ERA14FA464

The in-flight collision with a tree in a heavily wooded area during controlled flight while the pilot was attempting a forced landing for reasons that could not be determined based on the available evidence. Contributing to the delay in locating the wreckage were the nonactivation of the emergency locator transmitter and delayed coordination between the Civil Air Patrol and multiple local and state agencies.

The private pilot was conducting a personal cross-country flight. Witnesses at the airport reported that they observed the airplane depart and climb out and that everything appeared to be normal. The airplane proceeded west of the departure end of the runway, made a left climbing turn, and then proceeded in a southerly direction. GPS data showed that the airplane then climbed to about 817 ft mean sea level, which was below the floor of available radar coverage. The airplane then continued in a southerly heading while descending with the ground speed increasing until about 2 minutes 30 seconds after takeoff, at which point the airplane made a right 270-degree turn for unknown reasons. The airplane continued to descend during controlled flight. The airplane subsequently impacted trees and the ground and then came to rest inverted about 1.7 nautical miles and 187 degrees from the departure end of the departure runway. No distress call was received from the pilot. About 2 days later, an employee of the intended arrival airport called the departure airport and reported the airplane overdue. Subsequently that same day, the Civil Air Patrol, multiple local and state agencies, the pilot's son, and several privately operated aircraft began search operations; however, despite several weeks of ongoing search efforts, the airplane was not located. About 6 months later, the inverted wreckage was spotted by an individual in a heavily wooded area. No emergency locator transmitter (ELT) signal was ever received, and the ELT switch was found in the "off" position. The investigation determined that miscommunications, which led to delayed coordination, occurred between the Civil Air Patrol and the multiple local and state agencies during the initial search efforts. The delayed coordination between the response agencies, the nonactivation of the ELT, and the airplane's flight below radar coverage hampered the search efforts. However, the accident was not survivable; therefore, these issues did not contribute to the pilot's death. Examination of the airframe revealed no evidence of fire. The engine, which had separated during the impact sequence, exhibited heat damage, which precluded testing of its operability. However, the No. 3 cylinder was found to have low compression, which likely existed when the flight departed. Full flight control continuity was confirmed, but the flap extension could not be determined. Although a hole was noted in a fuel supply line immediately adjacent to an engine control cable, extensive corrosion precluded a determination of whether the hole was preexisting or occurred postimpact. Witnesses reported that the canopy opened while the pilot was taxiing to begin the flight, and it was found unlatched. However, the pilot was able to relatch it for taxi. Given that the fuel shutoff was found in the "off" position, it is likely that the pilot was preparing for a forced landing and unlatched the canopy at that time rather than it inadvertently becoming unlatched in flight. Based on the available evidence, the reason for the forced landing could not be determined.

According to the NTSB Survival Factors Specialist's Factual Report, during a search for the missing airplane, the U.S. Air Force Rescue Coordination Center (AFRCC) provided video of the Tampa area radar to the Civil Air Patrol (CAP) Incident Commander. During the search process, two incident command centers were established. The first incident command center for the Citrus County Sheriff's Office was established at the Homosassa fire station, and consisted of multiple local and state agencies. The second incident command center for the Civil Air Patrol (CAP) was located in Bradenton, Florida, which was nearly 1.5 hours away. The report further indicates that an air search was performed by the Marion County special operations unit of the area south of the departure airport; however, the wreckage was not visually spotted. A copy of the report is contained in the NTSB public docket. During the search for the missing airplane, or about 3 days after the missing airplane was reported, a detective with the Citrus County Sheriff's contacted the NTSB and relayed that he was at the incident command post at the Homosassa fire station with multiple local and state agencies, and about 100 personnel involved in a ground based search for the missing flight. The detective stated that he felt they were not looking in the correct area and the personnel from the CAP were not located at their command post. He also indicated he felt there was miscommunication among the multiple agencies and the CAP because CAP was located at a different location. The individual also expressed frustration to NTSB about the lack of coordination with AFRCC, and the person who was trying the find the airplane based on radar data. Subsequently, the NTSB put the 2 individuals in contact with each other. Copies of the NTSB Record of Conversations with the individuals are contained in the NTSB public docket. The wreckage was subsequently located beneath the area that was aerially searched by the special operations unit of the Marion County Sheriff's Office. Radar Data According to the NTSB Radar Summary, empirical radar target data for the departure airport information indicates that the floor of radar coverage was between 1,000 and 1,200 feet mean sea level. Correlating of recorded GPS data with radar data revealed radar data does not match the recorded GPS data; therefore, the accident airplane did not climb high enough to be seen by the radar. A copy of the radar summary and radar used for it is contained in the NTSB public docket. The airplane was equipped with an Electronics International R-1-4-G30R330 tachometer and a Grand Rapids Technologies, Inc., Model 2000 Engine Information System (EIS). A Garmin GPSmap 396 GPS receiver and a Garmin D2 Pilot watch were found at the accident site. All identified components were recovered and sent to the NTSB Vehicle Recorder Division for read-out. According to the NTSB Electronic Devices Specialist's Factual Report, it was not possible to correlate the RPM history from the electronic tachometer with the GPS data because the large interval between sample rate and the unknown time when the GPS receiver was first powered relative to the tachometer. The last recorded tachometer reading of 2,760 rpm occurred at 8:09 elapsed time since instrument power up. No information was retrieved from the EIS, but data was downloaded from the GPSMAP 396 receiver. Data associated with the accident flight revealed the recording began at 1351:00, and depicted the airplane taxiing to the approach end of runway 28. The airplane was noted to be accelerating on the runway at 1357:26, and continue the takeoff. When the flight was west of the departure end of the runway, at 1358:29, the airplane made a left climbing turn and proceeded in a southerly direction attaining the maximum GPS altitude of 817 feet mean sea level (msl). Between 1359:16, and 1359:24, the airplane continued on a southerly heading but descended from 817 feet to 804 feet msl. The airplane continued in a southerly heading while descending with an increasing ground speed until about 1359:35, then a right 270 degree turn was initiated. The airplane then proceeded in a southerly direction while descending, and the last GPS target at 1359:53, was located at 29.03224 degrees North latitude and 082.3862 degrees West longitude. The airplane at that time was flying at 154 feet GPS altitude on a southerly heading at 105 knots groundspeed. The accident site was located 0.11 nautical mile and 227 degrees from the last GPS data point. A copy of the report and downloaded data are contained in the NTSB public docket. The pilot was not in contact with any FAA air traffic control facility at the time of the accident. The Marion County Airport is equipped in part with runway 10/28 (previously identified as 9/27) which changed in December 2012. The airport common traffic advisory frequency is 122.8 MHz, which is not recorded, and at the time of departure was not monitored by airport personnel. The NTSB retained ELT was sent to the FAA Los Angeles Aircraft Certification Office for examination and testing at the manufacturer's facility with FAA oversight. Testing of the ELT consisted of a transmitter functional test, periodic maintenance test, acceptance test report (ATP), and measurement of the voltage of the alkaline batteries; the testing was performed on May 27, 2015. During the transmitter functional test, a swept tone signal was barely audibly heard and faded out during the first test. A subsequent test no tone was heard. During the periodic maintenance test steps 1 through 3 could not be performed as they are done on aircraft, but during test of the beacon the same weak swept tone response for the tests (functional and G-switch) was noted; the signal power was measured to be 21.3 dBM (minimum specification is 17.0 dBM). The ELT main unit expiration date was listed as May 16, 2011. All batteries voltage measured 1.565 volts or higher, and no evidence of battery leakage was noted; all batteries replace date were March 2016. A functional test of the G-switch was performed with the ELT main unit switch in the arm position and rapid forward and aft movement of the ELT; the main unit light illuminated as expected and a very weak swept tone was heard. A copy of the report from FAA is contained in the NTSB public docket. A review of the installation and operation manual instructions by the ELT manufacturer indicates the specified mounting tray consists of a flat piece with raised edges on the forward and aft sides of the tray extending across the width of the tray, and raised edges on both sides of the tray extend for a certain length of the tray. The tray by design is intended to prevent movement of the ELT out of the tray as a result of impact forces. Examination of the fractured fuel supply line from the fuel shutoff valve on the instrument panel to a fitting installed on the firewall was performed by the NTSB Materials Laboratory located in Washington, D.C. The results of the examination revealed severe pitting corrosion of both the tube and cockpit side fittings in the area of separation. The corrosion had removed significant material from the surfaces of the fittings and from both the exterior and interior surfaces of the tube. No fracture features were present on the tube separation. A hole and cracks were also apparent adjacent to the separation, and were consistent with corrosion penetration. The remaining length of the cockpit side tube showed lesser amounts of corrosion, and the engine side fuel tube showed little or no corrosion. A copy of the NTSB Materials Laboratory Factual Report is contained in the NTSB public docket. A postmortem examination of the remains of the pilot was performed by the District Five Medical Examiner's Office. The cause of death was listed as "Multiple blunt force injuries due to airplane crash." Forensic toxicology testing was not performed. The airplane crashed in