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NTSB investigation record

ERA11FA133

Completed

Potez-air fouga Cm170Magister· N415FM

Date
February 2, 2011
Location
Kissimmee, FL
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot/mechanic's improper decision to continue a tight-turning landing pattern after a loss of hydraulic pressure, and his subsequent failure to maintain adequate airspeed during that pattern, which resulted in an accelerated maneuver stall. Contributing to the accident was a loss of hydraulic pressure after the extension of the landing gear.

Investigator assessment

Analysis narrative

After the repair of a number of hydraulic leaks, a post-maintenance check flight was conducted from the vintage jet trainer's home airport with a visiting pilot/mechanic and the pilot/owner onboard. After the airplane took off, it departed the airport traffic pattern for in-flight tests. About 11 minutes later, the airplane reentered the airport traffic pattern and completed a left, overhead, mid-field break about 600 feet above ground level (agl). A voice recognized as the pilot/mechanic's then advised the tower that the three landing gear were down and locked, and the airplane arrived at the abeam position about 500 feet agl and 215 knots. The airplane then eased out of the turn and briefly flew a straight course that angled toward the runway before commencing a sharp turn toward the runway with an observed 90-degree angle of bank. The airplane was then seen descending rapidly before pitching up, overshooting the extended runway centerline, nosing down, and impacting the ground. Both pilots were ejected when the airplane impacted the ground, and neither of the destroyed cockpits nor an airport security video could provide definitive evidence as to which pilot was in which seat. However, because the pilot/mechanic’s voice was on all radio transmissions, including a transmission that he was unfamiliar with the airport, it is likely that he was in the front seat and flying the airplane. Wreckage examination revealed that the airplane had impacted the ground in an approximately 45-degree left angle of bank, about 5 degrees nose-low. The landing gear were down and the push button selectors were in the "normal" position, indicating that landing gear were extended normally. The two left-wing flap segments were separated from the extensively damaged wing, and the differing cockpit wing flap indicators were unreliable due to cockpit and airplane damage. However, the two relatively intact right-wing flap segments were up and flush with the wing, consistent with the flaps being up at impact. The emergency airbrake selector was in the "out" position, indicating that the pilot/mechanic had recognized a loss of hydraulic pressure after lowering the landing gear, but before he could effectively deploy airbrakes or flaps. There are no means to lower flaps following a loss of hydraulic pressure. The pilot/mechanic should have extended the downwind leg for a flaps-up approach, per the abnormal procedures. However, he continued the high angle-of-bank, as-configured approach, but did not maintain sufficient airspeed to preclude an "accelerated maneuver stall."

Source record

Factual narrative

HISTORY OF FLIGHT On February 2, 2011, about 1729 eastern standard time, a Potez-Air Fouga CM 170 Magister, N415FM, was substantially damaged when it impacted terrain during a traffic pattern approach to landing at Kissimmee Gateway Airport (ISM), Kissimmee, Florida. The certificated commercial pilot/owner, and the certificated commercial pilot/mechanic were fatally injured. Visual meteorological conditions prevailed. The flight was not operating on flight plan during the local 14 Code of Federal Regulations Part 91 maintenance test flight. According to a work order, the flight was being conducted subsequent to the repair of a number of hydraulic leaks. Federal Aviation Administration (FAA) air traffic control tower transcripts and voice tape information were combined with radar data to produce a sequence of events. Tower transcript times and the more-accurate radar return times did not match, with the tower time of the accident occurring just before 1733:21, and the airplane's last radar return occurring at 1728:52. According to a police officer, he also observed the airplane in the landing pattern at 1728. Although not exact, a 4 minute, 30 second adjustment was applied to the tower transcript times to more accurately reflect actual transmission times: At 1705, a pilot, whose voice was identified by a close friend as that of the pilot/mechanic, and whose voice was heard on all subsequent transmissions, called for taxi, and stated: "I'm unfamiliar with the airport." The ground controller then provided progressive taxi instructions to runway 24. At 1717, the airplane was cleared for takeoff. The tower controller also confirmed the pilot's preference for an overhead entry upon return, and asked how long the flight would last, to which the pilot/mechanic responded, "less than 15 minutes." The controller then advised the pilot to expect a runway 24 "initial to the three sixty overhead." Radar data indicated that after departure, the airplane proceeded to the southwest at a groundspeed of about 160 knots, and an altitude of 1,600 feet above mean sea level (msl) until approximately 7 nautical miles from the airport, when it began maneuvering. After about 4 minutes of maneuvering, at groundspeeds varying down to approximately 130 knots, the airplane began proceeding back toward the airport. At 1724, the pilot/mechanic reported, "we had a good check here, we'd like to come back for landing," and was told to report the "initial" for runway 24. The controller then asked the pilot if he'd like "one thousand or one thousand five hundred," and the pilot/mechanic responded, "one thousand would be fine." The controller then advised, "report the initial for runway two four, right break," to which the pilot/mechanic responded, "right break from the right side." Radar data indicated that the airplane proceeded back toward the airport, at an altitude of about 1,100 feet msl, with gradually increasing groundspeed. At 1727, the pilot/mechanic reported, "we're going to plan a tower line break," and the controller responded, "okay then, plan on a left break for runway two four," which the pilot/mechanic confirmed. Radar data indicated that the airplane flew a right downwind leg, about a 1 nautical mile northwest of the runway, and about 1,100 feet msl and 210 knots groundspeed. Approaching the extended centerline of the runway, the airplane was about 1,000 feet msl at 212 knots groundspeed. At 1727:50, the tower controller cleared the airplane for a "left break, cleared to land," which the pilot/mechanic read back. Radar data indicated that the airplane flew over the runway, arriving at a mid-field break position about 700 feet msl and 216 knots groundspeed. The airplane then commenced a left break. At 1728:35, the pilot/mechanic reported, "three green." There were no further transmissions from the airplane. Additional radar data indicated that after the left break, the airplane climbed to 900 feet msl after about 90 degrees of turn. By about 180 degrees of turn, and almost abeam of the runway threshold, the airplane was again at 700 feet msl, at 215 knots. The last three recorded altitudes were at 600, 500, and 600 feet msl respectively. The last radar recorded position was about 075 degrees magnetic, 2,700 feet from the threshold of runway 24, and 800 feet laterally from the runway's extended centerline. The airplane's groundspeed was then about 202 knots. A plot of the air traffic pattern radar track, together with the impact location, indicated that from the overhead position, the airplane made a half-circle turn to the abeam position, then eased out of the turn briefly to a straight course that angled toward the runway. The airplane then entered a sharp turn to arrive at the impact location. According to a certificated flight instructor who was at the hold short line waiting to take off, he saw the airplane fly overhead to a left break. As the airplane turned toward the final approach course, he saw it pitch up, and the angle of bank increased. The airplane overshot the final approach course, and was banked approximately 90 degrees when it lost altitude and impacted the ground short of runway 24. Another witness saw the airplane approaching the airport, then make a "steep" descent. It appeared that the pilot attempted "gain control," but the airplane made a "second drop" before the witness lost sight of it. A third witness was stopped at a red light when he saw the airplane making "almost 90-degree banking turns." The airplane, with the landing gear down, seemed as if it was slowing down and "losing lift." It then appeared that the pilot "tried to lift the nose of the plane and gain more altitude but was unsuccessful." The witness then lost sight of the airplane beyond a tree line. PERSONNEL INFORMATION The pilot/mechanic, age 53, held a commercial pilot certificate, with airplane single engine land, multi-engine land, and instrument airplane ratings. He also had Federal Aviation Administration (FAA) authorization to fly eight "classic" military aircraft, including the CM 170, and held an "authorized aircraft instructor" certificate for the CM 170 that expired November 30, 2008. The pilot/mechanic additionally held an airframe and powerplants mechanic certificate with inspection authorization. The pilot/mechanic's latest FAA second class medical certificate was issued on September 9, 2010, and at the time, he indicated 8,300 hours of total flight time. Family members stated that they had the pilot's logbook, but would not provide it to either the NTSB or FAA, nor provide pilot information from it to confirm flight hours, recent experience in model or proof of a biennial flight review, despite multiple requests. The pilot/owner, age 61, held a commercial pilot certificate, with airplane single engine land, multi-engine land, single engine sea, multi-engine sea and instrument airplane ratings. He also had an FAA authorization to fly the CM 170. The pilot/owner also held a flight instructor certificate with airplane single engine, multi-engine, and instrument airplane ratings. The pilot/owner's latest FAA second class medical certificate was issued on January 9, 2009, and at the time, he indicated 1,500 hours of total flight time. According to family members, the pilot's logbook could not be located. Both pilots were ejected from the airplane at the impact site, and neither cockpit contained personally identifiable items to determine which pilot was seated in which seat. An airport video of the airplane taxiing was not sufficiently clear to determine seat positions by the helmets worn. AIRCRAFT INFORMATION The French-designed, tandem-seat, V-tailed CM 170 Magister, serial number 415, was manufactured in Toulouse, France, in 1963, and registered to the pilot/owner in 2000. There was no hour meter found in the wreckage, and aircraft logbooks were not located, either at

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