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NTSB investigation record

ERA16FA165

Completed

Vans Rv12· N276VA

Date
April 19, 2016
Location
Stevensville, MD
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's failure to maintain airplane control during approach for landing in gusting crosswind conditions, which resulted in an exceedance of the airplane's critical angle of attack and a subsequent aerodynamic stall.

Investigator assessment

Analysis narrative

The airline transport pilot of the light sport airplane was approaching the airport for landing in gusty front quartering crosswind conditions. Witnesses observed the airplane on final approach between 50 and 75 ft above ground level. The airplane's nose pitched up, followed by a roll to the right. The airplane then entered a nose-down attitude and descended to ground contact, impacting level terrain about 750 ft from the runway and slightly left of the extended runway centerline. Examination of the wreckage did not reveal any preimpact mechanical malfunctions that would have precluded normal operation. Before the accident flight, the pilot had about 2.4 hours of experience in the accident airplane make and model but had been signed off to fly the airplane by an instructor. Witness observations of the final moments of flight are consistent with an aerodynamic stall. It is likely that the pilot failed to compensate for the gusty crosswind and turbulent conditions during the approach for landing, which resulted in an exceedance of the airplane's critical angle of attack, aerodynamic stall, and subsequent loss of control.

Source record

Factual narrative

W29 was a nontower-controlled airport. The field elevation was 15 feet msl and the airport was equipped with one asphalt runway. Runway 11/29 was 2,713 ft long by 60 ft wide and had nonprecision markings. Runway 29 was equipped with a 2-light precision approach path indicator (PAPI) with a 3.00° glidepath. The airport property was on the eastern shore of the Chesapeake Bay. According to the VANs RV-12 Pilot Operating Handbook. "During gusty wind conditions, fly the landing approach at approximately 5 knots above normal and touch down with the nose slightly lower than for a normal landing. Crosswind approaches can best be accomplished by using the wing down top rudder method touching first on the down wing side main wheel, followed by the other main wheel, and finally lowering the nose wheel all the while keeping the stick into the wind." The Airplane Flying Handbook (FAA-H-8083-3B), Chapter 8, " Crosswind Approach and Landing," stated in part: The wing-low (sideslip) method compensates for a crosswind from any angle, but more important, it keeps the airplane's ground track and longitudinal axis aligned with the runway centerline throughout the final approach. For landing in turbulent conditions, use a power-on approach at an airspeed slightly above the normal approach speed. This provides for more positive control of the airplane when strong horizontal wind gusts, or up and down drafts, are experienced. Like other power-on approaches, a coordinated combination of both pitch and power adjustments is usually required. At 1248, the weather recorded at W29 included 10 miles visibility, temperature 26°C, dew point 6°C, and altimeter 29.99 inches of mercury (inHg). At 1245, the reported weather at ESN included wind from 320° at 10 knots gusting to 16 knots, 10 miles visibility, scattered clouds at 25,000 ft, temperature 26°C, dew point 6°C, and an altimeter setting of 30.02 inHg. The closest upper air sounding site was from Aberdeen Proving Grounds (APG), Maryland, located about 32 miles north-northeast of the accident site on the western shore of the Chesapeake Bay. The 0800 sounding indicated a morning surface-based inversion to about 800 ft. Winds were from the northwest at 10 knots and increasing in speed to over 20 knots immediately above the inversion. The strong shear resulted in a potential low-level wind shear conditions and turbulence. The Office of the Chief Medical Examiner, State of Maryland, Baltimore, Maryland, performed an autopsy of the pilot; the cause of death was multiple injuries. In addition, evidence of a scar from a previous stroke was identified, as well as significant heart disease. The pilot had an intact artificial aortic heart valve, severe coronary artery disease with 75% stenosis of the left anterior descending artery and 30% in the right coronary artery. No gross evidence of scarring from a previous heart attack was described. The medical examiner's toxicology testing identified amlodipine in the pilot's urine but not in blood. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing and identified losartan, rosuvastatin, carvedilol, and salicylate in urine, amlodipine in liver and cavity blood, and rosuvastatin in blood. Losartan, carvedilol, and amlodipine are prescription blood pressure medications. Salicylate is a metabolite of aspirin; rosuvastatin is a prescription cholesterol lowering agent. None of these medications are generally considered impairing. Records from the pilot's primary care doctor between April 2013 and April 2016 indicated that the pilot had undergone an aortic valve and aortic root replacement in 2012, and that he had longstanding hypertension and high cholesterol. He had also been diagnosed with a transient ischemic attack sometime before 2013. A list of regular medications was not included in the records after 2014. According to Federal Aviation Administration (FAA) records, the pilot, age 63, held an airline transport pilot certificate with ratings for airplane single- and multi-engine land. He also held a flight instructor certificate for airplane single engine. The pilot was issued an FAA first-class medical certificate in April 2008, which expired for all classes in April 2010. At the time of the accident, he did not possess an FAA medical certificate, nor was he required to for the accident flight in the light sport airplane. On the application for his last medical certificate, the pilot reported 5,136 total hours of flight experience. According to a review of the flight school's electronic records and correspondence with the owner of the school, the pilot completed two flights with a flight instructor in March and April 2016, totaling 2.4 hours of flight instruction and 3 hours of ground instruction. The pilot received an instructor signoff to fly the accident airplane on April 7, 2016. No pilot logbooks or additional flight records were recovered. The flight instructor who provided the instruction and the signoff stated that the pilot had called several weeks earlier to receive a checkout in the RV-12 and stated that he did not have any experience in light sport aircraft. During the instruction flights, they performed various maneuvers, including steep turns, stalls, normal and soft field takeoffs, landings, and go-arounds. He stated that the pilot seemed "very comfortable" with the airplane and flew very well. According to FAA records and the airframe manufacturer, the two-seat, low-wing, fixed landing gear airplane was manufactured by Van's Aircraft, Inc., and received its special airworthiness certificate for light sport on June 23, 2015. The airplane's most recent 100-hour inspection was completed on March 16, 2016. At the time of the inspection, the airplane had accrued 298.6 total hours of operation. The airplane was equipped with a Rotax 912-ULS-2 engine. The pilot's operating handbook stated that stall speed with the flaps extended at maximum gross weight was 41 knots; with the flaps retracted, the stall speed was 45 knots. The maximum direct crosswind was 11 knots. The center fuselage and wings remained intact but were significantly damaged during the accident sequence. The wing spar remained attached to both wings and carried through the fuselage. Both wings remained attached to the U-channel with the spar pins locked in place. Fire consumed the center section of the airplane, where the 20-gallon fuel tank was located just aft of the cockpit seats, and also consumed the aft fuselage and empennage. The left wing remained attached to the fuselage and carry-through wing spar. The outboard 90 inches remained intact to the wing root, where it was consumed by fire. The wing displayed very little compression and minor buckling on the forward outboard portion. The trailing edge displayed fire damage propagating outboard from the fuselage. The left flaperon remained attached and operated normally. The right wingtip was deformed from the impact and the wing exhibited numerous compression bends along the entire span. It also exhibited fire damage at the root. The fire propagated outward from the midpoint of the wing aft and outboard of the trailing edge about 50% of its span. The right flaperon was ripped from its mounts and separated from the airplane during the accident sequence; it was found about 30 ft east of the main wreckage. The aft root portions of the wings were destroyed by the fire. The flaperon handle was secured in the retracted position and the left flaperon displayed a neutral position. The right flaperon separated from the wing during the accident sequence and was found about 20 ft left of and behind the main wreckage. The push-pull tubes from the mixing box aft were broken and severed. The mixing box was not retrievable due to thermal damage. The rudder was mostly destroyed by fire, but the lower attach point was functional and remained connected to the frame. Both rudder control c

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