NTSB Factual Report

HISTORY OF FLIGHT

On June 22, 2006, about 1410 eastern daylight time, a Cessna 172N, N572BA, operated by Twin Cities Air Service LLC. was destroyed when it impacted terrain while maneuvering near Newry, Maine. The certificated flight instructor and the three passengers were fatally injured. Visual meteorological conditions prevailed for the local flight that departed Bethel Regional Airport (0B1) Bethel, Maine, about 1400. No flight plan was filed for the local instructional flight conducted under 14 CFR Part 91.

According to an Air Force Junior Reserve Officers Training Corps (AFJROTC) instructor, the passengers were high school students receiving a cadet orientation flight as part of a summer camp program.

According to witnesses, the Cessna 172 and a Cessna 152 that were to be used for the day's cadet orientation flights arrived about 30 minutes late. The Cessna 172 landed "longer than expected." After a short discussion with an AFJORTC instructor about duration of the flights, the flight instructor performed a "fast" preflight inspection of the Cessna 172, and boarded three cadets for the first of several planned orientation flights.

Both airplanes then departed. After takeoff, the Cessna 152 remained in the traffic pattern; however, the Cessna 172 proceeded towards Barker Mountain. It then turned right through a pass on the near side of the mountain and disappeared from view. Approximately 20 minutes later, the Cessna 172 returned for landing. The Cessna 152 also landed, after flying a "normal traffic pattern," however; the Cessna 172 approached the runway "with a good angling correction" from the northeast, and flew a "real tight" traffic pattern with flaps extended. It then entered a side slip to a point about 30 feet above runway 32, and touched down with a "slight wing rock," once again landing long.

The flight instructor then loaded another three cadets and departed. The Cessna 172 made an "immediate" right turn directly towards Barker Mountain in a tail low attitude. As it approached the mountain it turned farther right until it was paralleling the mountain face. It then passed over the mountain and disappeared from view.

The accident occurred during the hours of daylight. The wreckage was located at 44 degrees, 27.257 minutes north latitude, and 70 degrees, 53.091 minutes west longitude.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) records, the flight instructor held a commercial pilot certificate with ratings for airplane single-engine-land, airplane-multiengine-land, and instrument airplane. His most recent FAA first-class medical certificate was issued May 19, 2006. Examination of his logbook revealed he had accrued 861.6 total hours of flight experience.

AIRCRAFT INFORMATION

According to FAA and maintenance records, the airplane was manufactured in 1979. The airplane's most recent 100-hour inspection was completed on June 21, 2006. At the time of the inspection, the airplane had accrued 6,750.9 total hours of operation and the engine had accrued 863.1 hours of operation since its last overhaul.

METEOROLOGICAL INFORMATION

A weather observation taken about 18 minutes before the accident, at Berlin Municipal Airport (BML), Berlin, New Hampshire, located approximately 19 nautical miles northwest of the accident site, recorded the winds as 160 degrees at 4 knots, visibility 10 miles, few clouds at 6,000 feet, temperature 73 degrees Fahrenheit, dew point 61 degrees Fahrenheit, and an altimeter setting of 30.00 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The main wreckage came to rest in a heavily wooded area, 2,070 feet above sea level on Barker Mountain. Impact marks, along with broken portions of tree trunks, were visible 43 feet north of the main wreckage approximately 60 feet up the surviving portions of the trees. Multiple portions of fragmented tree trunks, which exhibited propeller strike marks perpendicular to the longitudinal axis of the trunk existed throughout the accident site.

All major components of the airplane were accounted for at the accident site, and no preimpact malfunctions of the airplane or engine were discovered.

The cabin was consumed by a postimpact fire. The engine, firewall, and remains of the instrument panel were orientated on a heading of 180 degrees magnetic, and canted 20 degrees to the left. An approximate 8-foot section of the aft fuselage along with the empennage was inverted, displayed varying degrees of impact damage, and was orientated on a heading of 260 degrees. The left and right wings were found in their respective mounting locations, in close proximity to the remains of the fuselage. Their leading edges displayed multiple impact marks.

All flight control surfaces displayed differing degrees of damage. The flap actuator correlated to a 10-degree flap position. The elevator trim correlated to approximately neutral. Flight control continuity was confirmed for the aileron, rudder, elevator, and pitch trim control systems.

Examination of the cockpit revealed that the throttle control was full open and the mixture control was in the full rich position. Both cabin door latch assemblies were in the closed and locked position, and exhibited scratches at the door latch pins.

Examination of the propeller revealed that it had remained attached to the engine and exhibited chordwise twisting, leading edge gouging, leading edge polishing, and chordwise scratching.

Examination of the engine revealed that the aft portion was fire damaged. Continuity of the intake system, exhaust system, valve train, and crankshaft were confirmed. The single drive, dual magneto was consumed by fire. Only the impulse coupling and drive shaft remained. The ignition harness was broken at multiple locations and exhibited fire related damage. All spark plugs were removed for inspection, and their electrodes were intact. All four cylinders were examined internally with a lighted borescope, and no anomalies were observed. The crankshaft was rotated through an accessory drive, and compression was noted on all four cylinders. The valve covers were removed, and oil was noted in all rocker boxes. The oil suction screen and oil filter were examined, and no contamination was observed.

Examination of the fuel system revealed that both wing tanks were breached. No blockages or preimpact anomalies of the surviving portions of the fuel tanks and fuel lines were noted. The fuel strainer screen was intact and showed no evidence of prefire discoloration or debris on its face. No evidence consistent with a preimpact failure or malfunction of the carburetor was observed, and the finger screen was clean and absent of debris.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination was performed on the flight instructor by the State of Maine's Office of the Chief Medical Examiner.

Toxicological testing of the flight instructor was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma.

ADDITIONAL INFORMATION

According to a cadet who had flown with the flight instructor on a previous occasion and on the day of the accident, the accident day flight was "different" from the flight he had participated in with the same flight instructor on a previous occasion.

According to the cadet, during a flight with a group of Civil Air Patrol cadets in February of 2006, the flight instructor asked the cadets if they were getting bored. He then performed two "dips" which were "pretty steep," and then did what the cadet described as a "zero g" maneuver. During the maneuver the flight instructor climbed the airplane to approximately 3,500 feet msl and then descended to "less than" 2,000 feet msl. The cadet also observed, "stuff floating around" and a pen "came off" the top of the airplane's instrument panel.

A witness reported that on the day of the accident two light colored, high wing airplanes were flying southeast "awfully low" near Paris, Maine, between 1230 and 1300. The witness added that first airplane was going "fairly flat" but the second airplane was "going back and forth," and seemed to be "playing, making sweeps." A review of a local area map revealed the witness was located in a position to observe a direct repositioning flight from Auburn/Lewiston Municipal Airport (LEW), Auburn, Maine (the accident airplane's base), to 0B1.

The cadets, who flew with the flight instructor on the first orientation flight on the day of the accident, stated that the flight instructor flew the airplane barefoot in order to "feel the rudders better." After departing and turning right, the flight instructor headed over the top of some "ATV trails and logging roads." He then circled the Sunday River Ski Resort. The flight then proceeded around a mountain, and the flight instructor initiated a climb. The plane then stalled, "fell backwards and to the left," and then dove towards the ground. At approximately 75 to 100 feet above the treetops, and 300 feet from the side of the mountain, the flight instructor recovered and headed back in the direction of the airport.

Towards the end of the flight, the flight instructor once again pulled up, this time into a "zero g maneuver." During the maneuver, he pushed the throttle full in, and then "pulled the mixture" to idle cutoff, and pushed the nose of the airplane down. After approximately 5 seconds, he increased the "mixture" and recovered. While returning to land, the pilot missed the turn to line up with the runway, and "pulled a tight turn, and pulled tighter when that did not work."

One cadet who estimated he had been in an airplane at "least ten times" as both a passenger or when flying, estimated that during the flight they were between 1,000 to 1,200 feet. He also estimated that they were flying close to the treetops, which was "kind of scary."

According to the Department of The Air Force, the AFJROTC Cadet Orientation Flight Program was designed to introduce cadets to general aviation through hands-on familiarization flights in single-engine aircraft. The program was voluntary, primarily motivational, and was used to stimulate an interest in general aviation and aerospace activities. Over 1,000 AFJROTC cadets participated in the Flight Orientation Program per year.

Corrective Actions

On January 1, 2007, the AFJROTC released a cadet orientation flight syllabus containing guidance and requirements for orientation flights.

These guidelines and requirements included that every flight be in compliance with 14 CFR Part 91, conform to the syllabus, consistent with safety, "aircraft/aircrew" capabilities, and available resources. Also included were prohibitions on the performance of aerobatic maneuvers, responsibility of the pilot to follow the syllabus, emphasized safety as the overriding concern, and qualification criteria for pilots to act as pilot in command of orientation flights.

Additionally, the guidelines and requirements included the use of operational risk management for examination of proposed facilities and activities to identify hazards, assess risks, and decide on risk controls that could be included in an operational plan.

NTSB Probable Cause

The flight instructor's failure to maintain altitude/clearance while maneuvering, which resulted in an impact with trees.