CEN17FA196

The pilot's failure to maintain control of the airplane while flying at a low altitude, which resulted in the airplane exceeding the critical angle of attack and a subsequent aerodynamic stall.

The private pilot and the passenger were on a local flight in the airplane; the pilot was seated in the rear seat and the passenger was in the front seat. Several witnesses, located west of the accident location, observed the airplane flying low, heading north, just west of a river. After overflying several people on a pond, the airplane continued to the north briefly and then started a right turn. The nose of the airplane dropped, and the airplane descended rapidly below the tree line. The passenger stated that the airplane started to turn and then went straight down. The airplane impacted the river and came to rest in the water. The passenger, who was seated in the front seat, did not recall exiting the airplane but did recall being underwater, surfacing, and swimming to the bank of the river. The pilot, who was seated in the rear seat, was ejected from the airplane and found face down in the water when first responders arrived. Examination of the airplane indicated that it impacted the river in about a 45° nose-down attitude. No evidence was found of any preimpact mechanical malfunctions or failures with the airframe, flight controls, engine, or related systems that would have precluded normal operation. Witness statements, the passenger's statement, and the damage to the airplane are consistent with an aerodynamic stall followed by an uncontrolled descent and impact with the river. An examination of the lap belts and shoulder harnesses in the airplane revealed that the front and rear lap belts were buckled; the front and rear shoulder harness straps were not attached to the buckles; and one side of each lap belt was not attached to its mounting bracket. For the rear seat, the left mounting bracket for the lap belt had failed in overload likely during the impact sequence. For the front seat, the left-side webbing of the lap belt was found not attached to the mounting bracket, and the right-side webbing of the lap belt was found knotted to the mounting bracket, which was an improper method for attaching the belt to the bracket. The pilot had fastened the lap belt for the passenger before the flight; had the webbing not been secured at that time, it is likely that the passenger and the pilot would have noted that fact. Therefore, it is likely that the left-side webbing was also knotted to the wire bracket and came undone during the impact sequence. Based on the passenger's statement that he was not wearing a shoulder harness, the inflight video taken by the passenger, and the postaccident finding that the front and rear seat shoulder harness straps were not attached to the buckled lap belts, it is apparent that neither the pilot nor the passenger were using the shoulder harness portions of their restraint system at the time of the accident. The damage to the airplane, the location of the pilot following the accident, and the injuries to both the pilot and the passenger are consistent with the pilot being ejected forward, into the back of the front seat, and then likely out the front windscreen of the airplane. The passenger's facial injuries were consistent with the passenger impacting the airplane's instrument panel. Investigators were unable to determine what method, if any, was used to approve the installation of the shoulder harness. It is unknown if the seatbelts and shoulder harnesses installed were part of a properly certified restrain system. Without the method of certification or approval of the restraint system, investigators were further unable to determine what role the failure to use the restraint system played in the pilot's ejection, mitigation of the pilot's injuries, and protection from injuries for the front seat occupant. However, both occupants likely would have benefited from the use of a properly certificated and installed four-point restraint system in this accident.

The Sacred Heart Hospital, Eau Claire, Wisconsin, performed the autopsy on the pilot on May 25, 2017, as authorized by the Barron County Medical Examiner. The autopsy report listed the pathologic diagnosis as "fresh water drowning secondary to aircraft accident" The autopsy listed blunt force trauma to the head including facial lacerations and abrasions which "likely [led] to a loss of consciousness.". The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens collected during the pilot's autopsy. Results were negative for all tests conducted. The passenger was hospitalized for 22 days following the accident. He sustained a broken left ankle, a broken lower spine, multiple facial fractures, a collapsed lung, and a concussion. According to a sun position calculator, the sun was at an azimuth of 280° and an inclination of 21° above the horizon at the time of the accident. The pilot's most recent FAA third-class airman medical certificate was issued on December 27, 2015, without limitations. At that time, the pilot reported no chronic medical conditions and no medication usage. The last page of the pilot's logbook contained 14 logged flights between March 25, 2017, and May 7, 2017. Six flights, including the last 3 flights, were logged in a Cessna 172. The remaining 8 flights were in the accident airplane. The pilot's total logged flight time was 177.8 hours; of which 17.1 hours were logged in the same make and model as the accident airplane. The airplane, a Piper J3C-65 (serial number 6144), was manufactured in 1941. It was registered with the FAA and held a standard airworthiness certificate for normal operations. The airplane was not equipped with shoulder harnesses when it was manufactured. A Continental C85-12F engine, rated at 85 horsepower at 2,575 rpm, powered the airplane. The engine was equipped with a McCauley 2-blade propeller. The airplane was equipped with two tandem seats and dual flight controls. The instrument panel was just forward of the front seat. When the pilot was the sole occupant, the pilot would fly from the rear seat. With a passenger, it was typical for the pilot to fly from the rear seat. The airplane was maintained under an annual inspection program. A review of the maintenance records indicated that an annual inspection had been completed on May 15, 2016, at an unknown airframe total time and a tachometer time of 205.22. The airplane had flown approximately 40.54 hours between the last inspection and the accident. Restraint Systems The airplane was equipped with four-point restraint systems for both the front and rear seat positions. The front and rear seat shoulder harnesses had a data tag that read "Hooker Custom Harness, Inc." The model number was 2Y482430-3D and the date of manufacture was August 4, 2015. The front and rear seat lap belts had a data tag that read "Hooker Custom Harness, Inc". The model number was 2062340 and the date of manufacture was August 4, 2015. In a telephone interview with the pilot's father, who was a member of the family partnership that owned the airplane, he stated that he had replaced the shoulder harnesses in the airplane in June 2016. There was no logbook entry for this replacement nor was a specific supplemental type certificate (STC) referenced. According to a representative with Hooker Custom Harnesses, Inc, they do not sell an STC specific to the Piper J3 airplane. There were no logbook entries identifying when the shoulder harnesses were first installed in the airplane or who performed the work. In addition, a review of the FAA airworthiness records did not contain any paperwork showing that this major alteration was done. In a follow-up email, the pilot's father stated that the airplane was rebuilt in 2013. He vaguely recalled being asked by the mechanic who rebuilt the airplane to order F Atlee Dodge fittings for the shoulder harness. A review of the F Atlee Dodge website revealed that they do not sell an STC for shoulder harnesses specific to the Piper J3 airplane. In September 2000 the FAA issued Policy Statement ACE-00-23.561-01 "Issuance of Policy Statement, Methods of Approval of Retrofit Shoulder Harness Installations in Small Airplane." This document presented the guidelines for approval of retrofit shoulder harness installations. According to the document, a retrofitted shoulder harness installation in a small airplane may receive approval by STC, field approval, or as a minor change. An STC was identified as the "most desirable and most rigorous" approval method. A field approval would be "appropriate for alterations that involve little or no engineering." Approval as a minor change that would have no "appreciable effect" on the structural strength or airworthiness of the airplane. All three methods required a logbook entry and, for the STCs and field approvals, the completion of an FAA for 337 "Major Repair and Alteration". The accident site was located in the Red Cedar River at an elevation of about 1,040 ft mean sea level (msl). The airplane impacted on a magnetic heading of about 200°. The main wreckage included the fuselage, the left wing, the right wing, the empennage, and the engine and propeller assembly. The right wing remained partially attached to the airframe at the forward attach point. The aft spar separated at the root with signatures consistent with impact and overload. The right aileron remained attached and was unremarkable. The leading edge of the right wing exhibited accordion crushing along the entire span and the fabric was torn. The control cable and the balance cable from the aileron inboard to the cockpit flight yoke were continuous. The left wing remained partially attached to the airframe at the forward attach point. The aft spar separated at the root with signatures consistent with impact and overload. The left aileron remained attached and was unremarkable. The leading edge of the left wing was crushed and wrinkled along the entire span and the fabric was torn. The control cable and the balance cable from the aileron inboard to the cockpit flight yoke were continuous. The empennage included the horizontal and vertical stabilizer, elevator, rudder, and tail wheel. The forward lower portion of the vertical stabilizer, at the fuselage, was wrinkled. The horizontal stabilizer, elevators, tail wheel, and rudder were unremarkable. The control cables for the rudder were continuous from the flight controls in the cockpit, aft to the rudder. The push tube for the elevator was continuous from the elevator control forward to the aft yoke and continuous from the aft yoke forward to the forward yoke. The separation point between the push tube and the aft yoke was consistent with impact and overload. The crush angle on the nose and forward fuselage was about 45°. The instrument panel exhibited impact damage on both the upper and lower portions of the panel. The ELT was found selected in the "off" position. The front seat remained attached to the floor of the airplane. The lower seat cushion for the front seat was not recovered. The lap belt for the front seat was latched at the center buckle; the shoulder harnesses were wrapped around structural tubing above the seat and were not latched at the center buckle. The seat back of the front seat was bent forward about 45°. The floor of the forward fuselage was crushed up and aft, between 7 and 10 inches, into the lower portion of the cabin's occupiable space. The right side of the front lap belt was tied in a knot to a wire bracket that was attached to the seat. The wire bracket was stock to the original airplane design. The left side of the front lap belt was not secured to its wire bracket after the accident. The wire bracket was present and intact in its normal location on the seat frame. There was no visible damage to the seatbelt webbing; however, the left end of the seatbelt webbing was cr