NTSB Factual Report

HISTORY OF FLIGHT

On September 17, 1999, at 1248 central daylight time, a Piper PA-38-112, N9575T, operated by Decatur Aviation Inc., Decatur, Illinois, was destroyed during impact with the terrain following an in-flight loss of control, near Warrensburg, Illinois. Visual meteorological conditions prevailed at the time of the accident. The Federal Aviation Administration (FAA) private pilot checkride was operating under the provisions of 14 CFR Part 91 and was not on a flight plan. The private pilot candidate and FAA Designated Examiner were fatally injured. The local flight originated from the Decatur Airport, Decatur, Illinois, at 1217.

A witness to the accident was working in an agricultural field approximately 1/4 statute mile from the accident site. The witness reported that, "I saw the last 200 foot of the plane crash. I think [the] plane was spinning counter clockwise dropping like a rock from the sky. It crashed nose first in the field just east of where I was sitting."

The witness reported that approximately two minutes prior to the accident he, "Saw large whirl wind in S.E. [southeast] corner of our corn field. Approx[imate] size 100' tall by 40-50 ft wide with thousands of corn stalks leaves swirling in it." The witness reported that the whirlwind's size was described by one of his fellow workers, located approximately 3-statute miles from the accident site, as a "small tornado".

The witness' written statement is appended to this factual report.

Aircraft radar track data for the period before and after the reported accident time was obtained from FAA Air Traffic Control. The obtained data indicated there was a single aircraft, which was transmitting a visual flight rules (VFR) 1200 transponder beacon code, maneuvering near the accident location around the time of the accident. According to the data, the aircraft's Mode-C transponder altitude encoding function was transmitting erroneous information, and accurate altitude data was not obtained.

A plot of the aircraft radar track data was generated, and is appended to this factual report along with a copy of the source data.

PERSONNEL INFORMATION

According to FAA records, the private pilot candidate was the holder of a private pilot certificate with a glider rating, which was issued on September 13, 1997. FAA records show the pilot's last medical examination date was March 3, 1999, and the pilot was issued a third-class medical certificate with the limitation, "MUST WEAR CORRECTIVE LENSES."

The private pilot candidate reported on FAA Form 8710-1 "Airman Certificate and/or Rating Application", dated September 16, 1999, that his total flight time was 132 hours. The private pilot candidate listed his total time in the accident make and model as 71 hours and his total time in single engine land airplane as 71 hours. The private pilot candidate stated that 37 of the 71 hours were as pilot-in-command (PIC). The private pilot candidate reported that he had 61 hours of flight time in a glider, of which 39 hours were as PIC.

According to the private pilot candidate's flight logbook, he had flown 45.7 hours the last 90 days and 12.1 hours in the last 30 days, all of which were in the accident make and model of airplane. The pilot had flown 2.1 hours during the previous 24 hours and all 2.1 hours were flown in the accident make and model of airplane.

According to the flight logbook, the private pilot candidate had an endorsement for the private pilot practical exam, dated September 17, 1999. According to the logbook, spin entry, spins, and spin recovery techniques were not demonstrated to, or executed by, the private pilot candidate in an airplane. According to Federal Aviation Regulations (FAR) 61.105 Aeronautical Knowledge, private pilot candidates are required to have satisfactory aeronautical knowledge of, "stall awareness, spin entry, spins, and spin recovery techniques for airplane and glider category ratings." The private pilot candidate took the required aeronautical knowledge test on August 3, 1999, and received a passing score. According to FAR 61.107 Flight Proficiency, a private pilot candidate does not need to have logged any flight training in spin entry, spins, and spin recovery techniques in order to be eligible for a private pilot certificate.

According to FAA records, the FAA Designated Examiner was the holder of a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane operations. The examiner also held a certified flight instructor certificate with ratings for single-engine land, multi-engine land, and instrument airplane operations. According to FAA records, designated examiner authority was granted to the examiner on March 16, 1999, by the Springfield Flight Standards District Office, Springfield, Illinois. FAA records show the pilot's last medical examination date was October 12, 1998, and the pilot was issued a second-class medical certificate with the limitation, "MUST WEAR CORRECTIVE LENSES FOR NEAR AND DISTANT VISION".

The FAA Designated Examiner reported on FAA Form 8710-1 "Airman Certificate and/or Rating Application", dated March 16, 1999, that his total flight time was in excess of 29,250 hours. According to NTSB Form 6120.1/2, completed by a representative of Decatur Aviation Inc., the examiner had accumulated more than 2,000 hours in the accident make and model of airplane as pilot-in-command. The examiner was reported to have flown more than 18,000 hours in single-engine land airplanes and 14,000 hours in multi-engine airplanes. The examiner had flown 31.5 hours in the last 90 days, of which 6.3 were in the accident make and model of airplane. The examiner had flown 17.2 hours in the last 30 days, of which 3.4 were in the accident make and model of airplane. According to company flight logs and NTSB Form 6120.1/2, the examiner did not fly within 24 hours of the accident.

AIRCRAFT INFORMATION

The aircraft was a Piper PA-38-112, Tomahawk, serial number 38-78A0135. The Tomahawk is a single-engine, low wing monoplane of all metal construction equipped with a fixed landing gear, and can accommodate a pilot and a passenger in a side-by-side seating arrangement. The Tomahawk has a T-tail empennage configuration with a fixed horizontal stabilizer mounted on top of the vertical fin.

The FAA issued the airplane a Standard Airworthiness Certificate on April 25, 1978, and the airplane was certificated for both normal and utility categories. The airplane had accumulated a total-time of 6019.25 hours at the time of the accident. The last annual inspection was completed on July 16, 1999, and had accumulated 13.35 hours since the inspection. According to the aircraft maintenance logbooks, all applicable FAA Airworthiness Directives were complied with at the completion of the last annual inspection.

The FAA issued Airworthiness Directive (AD) 78-22-01 "Rudder or Elevator Binding" for the Piper PA-38-112 Tomahawk aircraft on October 30, 1978. The purpose of AD 78-22-01 was, "To prevent possible binding of the rudder or elevator in flight... ." A one-time compliance with the AD could be accomplished by completing all portions of Piper Service Bulletin 607A. According to the maintenance logbook, AD 78-22-01 was fully complied with on December 22, 1978. Copies of AD 78-22-01, Piper Service Bulletin 607A, and the maintenance logbook entry are attached to this factual report.

Piper Service Bulletin 876, entitled "Additional Flow Strip Installation", was issued on April 12, 1979. The purpose for issuance of Piper Service Bulletin 876 was reported as, "The installation of two (2) additional flow strips to the leading edges of the wings has been found to improve operational characteristics during stall maneuvers. This Service Release announces the availability of a Flow Strip Installation Kit." A copy of Piper Service Bulletin 876 is attached to this factual report.

The FAA issued Airworthiness Directive (AD) 83-14-08 "Stall Characteristics" for the Piper PA-38-112 Tomahawk aircraft on September 27, 1983. The purpose of AD 83-14-08 was to mandate that all areas addressed in Piper Service Bulletin 876 to be accomplished within 100 hours time-in-service of the AD effective date. According to the airframe maintenance logbook, AD 83-14-08 was complied with on September 1, 1983. The logbook entry states, "... C/W [complied with] AD 83-14-08 installed kit 763-930 and had airspeed [indicator] remarked see maintenance release." Copies of AD 83-14-08, the maintenance logbook entry, and airspeed indicator maintenance release tag are attached to this factual report.

Piper Service Bulletin 661, entitled "Control Column Installation Modification", was issued on August 22, 1979. The purpose for issuance of Piper Service Bulletin 661 was reported as, "It has been reported that roughness or binding of the control shaft in the instrument panel cutout hole can occur when the control wheel is full aft and direct forward or upward-and-forward pressure, rather than linear pressure along the control shaft, is applied. This Service Release contains instructions for the modification of the control wheel shaft bushing assembly to provide a smoother forward movement of the control shaft from a fully aft and up position." A copy of Piper Service Bulletin 661 is attached to this factual report.

Piper Service Bulletin 800, entitled "Elevator Control Travel Modification", was issued on November 19, 1984. The purpose for issuance of Piper Service Bulletin 800 was reported as, "It has been reported that when either control wheel is full aft and an upward-and-forward pressure is applied, the potential exists that the pilot may be unable to move the control yoke out of the full aft position. This Service Bulletin provides instructions to modify the elevator up travel to alleviate the above described problem." A copy of Piper Service Bulletin 800 is attached to this factual report.

The FAA issued Airworthiness Directive (AD) 85-11-06 "Control Loss" for the Piper PA-38-112 Tomahawk aircraft on May 20, 1985. The purpose of AD 85-11-06 was to mandate that Piper Service Bulletins 661 and 800 to be accomplished within 50 hours time-in-service of the AD effective date. According to the airframe maintenance logbook, AD 85-11-06 was complied with on July 25, 1985. The logbook entry states, "Complied with AD 85-11-06 Ele. [Elevator] Control, dated 5-30-85 by compling [complying] with Piper S/B's [Service Bulletins] 661 & 800 per AD." Copies of AD 85-11-06 and the maintenance logbook entry are attached to this factual report.

The aircraft Pilot Operating Handbook (POH) included a "Weight and Balance Supplement" sheet, dated February 24, 1989, which listed the following information:

New Empty Weight 1,166.5 lbs New Empty Weight CG 73.51 inches New Useful Load 503.5 lbs New Empty Weight Moment 8,5753.12 in/lbs

The POH listed the PA-38-112 certificated maximum gross weight as 1,670-lbs.

FAA records show the private pilot candidate's weight, as of the last medical examination dated March 3, 1999, was 214 lbs.

FAA records show the FAA Designated Examiner's weight, as of his last medical examination dated October 12, 1998, was 206 lbs.

According to fueling records and written statements provided by employees of Decatur Aviation Inc. the accident airplane was fully fueled prior to the accident flight. The Piper PA-38-112 POH lists the maximum usable fuel capacity as 30 gallons or 180 lbs.

Based on the above information, the aircraft's approximate weight was determined to be 1,766.5 lbs at the beginning of the flight. The center-of-gravity location was determined to be 76.789-inches aft of the datum point.

A time log was located in the accident aircraft and indicated that the accident flight began at 2,726.4 hours, and the hour-meter indicated 2,727.2 hours at the accident site. The duration of the accident flight, from engine start-up to the time of the accident, was calculated to be 0.8 hours.

The weight and balance supplement sheet, the aircraft time log, and the weight and balance section from the Piper PA-38-112 POH are appended to this factual report.

The engine was a 112-horsepower Avco-Lycoming, O-235-L2C, serial number L-15518-15, and at the time of the accident had accumulated 6,019.25 total hours since new. The engine had accumulated 697.55 since the last major overhaul, which was completed on June 1, 1995.

The propeller was a Sensenich, 72CK-0-56, serial number K6382, and at the time of the accident had accumulated 71.5 hours since overhaul. The last propeller overhaul was completed on November 30, 1998. The propeller was inspected on July 16, 1999, and had accumulated 13.35 hours since inspection.

METEOROLOGICAL INFORMATION

A weather observation station, located at the Decatur Airport (DEC), 14.2 nautical miles (nm) southeast of the accident site, reported the weather two minutes after the accident as:

Observation Time: 1250 cdt Wind: Variable Direction at 5 knots Visibility: 10 statute miles Sky Condition: 4,900 Scattered Temperature: 20-degrees centigrade Dew Point Temperature: 08-degrees centigrade Pressure: 30.26-inches of mercury

Wind data was obtained from a weather station located approximately 19 nautical miles northwest of the accident site. The upper atmospheric winds were reported to be:

Reporting Time: 0700 cdt Feet mean sea level (msl) Wind Direction/Velocity (degrees true/knots) 584 350/05 669 360/05 997 030/06 1,998 065/07 2,818 050/06 2,999 045/06 3,999 025/08 5,112 015/09

Reporting Time: 1900 cdt Feet mean sea level (msl) Wind Direction/Velocity (degrees true/knots) 584 040/03 669 050/02 997 055/01 1,998 040/03 2,818 045/03 2,999 045/05 3,999 040/05 5,112 055/03

WRECKAGE AND IMPACT INFORMATION

The National Transportation Safety Board's (NTSB) on-scene investigation began on September 17, 1999.

A global positioning system (GPS) receiver reported the accident site position as 39-degrees 59.332-minutes north latitude, 89-degrees 06.037-minutes west longitude. The accident site was approximately 0.14 nm south of Hampshire Road and 0.2 nm east of Lincoln Memorial Parkway near the town of Warrensburg, Illinois.

The aircraft impacted in an open, level, recently harvested cornfield. There were no trees or other ground obstructions in the vicinity of the accident site. The angle between the terrain and the longitudinal centerline of the engine was measured at 35-degrees. No wreckage propagation was noted from the initial impact location. The heading of the aircraft wreckage was measured with a compass along the aircraft's longitudinal axis and was 110-degrees magnetic. All components of the aircraft were located at the accident site and all flight control surfaces remained attached at their respective airframe positions.

The left wing remained attached to the fuselage and exhibited full span aft directional bending. Leading edge compression damage was noted along the entire wingspan. The leading edge skin was crushed aft to the forward wing spar and the bottom cap of the forward spar was deformed in the aft direction. The aft spar was found fractured approximately 1-3/4 feet outboard of the wing root and the flap actuation torque tube was bent in the aft direction. The left wing flap remained attached to the flap actuation torque tube, and the flap was in a fully retracted position. The left wing flap was buckled along its entire span. The left aileron remained attached to the wing and the left aileron counterbalance weight was found with the aileron. The left aileron was buckled along its entire span. Both aileron cables were found attached to the left aileron bellcrank and to the aileron torque tube located in the fuselage. The aileron actuation push/pull rod was found attached to the aileron bellcrank and the flight control surface. The left wing fuel tank was ruptured and no residual fuel was noted. The left main gear was found attached to the wing structure and was bent in an aft and outboard direction. Both inboard and outboard stall strips were installed on the

NTSB Probable Cause

Aircraft control not being maintained by the private pilot candidate and the inadequate supervision by the FAA Designated Examiner. Factors relating to the accident were the inadvertent spin, the unsuccessful remedial action attempted by the flightcrew, and the flightcrew's decision to operate the airplane over the certified maximum gross weight.