Primary finding
Probable cause
The pilot's failure to maintain airspeed while turning from the downwind to the base leg of the traffic pattern, which resulted in a subsequent aerodynamic stall, spin, and impact with terrain. Contributing to the accident were the pilot's lack of currency and proficiency in controlling the airplane and his decisions to forego recurrent training and to land on the nontraditional runway.
Investigator assessment
Analysis narrative
The pilot, who was the owner/builder of the accident airplane, flew his airplane with a group of three other airplanes of the same make and model to a fly-in event located about 115 nautical miles from their home airport. The flight made two intermediate stops during the trip due to adverse weather, and, each time, witnesses reported observing the accident pilot having difficulty controlling the airplane at low speed and while landing. The other airplanes landed without incident. When one of the other pilots in the group asked the accident pilot about his difficulty during the previous two landings, the accident pilot stated that he was having difficulty controlling the airplane with a passenger onboard and that the additional weight was "throwing him off." The pilots subsequently took off. The weather conditions at the final destination airport included wind aligned within 20 degrees of the runway heading at 11 knots, gusting to 19 knots. One of the pilots chose to land on the airport's 5,000-foot-long paved runway and did so without incident. The accident pilot and two of the other pilots chose to land on a 2,000-foot-long auxiliary turf runway in use exclusively for the fly-in event. Due to space constraints, pilots were advised to avoid overflying areas with aircraft and personnel, which required a traffic pattern that was closer than customary to the auxiliary runway. The other two pilots landed their airplanes without incident; however, the accident pilot made two aborted approaches. Witnesses reported that, during the two aborted approaches, the airplane appeared to enter an aerodynamic stall as it turned onto the final approach to the runway. During the third and final attempted landing, the airplane appeared to enter a stall while turning from the downwind to the base leg of the traffic pattern and subsequently entered a spin and descended into terrain. The pilot's logbook showed that he had not logged the required number of takeoffs and landings for carrying passengers before departing on the morning of the accident flight. In addition, the pilot had not logged the completion of a flight review in nearly 5 years. Witness observations of the pilot's flying performance on the day of the accident indicate that he also was not proficient in the airplane's operation, particularly with a passenger aboard. The pilot missed several opportunities to avoid or mitigate the outcome of the accident. He could have taken additional recurrent flight training offered to him before and on the day of the accident flight. Additionally, upon recognizing his difficulties with the initial two diversionary landings, the pilot could have chosen to perform some additional practice with a flight instructor who was traveling with the group, or return home, rather than continuing the flight to the more demanding environment of a fly-in event. Further, upon recognizing his difficulties while unsuccessfully attempting to land the airplane twice with the nontraditional, constrained traffic pattern offered by the auxiliary turf runway, the pilot could have chosen to land on the longer, paved runway.
Source record
Factual narrative
SFQ was located at an elevation of 70 feet, and had two intersecting runways oriented in a 4/22 and 7/25 configuration. Runway 4 was 5,009 feet-long by 100 feet-wide and was equipped with a 4-light precision approach path indicator. A fly-in event was being held at the airport over the weekend that the accident occurred, and a suggested arrival procedure was published by the event organizers. A NOTAM in effect at the time of the accident closed runway 7/25, but an auxiliary grass runway paralleling the paved runway was available for use by, "ultralights, antiques, and gliders." According to one of the event organizers, the runway was comprised of two cut lengths of grass, classified "groom" and "fairway." The groom was the center of the runway area and was 2,010 feet-long by 90 feet-wide, while the encompassing fairway area was 20 feet wider than the groom area on the left and right side. The published ultralight arrival procedure warned pilots that when landing on grass runway 7, they should maintain a base traffic pattern leg that was close enough to the runway threshold as to avoid overflying aircraft that would be parked on a perpendicular, closed runway. The threshold of the grass runway was located nearly coincident with the suggested base leg flight path. Weight and Balance The pilot operating handbook (POH) recovered from the wreckage showed that the airplane had an empty weight of 645 pounds. Given pilot and passenger's combined weight of 436 pounds, and baggage of 60 pounds, the airplane had a zero fuel weight of 1,141 pounds. The airplane's calculated zero fuel center of gravity was 66.5 inches aft of the datum. With both of the airplane's fuel tanks filled to capacity, the airplane's calculated gross weight was 1,249 pounds, with a center of gravity 67 inches aft of the datum. The listed maximum takeoff weight of the airplane was 1,200 pounds, and the acceptable center of gravity range was between 62.5 and 73 inches aft of the datum. Pilot Operating Handbook Excerpt The POH recovered from the wreckage had several pages with text that appeared to have been highlighted with a marker. One such section of text was the section detailing the stall characteristics of the airplane. The handbook stated, "[Stalls have a warning buffet] due to the turbulent air from the wing root flowing over the elevator. The stall occurs with a definite break. [Rudder may be needed to hold the wings level.] Recovery is quick with the release of back pressure. Turning, accelerated power on and power off stalls all demonstrate the slight buffet and quick recovery." The bracketed sections of the quote above appeared highlighted in the text of the recovered POH. An autopsy was performed on the pilot by the Commonwealth of Virginia, Office of the Chief Medical Examiner, Norfolk, Virginia. The stated cause of death was, "multiple blunt force trauma." The medical examiner also performed an autopsy on the passenger. The combined post-mortem weight of the pilot and the passenger was 436 pounds. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. No carbon monoxide or ethanol were detected in the samples submitted. Unquantified amounts of Cetirizine and Metoprolol were detected in samples of the pilot's blood and urine. An unquantified amount of Naproxen, and 46.5 micrograms per milliliter of Salicylate were detected in samples of the pilot's urine. The weather conditions reported at SFQ, at 1255, included winds from 050 degrees magnetic at 11 knots, gusting to 19 knots, an overcast ceiling at 1,200 feet, 10 statute miles visibility, a temperature of 14 degrees C, a dew point of 12 degrees C, and an altimeter setting of 30.00 inches of mercury. The pilot was the owner and builder of the airplane. Review of the airplane's airworthiness and maintenance records revealed that a special airworthiness certificate and operating limitations as an operating experimental light sport airplane were issued by the FAA on January 28, 2008. According to the maintenance log entry on that date, the next condition inspection of the airplane was due in January 2009. Three subsequent maintenance entries were made between June 2010 and April 2012, detailing replacement of the engine oil and oil filter, replacement of the fuel lines, synchronization of the carburetors, and adjustment of the throttle cables. No other entries were found, nor did any of the entries detail the completion of any condition inspections. The pilot, age 73, held a private pilot certificate with a rating for airplane single engine land. The pilot's most recent FAA third-class medical certificate was issued on June 17, 2008 with the limitation, "Holder shall wear glasses which correct for near and distant vision while exercising the privileges of his airman certificate." Review of the pilot's personal flight log showed flight hours logged between the time he began his initial flight training in 1991 and April 2012. During that period the pilot logged 231 total hours of flight experience. Of that time, 185 hours were logged flying almost exclusively Cessna 152, Cessna 172, and Grumman AA5B airplanes, all of which occurred between 1991 and 2002. The pilot subsequently logged 2.2 hours of dual instruction in the accident airplane make model in 2003, and 2.5 hours of dual instruction in 2008. Following the 2008 flight, a flight instructor endorsed the pilot's logbook for satisfactory completion of a flight review. No subsequent endorsements were contained within the log. Beginning in October 2008, the pilot made numerous flights in the accident airplane after completing its construction. During the remainder of that year the pilot logged 9 total flight hours, all of which were in the accident airplane. In the subsequent years leading to the accident flight, the pilot logged the following flight hours annually: 2009, 18 hours; 2010, 0 hours; 2011, 14.5 hours; 2012, 13 hours. All of the hours logged were in the accident airplane, and included both solo and dual instruction received flight hours. The final log entry was dated April 29, 2012, and no subsequent flight hour entries were recorded. The wreckage came to rest in a vacant field. The forward portion of the airplane including the engine, firewall, and instrument panel, were displaced aft and were severely crushed. The wings and empennage remained relatively intact with minor impact-related damage. Control continuity was confirmed from the flight control surfaces to each of the primary flight controls. The elevator control tube was separated from its forward attach point consistent with impact, and there was a significant disruption of floor structure directly above the fracture. The flaps appeared retracted and the flap handle was displaced from the flaps retracted position between the first and second detent. The electrically actuated elevator trim tab was deflected slightly trailing edge down. An undetermined quantity of 100LL fuel was present in both fuel tanks. A sample of fuel appeared blue, and absent of debris or water. There was also a strong smell of fuel at the scene, and there was evidence of fuel spillage in the vicinity of the engine. Baggage recovered from the aft baggage area was weighed on the morning following the accident, and found to have a total weight of 60 pounds. The emergency locator transmitter, which was installed under the pilot's seat, was crushed, and non-functional. First responders reported that both the pilot and the passenger were wearing seat belts and shoulder harnesses. The restraints displayed cuts consistent with post-accident extraction. One of the three composite propeller blades was separated from the propeller hub at its root. The outer 2/3 of the second blade had separated from the inner portion at a fracture that was oriented roughly 45 degrees to the leading edge. The third blade remained intact and was relatively undamaged