NTSB Factual Report

Factual Narrative

[ THIS REPORT WAS MODIFIED ON JUNE 10, 2008 ]

On June 23, 2005, about 1340 eastern daylight time, a Cessna 172N, N5118D, was substantially damaged during a go-around from runway 3 at Katama Airpark (1B2), Edgartown, Massachusetts. The certificated private pilot and two passengers were seriously injured. Visual meteorological conditions prevailed for the flight that departed Plymouth Municipal Airport (PYM), Plymouth, Massachusetts. No flight plan was filed for the personal flight conducted under 14 CFR Part 91.

Katama Airpark was a non-towered airport. The airport manager at Katama stated that he received a telephone call several weeks before the accident. He was contacted, through an interpreter, by a representative of the Deaf Pilots Association (DPA). The representative asked about a group of DPA pilots flying to Katama. The representative provided the week during which the fly-in would occur. The airport manager reported that he asked that the representative provide the exact date before coming. However, the airport manager further stated that he received no further contact about the specific date of the fly-in.

The Secretary of the DPA stated that on May 22, 2005, he wrote a letter to the Katama Airpark manager advising of the fly-in sometime between June 21 and June 24. On June 3 and June 11, the Secretary's sister spoke to the airport manager via telephone to coordinate the fly-in, and agreed to call again the night before arrival to provide the exact date and estimated time of arrival. Via an interpreter, the Secretary reported that he called Katama on the evening of June 22, and the afternoon of June 23, to provide updates on the group's arrival. The Secretary could not recall who received the most recent telephone calls, but his wireless telephone invoice revealed a 3-minute call to Katama on June 22, and a 1-minute call to Katama on June 23.

The pilot of a red Waco biplane, N32126, stated that on the day of the accident, he planned to back-taxi on runway 3, a 3,700-foot-long, 50-foot-wide, turf runway. The pilot announced his intentions on the common traffic advisory frequency (CTAF), did not hear a response, and did not observe any traffic in the area. About one-third down the runway, the pilot observed an airplane on final approach for runway 3. The pilot attempted to contact the airplane on final approach, but heard no response. The pilot of the Waco then taxied off the runway and waited until the landing airplane rolled past him. The pilot announced his intentions on the CTAF, heard no response, and resumed the back-taxi on runway 3. About two-thirds down the runway, he observed another airplane approaching runway 6, a 2,700-foot-long, 50-foot wide, turf runway. The pilot of the Waco again cleared runway 3 in case the landing pilot decided to land on runway 3. The second airplane subsequently landed on runway 6.

The pilot of the Waco stated that he attempted to contact both pilots that landed, but heard no response. The pilot again announced his intentions of the CTAF, heard no response, and resumed the back-taxi on runway 3. As the pilot approached the runway threshold, he observed another airplane turning on final approach for runway 3. The pilot said he taxied the Waco off the runway, and the landing airplane began a go-around. The pilot of the Waco further stated, "I saw him pull the nose way up and observed the left wing drop, and the airplane hit the ground."

The airport manager at Katama stated that after the accident, he closed the airport via announcements over the CTAF. He also notified the Martha's Vineyard air traffic control tower, and the Bridgeport, Connecticut flight service station. However, several more airplanes continued to land on runway 3, while several emergency vehicles were on the airport.

The pilot of the accident airplane held a private pilot certificate, and a third class medical certificate. His most recent medical certificate was issued June 1, 2005, with a special restriction and waiver, "not valid for flying where radio use is required." The pilot of the accident airplane was interviewed via telephone, through an interpreter, several months after the accident. Due to his injuries, the pilot could not recall the accident. The pilot reported a total flight experience of 660 hours; of which, 500 hours were in the same make and model as the accident airplane. In addition, the pilot had flown 10 hours during the 30 days preceding the accident, and 3 hours during the 24-hour period prior to the accident. The pilot was hearing impaired, and could not hear or sense the vibration from the airplane's stall warning horn. . When the pilot was asked how he would know the airplane was stalling, he responding that his first indication would be the "buffeting" of the airplane.

The front seat passenger in the accident airplane was also a student pilot, and the student pilot's 11-year-old daughter was seated in a rear passenger seat. The student pilot was hearing impaired, and was not operating the airplane's radio. As the accident airplane turned onto a final approach for runway 3, he said he observed the Waco move on runway 3, and the airplanes were "nose to nose." The student pilot "blacked out" as he saw the Waco directly below the accident airplane. He then recalled his daughter trying to wake him after the accident. The student pilot's daughter later told him that before touchdown, the accident airplane was not flying normally, and the pilot was is a state of panic. She recalled that a seat broke and hit her foot, and she thought it was a result of the pilot pushing his leg against the flooring in a state of panic. The witness's daughter also remembered the Waco being directly below the accident airplane.

The Secretary of the DPA also witnessed the accident. He was flying in his Piper Archer, and was in the traffic pattern at the time of the accident. He observed a red biplane moving at the approach end of runway 3, while the accident airplane was on short final approach. The Secretary then observed, "the right wing and nose of the [accident] aircraft lift up, slide to its left, and then drop onto the ground near the numbers of Runway 6." The Secretary had an interpreter onboard who inquired about the airport status via CTAF while circling, and was able to receive communication that the airport was closed. He then returned to Plymouth, Massachusetts uneventfully.

The front-seat passenger of a Piper Cherokee in the traffic pattern, an instrument-rated private pilot, was handling radio communications. She said she heard the pilot of the Waco announce over CTAF, and ask the landing pilots why they were not using a radio. The passenger then responded to the Waco pilot's inquiry with a non-standard transmission, "We have several NORDO approaches, please maintain visual contact." Just about that time, the accident occurred. The passenger then tried to obtain guidance over CTAF, but did not receive any response stating that the airport was closed. She stated that she announced the intention for the airplane she was in was to land on runway 3, and heard no response. The airplane landed uneventfully, along with several other airplanes.

Another witness captured part of the accident sequence with a video recorder. Review of the recording revealed that the accident airplane was in a descending left bank attitude near the runway threshold. The pitch attitude appeared approximately neutral as the airplane continued to descend and roll right before impacting the ground. At the same time, a red biplane was taxiing in the vicinity of the runway threshold.

The accident airplane came to rest about 15 feet right of runway 3. The wreckage was examined by a Federal Aviation Administration (FAA) inspector. The disposition of the wreckage was consistent with an approximate 15-degree nose down, upright, vertical impact. The inspector confirmed flight control continuity and noted that the flaps were in the 10-degree extended position.

After the wreckage was recovered, the seats and seat tracks were examined by a representative from the airplane manufacturer, and a Safety Board investigator. The front left seat was a cast seat. The right portion of the seat base had separated from the seat, but remained attached to its respective seat track. The left side of the seat base remained intact, with the casters and seat clamps intact. One seat pin separated consistent with impact damage, while the other seat pin remained intact with an approximate 1/2-inch extension. The seat back also remained intact. The right seat base was intact. The base legs were bent consistent with a side load to the right. The seat clamps were deformed or separated consistent with a side load to the right. The right seat back remained intact. Both sets of seat tracks remained intact, and were separated about mid-span, consistent with impact damage. The rear bench seat remained intact, and was more deformed on the right side. All seat belts and shoulder harnesses were intact.

Review of FAA-H-8083-3A, Airplane Flying Handbook, revealed: "Go-Arounds (Rejected Landings):

Whenever landing conditions are not satisfactory, a go-around is warranted. There are many factors that can contribute to unsatisfactory landing conditions. Situations such as air traffic control requirements, unexpected appearance of hazards on the runway, overtaking another airplane, wind shear, wake turbulence, mechanical failure and/or an unstabilized approach are all examples of reasons to discontinue a landing approach and make another approach under more favorable conditions .... The go-around is not strictly an emergency procedure. It is a normal maneuver that may at times be used in an emergency situation. Like any other normal maneuver, the go-around must be practiced and perfected....

Although the need to discontinue a landing may arise at any point in the landing process, the most critical go-around will be one started when very close to the ground. Therefore, the earlier a condition that warrants a go-around is recognized, the safer the go-around/rejected landing will be. The go-around maneuver is not inherently dangerous in itself. It becomes dangerous only when delayed unduly or executed improperly...The improper execution of the go-around maneuver stems from a lack of familiarity with the three cardinal principles of the procedure: power, attitude, and configuration....

Attitude is always critical when close to the ground, and when power is added, a deliberate effort on the part of the pilot will be required to keep the nose from pitching up prematurely. The airplane executing a go-around must be maintained in an attitude that permits a buildup of airspeed well beyond the stall point before any effort is made to gain altitude, or to execute a turn. Raising the nose too early may produce a stall from which the airplane could not be recovered if the go-around is performed at a low altitude.

A concern for quickly regaining altitude during a go-around produces a natural tendency to pull the nose up. The pilot executing a go-around must accept the fact that an airplane will not climb until it can fly, and it will not fly below stall speed. In some circumstances, it may be desirable to lower the nose briefly to gain airspeed. As soon as the appropriate climb airspeed and pitch attitude are attained, the pilot should 'rough trim' the airplane to relieve any adverse control pressures. Later, more precise trim adjustments can be made when flight conditions have stabilized." Review of the Pilot/Controller Glossary, contained in the Aeronautical Information Manual, revealed: Lost Communications - Loss of the ability to communicate by radio. Aircraft are sometimes referred to as NORDO (No Radio)."

The reported weather at Martha's Vineyard Airport, Vineyard Haven, Massachusetts, located about 5 miles northwest of the accident site, at 1353, was: wind from 080 degrees at 9 knots; visibility 10 miles; sky clear; temperature 69 degrees F; dew point 45 degrees F; altimeter 30.14 inches Hg.

NTSB Probable Cause

The pilot's failure to maintain airspeed during a go-around, which resulted in an inadvertent stall and subsequent impact with terrain.

[THIS REPORT WAS MODIFIED ON JUNE 10, 2008]