with airplane multiengine land and turbojet ratings, and a flight engineer certificate with a turbojet rating. He also held type ratings in B-767, B-757 and CE-500 airplanes. His most recent FAA second-class medical certificate was issued in July 2008, at which time he reported 11,611 total hours of civilian flight experience. His most recent flight review was completed in January 2009. According to the CJ6 pilot, he and the accident pilot had been "squadron mates" in the US Navy.

The pilot cataloged the airplane's hour meter values in his personal flight logbook. Examination of the logbook revealed that he flew the airplane four times in October and November 2007, and accumulated about 5 hours in the airplane. He did not fly the airplane again until March 2008; between March and the end of December 2008, he flew 31 flights, and accumulated about 34 hours in the airplane. The pilot's logbook indicated that between January and June 20, 2009, which was the last entry in the logbook, the pilot flew another 30 flights, and accumulated another 37 hours in the airplane.

The Florida District 23 Medical Examiner autopsy report indicated that the cause of death was "blunt force trauma," and that alcohol and drug test results were all negative. The Civil Aeromedical Institute (CAMI) toxicology report indicated that tests for carbon monoxide, cyanide, ethanol and all screened drugs were negative. Correlation of on-scene and autopsy report information indicated that the pilot was seated in the left seat at the time of impact.

Pilot-rated Passenger

FAA records indicated that the passenger held a private pilot certificate with airplane single-engine land and sea ratings, and a commercial certificate with a glider rating. He also held an experimental aircraft builder repairman certificate. The pilot-rated passenger's personal logbook indicated that he had approximately 898 hours of flight experience, and his most recent logged flight was on March 7, 2009, which was also his most recent flight review. His most recent FAA third-class medical certificate was issued in April 2008.

The Florida District 23 Medical Examiner autopsy report indicated that the cause of death was "blunt force trauma," and that alcohol and drug test results were all negative. The CAMI toxicology report indicated that tests for carbon monoxide and cyanide were not performed, and that the test for ethanol was negative. The CAMI report stated that amlodipine and diphenhydramine were detected in the liver and urine.


AIRPLANE INFORMATION

According to FAA records, the airplane was built in 1992, by someone other than the accident pilot, and it was owned by several other individuals prior to its purchase by the accident pilot. A maintenance records entry dated May 2002 indicated that the prior maintenance records had been "lost," and that the airplane was "disassembled by persons unknown."

The accident pilot purchased the airplane in October 2007. At that time, the airplane hour meter registered 737.8 hours. In November 2008, the accident pilot made entries in the maintenance records that certified the airplane's performance, controllability and aerobatic capabilities.

The airplane was a two-place side-by-side, low-wing monoplane design that was fabricated primarily of composite materials. Construction plans, kit components, and raw materials were available from the kit manufacturer, Stoddard-Hamilton Aircraft. The accident airplane was equipped with retractable tricycle-style landing gear, and was powered by a Solair/Lycoming IO-320 series engine and a two-bladed, constant-speed Hartzell propeller.

The airplane was equipped with two separate fuel tanks. The 10-gallon header tank was located between the cockpit and the engine compartment. The 53-gallon main tank included most of the spanwise wing internal volume forward of the main spar, and a portion of the wing internal volume between the main spar and the rear spar. The fuel selector valve had three positions, "MAIN", "AUX", and "OFF." The airplane was equipped with three fuel fill ports. One fill port for the main tank was located on each wing, and the header tank fill port was located on the top of the fuselage, forward of the windshield.

The airplane Owner's Manual (OM) contained information about the operating procedures and performance, but due to the ability of individual builders to vary the equipment and configuration of each airplane, the information provided by the OM was generic in nature. The Introduction section of the OM contained a citation which stated that the manual cannot "serve as a substitute for adequate and competent flight instruction."

The OM defined a "NOTE" as "An operating procedure, condition etc., which it is considered essential to emphasize." The OM defined a "WARNING" as any "procedures, practices, etc. which may result in personal injury or loss of life if not carefully followed."

Section 2 (Limitations) of the OM stated that the airplane was capable of many aerobatic maneuvers, including loops and rolls, but contained a note which stated that those maneuvers "can be performed" but that "pilot ability and skill will determine whether they can be accomplished safely." The note also stated that pilots should "never attempt any maneuvers below 3000 feet AGL [above ground level]." The section contained a warning which stated that the Glasair was a "high performance aircraft" and that aerobatics were "to be approached with caution and only after prior dual instruction from an expert aerobatic instructor."

The Limitations section stated that the Glasair was "prohibited from intentional spins." Section 3 (Emergency Procedures) contained the warning "intentional spins are prohibited." Section 4 (Normal Operating Procedures) stated that stall recovery was "typical of most conventional aircraft" and that stall characteristics were "predictable in both power off and power on stalls." The section contained a note that stated "stall strips are mandatory…to induce the wing roots to stall first" and that without stall strips, "the stall may be unpredictable or erratic." Section 4 of the OM contained a warning that "intentional spins are prohibited" and that "we [the kit manufacturer] strongly recommend that stalls be practiced at 3000 ft. AGL or higher." Another warning in that section stated "do not use the ailerons to keep the wings level in a stall," since that would "more easily cause a spin entry or aggravate spin recovery."


METEOROLOGICAL INFORMATION

The 1253 recorded weather observation at Jacksonville Naval Air Station (NIP), located approximately 13 miles north of the accident site, included winds from 080 degrees at 14 knots, with gusts to 19 knots, 10 miles visibility, broken cloud layer at 3,200 feet with towering cumulus present, broken cloud layer at 15,000 feet, temperature 30 degrees C, dew point 21 degrees C, and an altimeter setting of 30.19 inches of mercury. The report also noted towering cumulus clouds to the southeast and northeast, with rain showers in the vicinity, to the northeast.


WRECKAGE AND IMPACT INFORMATION

According to information provided by the FAA inspectors who travelled to the accident scene about 24 hours after the accident, the debris field was approximately 75 feet long, and the vegetation in the area showed minimal disturbance. Tree and ground scars were consistent with a steep descent on an approximate southerly heading. The airplane was highly fragmented. The propeller was separated from the engine. The landing gear positions were consistent with being in the retracted position. Due to the fragmentation and terrain conditions, no reliable information regarding control continuity, instrument indications, power settings or fuel quantity was obtained on scene. There was no evidence of fuel at the scene, and no fire.

When the FAA inspectors arrived on scene, the ELT was still transmitting, and the FAA inspectors located the unit and shut it off. A Garmin GPSMap 496 global positioning system (GPS) unit was found in the wreckage and forwarded to the National Transportation Safety Board (NTSB) recorders laboratory for data download. The remainder of the wreckage was recovered to a secure storage facility for examination by the NTSB.


ADDITIONAL INFORMATION

Fueling History

According to the manager of HEG, the pilot was not in the habit of purchasing fuel at HEG. The fuel-servicing records at HEG for the two weeks preceding the accident were examined, and no sales in the pilot's name were discovered. Searches of recent fueling records at several other airports in the vicinity did not reveal any fuel purchases for the accident airplane. No assessment of the airplane's fuel status about the time of the accident was able to be made, but propeller damage was consistent with the engine running at impact.


Handheld Global Positioning System (GPS) Data

The GPS unit was equipped with non-volatile memory which retained flight track information after the unit was shut down. The specific data storage algorithms were partially user-defined; pilots can increase or decrease the frequency of the data capture (from the initial factory settings) as a function of time, displacement, and other parameters. Based on the data retrieved from the accident GPS, the pilot had altered the GPS data capture algorithm from the factory settings; the result was that the data capture rate was at a low frequency, and only a limited number of data points were available for recovery.

The unit recorded three separate flights on the day of the accident. In chronological sequence, these flights were designated as Flight 0 (the earliest flight), Flight 1, and Flight 2 (the accident flight). A total of 10 points comprised the Flight 0 dataset; the first data point was recorded at HEG at time 1333:46, and the last was recorded at 7FL4 at 1403:57. The time basis for the GPS data points was not specified in the unit, but all GPS times appeared to be 4 hours later than the then-current corresponding local times. The data points were not evenly spaced with respect to time, and intervals between points ranged between approximately 2 and 10 minutes.

A total of 6 data points comprised the Flight 1 dataset; the first data point was recorded at 7FL4 at time 1607:11, and the last was recorded at 28J at 1621:39. The data points were not evenly spaced with respect to time, and intervals between points ranged between approximately 2 and 4 minutes.

A total of 10 data points also comprised the accident flight dataset; the first data point was recorded at 28J at time 1635:05, and the last was recorded at 1656:13, at a GPS altitude of 1,382 feet, and about 2 miles west of the accident location. The data points were not evenly spaced with respect to time, and intervals between points ranged between approximately 2 and 3 minutes. The GPS altitudes for the data points that were located in the vicinity of the eyewitnesses to the formation flight, maneuvering, and the descending spiral ranged between approximately 600 and 1,700 feet.


Post-Recovery Wreckage Examination

On August 25 and 26, 2009, NTSB and FAA personnel examined the wreckage in detail at the storage facility. The wreckage was highly fragmented, almost all components were accounted for, and no indications of any pre-impact anomalies or failures were observed.


Engine and Propeller Examination

According to FAA records, the airplane was equipped with a Lycoming fuel-injected four cylinder model. No data plate was found on the engine or in the associated debris. The engine exhibited significant crush damage on lower side, and the lower case and oil pan were fractured. The engine mount exhibited significant crush damage in the aft and up directions.

The fuel distribution block remained attached to the engine. The fuel supply line to the block was intact, and remained attached to both the pump and block. The two fuel lines to the left cylinders were fracture-separated from the block. The block was opened; the diaphragm was intact, and the block interior was dry. The electric fuel pump was dry, while the engine-driven fuel pump contained a trace amount of fuel

The ignition system consisted of a Slick-brand magneto on the left side, and an electronic ignition unit on the right side. The four top spark plugs were removed; all exhibited wear and coloration consistent with normal operation. The magneto was rotated by hand, and sparking was observed at all four towers. The engine was rotated by hand. Thumb compression was detected on all four cylinders, and gear train continuity observed at the accessory case.

The two propeller blades remained attached to the propeller hub, but the hub was separated from the engine. Both blades were bent aft approximately 25 degrees; one at the mid-span point and one near the root. The blade bent near the root was also bent aft another 25 degrees at the tip. The cambered surfaces (backs) of both blades had burnishing which removed the paint and exposed the bare metal; the root-bent blade had about 30 percent of the metal exposed, and the other blade had about 15 percent of the metal exposed. Paint-burnishing that exposed bare metal was also present on the face of the root-bent blade; the bare area extended along the outer 40 percent of the span, and for 20 percent of the chord aft of the leading edge.


Airframe Examination

The fuselage was highly fragmented; the largest piece was a section of the tailcone between the cockpit and empennage. The flop tube and the electronic fuel sending unit from the header tank was recovered, but the header tank cap was not recovered

The left and right wings were highly fragmented. Both the left and right fuel cap assemblies were fracture-separated from the wing, but were recovered. The left flap was separated from the wing, and fragmented into two sections. The right flap was separated from the wing, but was intact.

The design of the fuselage-mounted aileron and elevator flight control assembly consisted of two transversely mounted center rods which attached to the cockpit control sticks and the respective flight control rods. The upper center rod measured 41 inches, and the ends fit into bushings on each side of fuselage, which enabled the rod to rotate about an axis parallel to the airplane lateral axis. The lower center rod measured 18 inches. The two cockpit control sticks were attached via pivoting joints to each center rod. Left and right transverse aileron control rods each extended approximately 78 inches from the lower center rod to the respective outboard bellcrank.

The aileron and elevator flight control assembly remained attached to the airplane only by the right transverse aileron control rod, which was bent about 135 degrees near the right main landing gear. Both control sticks were found attached to both center rods, and both sticks were deformed and fractured near their upper ends. Both center rods were intact but bent, and the upper rod was completely separated from its fuselage attach points.

Both the left and right transverse aileron control rods were recovered. The left rod was fracture-separated from the airplane at both ends; the outboard end was fractured at the rod end, and about 10 inches of the inboard end remained attached to lower center rod. The right rod was still attached at both ends, but was significantly bent and deformed. Both aileron system outboard bellcranks, which were mounted on the outboard sides of ribs just aft of the forward spar, were intact and remained attached to their respective ribs.

The left and right aileron control rods that connected the respective outboard bellcranks to the ailerons remained attached at their respective ends. The left control rod was undamaged, but the right aileron control rod was bent upwards approximately 90 degrees up at the aft rod end.

The left aileron (overall span 42 inches) was intact and remained attached to the wing by both hinges. The aileron balance weight was fracture-separated from the aileron but was recovered. About three quarters of the inboard section of the right aileron remained attached to the wing; the remaining quarter, including the balance weight, was not recovered. The inboard end rib of the left aileron was partially separated from the aileron.

The pitch control linkage from the cockpit to the elevator consisted of a forward longitudinal control rod, and aft fuselage bellcrank, an aft longitudinal control rod, and an elevator bellcrank. The forward control rod was fractured into two segments; a forward segment of approximately 37 inches, and an aft segment of approximately 10 inches. The forward segment was fracture-separated at both ends, and the aft segment remained attached to the fuselage bellcrank. The aft control rod measured approximately 70 inches, and was bent approximately 45 degrees about 40 inches from its aft end. The forward end was fracture-separated from the fuselage bellcrank, and the aft end remained attached to the elevator bellcrank. The elevator bellcrank remained affixed to both elevators.

The left horizontal stabilizer was intact and remained attached to the aft fuselage, along with the vertical stabilizer. The left elevator was intact and remained attached to the left stabilizer. The right horizontal stabilizer was fractured into a 15 inch inboard segment and a 35 inch outboard segment, which was missing an 11 inch spanwise segment of its inboard lower skin. The right elevator was fractured into two segments at the same span location as the right horizontal stabilizer. The outboard segment was intact, and remained attached to its stabilizer segment. The right elevator balance weight was fracture-separated, and was not recovered.

The pitch trim mechanism consisted of a lever assembly connected to a spring-centered traveler that was attached to the flap control rod. The trim control handle was fracture-separated from the remainder of the linkage. The flap control rod was fracture-separated into several pieces, but remained attached to its mount in the cockpit. Flap and pitch trim settings at the time of impact could not be determined.

The cockpit rudder pedal assembly consisted of two sets of pedals and associated linkage. Approximately 75 percent of the assembly was able to be identified from the recovered components. The inboard right pedal was intact, but only fragments of the other three pedals were located. The two rudder cables which connected the rudder pedal assembly to the rudder bellcrank in the aft fuselage, remained attached to the cockpit rudder pedal assembly, and also to the bellcrank. The cables were cut about 2 inches forward of the rudder bellcrank during the wreckage recovery process. The rudder was intact, remained attached to the vertical stabilizer, and was able to be moved easily by hand.

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