The Tragic Flight of N928CP

Started by Cindi, February 19, 2014, 07:57:57 PM

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Cindi



Tail number   N928CP
Accident date   July 17, 2002
Aircraft type   Cessna 172S
Location   Tyner, NC
Near 36.256389 N, -76.617223 W
Additional details:    None
NTSB description
HISTORY OF FLIGHT
On July 17, 2002, about 1522 eastern daylight time, a Cessna 172S, N928CP, registered to the Civil Air Patrol, Inc., crashed while maneuvering in the vicinity of Tyner, North Carolina. Visual meteorological conditions prevailed and no flight plan was filed for the local, public-use, counter-drug mission flight, from the Northeastern Regional Airport, Edenton, North Carolina. The aircraft was destroyed and a private-rated pilot, a commercially-rated copilot, and an observer received fatal injuries. The aircraft departed Northeastern Regional Airport, Edenton, North Carolina, at about 1300.
According to the personnel from the Chowan County Sheriff's Department and the Civil Air Patrol, the aircraft was being utilized in marijuana crop spotting. Another Civil Air Patrol aircraft was conducting the same mission in adjacent areas of the county. Witnesses observed both aircraft maneuvering in different areas throughout the county during the morning and afternoon at altitudes of about 300 to 500 feet above ground level (agl), with occasional maneuvering at lower altitudes. On the pass that N928CP crashed, witnesses stated the aircraft was in a large clockwise orbit, and was noticeably lower than 300 to 500 feet agl. A sputtering noise was heard by one witness, and another stated there was no engine sound at all just before she observed the aircraft depart normal upright flight. From an altitude of about 120 to 150 feet agl, she saw the aircraft simultaneously nose over vertically and commence a right half roll into the terrain.
PERSONNEL INFORMATION
The pilot-in-command and left seat occupant, age 38, was the holder of a private-pilot certificate with airplane single engine land, and instrument airplane ratings. He was issued a Federal Aviation Administration (FAA) second-class medical certificate on October 24, 2000, with no limitations. He was a First Lieutenant in the Civil Air Patrol's, (CAP) North Carolina Unit 137. A review of his pilot logbook revealed his last biennial flight review required by 14 FAR 61.56 occurred on May 15, 2001. He logged a total time of approximately 577 hours, of which 294 were in the accident make and model airplane. Of the 577 total time logged, 552 hours were as pilot-in-command. His logbook reflected he received his first CAP pilot checkout in March 1997. He had completed the CAP Cannabis Detection Course in May 1997, in the Cessna 172 type aircraft. CAP records revealed his most recent CAP flight check occurred on February 22, 2002; and was flown in a Cessna 182R airplane.
The second-in-command and right seat occupant, age 46, was a Captain in the CAP's North Carolina Unit 153, and was the holder of a commercial pilot certificate with airplane single engine land, rotorcraft helicopter, and instrument airplane ratings. His was issued a FAA second class medical certificate on October 7, 2001, with no imitations. Examination of CAP flight records for the pilot showed his most recent biennial flight review required by 14 FAR 61.56 occurred on February 8, 2002.
The observer, seated in the rear seat was not a licensed pilot and was on his first drug spotting mission which he volunteered for. He was a deputy with the Chowan County Sheriff's office.
AIRCRAFT INFORMATION
The airplane was manufactured in 2001, as a Cessna model 172S, serial number 172S8916, and was certificated in the normal and utility categories. At the time of manufacture, the airplane was equipped with a Textron Lycoming IO-360-L2A, 180-horsepower engine, and a McCauley 1A170E/JHA7660 fixed pitch propeller.
The airplane was last inspected on May 31, 2002, in accordance with an annual inspection, at a recorded tachometer time and aircraft total time of 299.1 hours. The airplane had accumulated approximately 74 hours since the inspection at the time of the accident.
METEOROLOGICAL INFORMATION
A METAR weather observation taken from the Elizabeth City Coast Guard Air Station/Regional Airport at 1454 hours (approximately 28 minutes before the accident) indicates the wind was variable at 3 knots, the visibility was 10 statute miles, clear skies existed, the temperature and dew point were 33 and 18 degrees Celsius, respectively, and the altimeter setting was 30.03 inHg. The accident site was located 24.7 nautical miles and 280 degrees from the airport.
WRECKAGE AND IMPACT INFORMATION
The airplane crashed into a cotton field during daylight hours behind a residence located at 644 Happy Home Road. The accident site was located at 36 degrees 15.390 minutes North latitude and 076 degrees 37.040 minutes West longitude, or about 16.0 nautical miles north of the departure airport.
Examination of the accident site revealed the airplane came to rest inverted on an easterly heading; all components necessary to sustain flight remained attached to the airplane. A ground scar measuring 23 feet in length with red colored lens was located just forward of the left wing nearly perpendicular to the longitudinal axis of the airplane. Another ground scar was located near the engine which remained attached to the airframe. The engine, engine mount, and engine cowling were crushed rearward. Chordwise crushing was noted to the leading edges of both wings; the left wing was partly detached at the wing root and was displaced aft. The right wing was also displaced aft; the inboard corner of the right wing flap penetrated the fuselage. The only damage to the empennage was slight impact bending of the tip of the vertical stabilizer. No evidence of preimpact failure or malfunction was noted to the flight control system for roll, pitch, or yaw. The flap selector and actuator were found positioned and extended 10 degrees, respectively. The right cockpit door was separated but found in close proximity to the main wreckage. The elevator trim tab was found positioned 10 degrees trailing edge tab up. Examination of the fuel system revealed the right fuel tank was not compromised, while the left fuel tank and the header tank were compromised. No fuel was noted in the fuel gascolator, while 1/2 teaspoon of fuel was noted in the inlet area of the fuel injection servo. Examination of the engine revealed the throttle and mixture controls at the partially separated fuel injection servo were full open and full rich, respectively.
Examination of the cockpit revealed the fuel selector was positioned to the "both" position. The auxiliary fuel pump switch was in the "off" position; impact damage to the switch assembly was noted. The fuel flow gauge was indicating 8.0 gallons-per-hour. The throttle and mixture controls were "full-in."
Examination of the engine revealed crankshaft, camshaft, and valve train continuity. Suction and compression was noted in all cylinders with rotation of the crankshaft. The right magneto which remained securely attached to the accessory case was noted to produce spark at all ignition leads with hand rotation of the crankshaft. Impact damage to the flange of the left magneto was noted; rotation of the magneto drive shaft by hand was noted to produce spark at all ignition towers. The oil suction and fuel injector screens were clean. The engine-driven fuel pump mount arm and flange were broken; a trace amount of 100 low-lead fuel was found in the flow valve chambers of the pump.
Examination of the fixed pitch propeller revealed both blades were bent aft to varying degrees and both exhibited chordwise scratches on the cambered side of the blade. Also, both exhibited minor nicks on the leading edges.
MEDICAL AND PATHOLOGICAL INFORMATION
Postmortem examinations of the pilot, copilot, and rear seat occupant were performed by the Chapel Hill, North Carolina, medical examiner's office. The cause of death for all was related to blunt force injuries.
Toxicological analysis of specimens of the pilot and copilot were performed by the FAA Toxicology and Accident Research Laboratory, located in Oklahoma City, Oklahoma. The results of analysis of specimens of both were negative for carbon monoxide, cyanide, ethanol, and tested drugs.
TEST AND RESEARCH
Examination and bench testing of the fuel injection servo (servo), fuel injector nozzles, fuel injector lines, and flow divider was performed with NTSB oversight at a FAA certified repair station. Examination of the servo revealed it had impact damage and the mixture control shaft and the throttle control lever were bent to varying degrees, and the throttle stop bushing was missing. Additionally, the idle adjustment screw was found backed out. Bench testing of the servo as received revealed the fuel flow in terms of pounds-per-hour was greater than the specified service limits; however, fuel flow was noted from idle to full throttle. The impact damaged mixture control shaft was removed and replaced, and a replacement throttle stop bushing was installed. With the throttle positioned to the idle position and the replacement throttle stop bushing installed, the throttle valve was contacting servo bore (.006 inch clearance required). The servo was then bench tested which revealed no discrepancies related to fuel flow at any position above the idle position. Visual examination of the flow divider revealed the manufacturer's part number "2576556-1", and serial number "0248722", were vibro peened onto the unit. The engine manufacturer's assembly number "63B22997-Assy" was also vibro peened onto the unit. The cover was safety wired with no lead seal noted. Bench testing of the flow divider revealed the unit opened at 2.0 psi, and was noted to operate normally. Disassembly of the flow divider after testing revealed no evidence of contamination; the spring was not failed and the measured free length of the spring was less than .750 inch. Bench testing of all four fuel injector nozzles revealed a correct spray pattern. No obstructions of the fuel injector lines were noted.
Review of the airplane maintenance records revealed no evidence that the flow divider had been removed, replaced, or overhauled. Further, there were no recorded engine related discrepancies on the "Aircraft Discrepancy Report" sheet for the accident airplane. The sheet contained 7 entries, with the first recorded date of November 13, 2001, and the last recorded date of May 5, 2002.
According to a representative of the manufacturer of the flow divider (Precision Airmotive Corporation), it was manufactured with a 2.0 pound spring as required by the flow divider part number 2576556-1. The spring installed in the accident flow divider at the time of the accident was a 2.0 pound spring based on the measured free length. Additionally, the safety wire pattern on the cover was consistent with that of the pattern used during manufacturing. The representative of the manufacturer of the flow divider further reported that a lead seal is not used during safety wiring of the cover.
At the time of manufacture of the accident engine, the required flow divider was Lycoming assembly number "63B22997", which equates to a Precision Airmotive Corporation part number "2576556-1."
One emergency medical technician who was on the scene within minutes of the crash, reported a stream of fuel the size of a finger leaking from the left wing root area; the stream of fuel was noted to last an estimated 15-20 minutes. Most other responders stated they smelled no strong smell of fuel within minutes of arriving at the wreckage. Additionally, the Civil Air Patrol party to the investigation member stated he visited the scene after the investigative team had departed and reported seeing chemically burned crop. He also reported digging into the soil in the area where the airplane had come to rest and smelling the odor of fuel in the dirt he extracted.
Fuel consumptions calculations indicate that based on witness accounts pertaining to takeoff and landing times, fueling information, and the number of flights performed, the airplane was estimated to have approximately 15.3 gallons of fuel on-board at the time of the accident.
ADDITIONAL INFORMATION
The airplane minus the retained fuel injection servo, fuel injector nozzles, fuel injector lines, flow divider, laminated passenger briefing card, Civil Air Patrol (CAP) checklist, Cessna laminated "Pilot's Checklist", and Jeppesen Low altitude IFR chart was released to Gary K. Woodsmall of the Civil Air Patrol on July 19, 2002. The retained components were released to Gary K. Woodsmall, on August 20, 2004




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This was a tragedy for the CAP members involved and their families. One thing that struck me about this crash was they were flying at an average altitude of 400 feet, sometimes even going below 300 feet off the deck.  At that low altitude in slow flight, you do not have much time to prepare yourself for an emergency landing if your engine suddenly fails. Are Counterdrug flights still going on?

Eclipse

#1
Quote from: Cindi on February 19, 2014, 07:57:57 PMOne thing that struck me about this crash was they were flying at an average altitude of 400 feet, sometimes even going below 300 feet off the deck.

Unless the ROE is different for CD flights, they were in serious violation of CAP regs (at least as they are written today) and common sense.

CAPR 60-1, Page 8
"e. Sustained flight below an altitude or lateral distance from any object of 1,000 ft during
the day or 2,000 ft at night is prohibited except for take-off and landing or in compliance with air
traffic control (ATC) procedures (such as IFR flight). At no time will the pilot allow the aircraft
to come within 500 feet of terrain or obstructions unless taking off or landing."


Are Counterdrug flights still going on? Yes, of course.

When tasked to do so, CAP provides information - how it is acted upon is not our concern, and the nature of the
missions we fly do not lend themselves, in any way, to this sort of mistake.

"That Others May Zoom"

Cindi

#2
Quote from: Eclipse on February 19, 2014, 08:24:20 PM
Quote from: Cindi on February 19, 2014, 07:57:57 PMOne thing that struck me about this crash was they were flying at an average altitude of 400 feet, sometimes even going below 300 feet off the deck.

Unless the ROE is different for CD flights, they were in serious violation of CAP regs (at least as they are written today) and common sense.

CAPR 60-1, Page 8
"e. Sustained flight below an altitude or lateral distance from any object of 1,000 ft during
the day or 2,000 ft at night is prohibited except for take-off and landing or in compliance with air
traffic control (ATC) procedures (such as IFR flight). At no time will the pilot allow the aircraft
to come within 500 feet of terrain or obstructions unless taking off or landing."


Are Counterdrug flights still going on? Yes, of course.

When tasked to do so, CAP provides information - how it is acted upon is not our concern, and the nature of the
missions we fly do not lend themselves, in any way, to this sort of mistake.

Thank you for the information. As an aside, there was mediation regarding this accident that was settled in February 2008 according to Comerford & Britt, LLP, Attorneys at Law:

"Aviation Accident / Wrongful Death

A 38 year-old police officer was piloting a volunteer Civil Air Patrol marijuana detection mission in the eastern part of North Carolina when his engine suddenly quit. The engine would not restart and the plane crashed in a cotton field, killing the pilot and two passengers instantly. The mission required low and slow flight on an extremely hot day in July, 2002. Unknown to the pilot, a husband and father of two children, the type of engine installed in the single engine propeller airplane had a history of sputtering and then quitting when operated at low RPM in hot weather. The condition caused vapor to fill the engine's fuel lines. The vapor, in turn, starved the engine of necessary air and prevented the engine from restarting in flight. The anonymous Plaintiff settled the case with the anonymous engine manufacturer, aircraft manufacturer, and component manufacturer after mediation in February, 2008."

Eclipse

An aircraft of that type should not be flown in those conditions at all, so other then the abstract of
using common sense and good pilotage, not sure what lessons to be learned.

More then likely the settlement was cheaper then litigation and was a "deep-pocket" search.

"That Others May Zoom"

RiverAux

No one is going to get a warrant based on a CAP sighting due to the way such sightings are reported (or at least the way we were instructed to do things the last time I got training).  So, CAP doesn't need to worry about it and seeing as how there hasn't been a problem in 30 years.....

Cindi

Quote from: RiverAux on February 19, 2014, 10:05:03 PM
No one is going to get a warrant based on a CAP sighting due to the way such sightings are reported (or at least the way we were instructed to do things the last time I got training).  So, CAP doesn't need to worry about it and seeing as how there hasn't been a problem in 30 years.....
That's good to know. I wish the mission pilot had known about how the engine acted running low RPMs in hot weather. Civil Air Patrol is not law enforcement but I remember back in 1970 as a cadet being issued a badge (I believe it was Deputy Sheriff) and wearing it on my flight jacket and driving a blue CAP jeep help doing crowd control at a Fourth of July event. I knew at the time that we should not of accepted the badges, but I enjoyed wearing it never the less. That same year, our squadron had 25 cadets go up in 25 antique airplanes that traveled to a Fly In Breakfast. It was our reward for helping park cars during their annual airshow. One of the planes was involved in a crash with another aircraft leaving the Fly In Breakfast killing a 14 year old cadet I had recruited (James Gillie Oppel 1955-1970). I doubt such an event would be permissible in the Civil Air Patrol today. Maybe we can't prevent all accidents, but we certainly can remember those that we have lost including the crew members on the last flight of N928CP. 

a2capt

Shortly after a Bushmaster 2000 (Ford Tri-Motor) crashed at an air show in Fullerton, (2004), an edict from CAWG came out saying that no CAP people could accept rides on aircraft at air shows.

.. apparently, they had offered cadets the opportunity to ride in said aircraft earlier in the day, and when CAP people witnessed the crash, there were concerns that cadets had been onboard.
The crash itself was due to a piss-poor pre-flight. Leaving a gust locking strap in place that was visible to the crowd as it flew overhead, out of control..

http://www.ntsb.gov/aviationquery/brief2.aspx?ev_id=20040929X01529&ntsbno=LAX04FA330&akey=1

Ford Tri motor crash

Probably had to change some pants in the tower that afternoon..

Cindi

#7
Quote from: a2capt on February 20, 2014, 12:29:09 AM
Shortly after a Bushmaster 2000 (Ford Tri-Motor) crashed at an air show in Fullerton, (2004), an edict from CAWG came out saying that no CAP people could accept rides on aircraft at air shows.

.. apparently, they had offered cadets the opportunity to ride in said aircraft earlier in the day, and when CAP people witnessed the crash, there were concerns that cadets had been onboard.
The crash itself was due to a piss-poor pre-flight. Leaving a gust locking strap in place that was visible to the crowd as it flew overhead, out of control..

http://www.ntsb.gov/aviationquery/brief2.aspx?ev_id=20040929X01529&ntsbno=LAX04FA330&akey=1

Ford Tri motor crash

Probably had to change some pants in the tower that afternoon..

Air shows and air races are dangerous not only for the pilots but also the bystanders on the ground. On September 16, 2011, at the Reno Air Races, a North American P-51D Mustang, named The Galloping Ghost, flown by James K. "Jimmy" Leeward crashed into spectators, killing the pilot and 10 people on the ground, and injuring 69 others. Some of the injured folks had to have their their limbs amputated. I won't show a video of the Galloping Ghost crashing into the crowd but it was a horrific site. I remember talking to Colonel Dion DeCamp briefly at an earlier Air Race that he was working. We talked about riding motorcycles. Unfortunately, Colonel Dion Ellsworth DeCamp himself died in the tragic crash of N881CP along with Colonel Edwin W. "Ed" Lewis, Jr. on November 8, 2007 near Las Vegas, Nevada. When Colonel DeCamp was leading the Steve Fossett search, his overriding concern was aircrew safety. Colonel DeCamp was an outstanding human being and a great wing commander. Sudden tragedy can happen to any of us on the ground or in the air; no one is immune.



Picture of N881CP at the Barron Hilton ranch airstrip during the Steve Fossett search

Mitchell 1969

Quote from: a2capt on February 20, 2014, 12:29:09 AM
Shortly after a Bushmaster 2000 (Ford Tri-Motor) crashed at an air show in Fullerton, (2004), an edict from CAWG came out saying that no CAP people could accept rides on aircraft at air shows.

.. apparently, they had offered cadets the opportunity to ride in said aircraft earlier in the day, and when CAP people witnessed the crash, there were concerns that cadets had been onboard.
The crash itself was due to a piss-poor pre-flight. Leaving a gust locking strap in place that was visible to the crowd as it flew overhead, out of control..

http://www.ntsb.gov/aviationquery/brief2.aspx?ev_id=20040929X01529&ntsbno=LAX04FA330&akey=1

Ford Tri motor crash

Probably had to change some pants in the tower that afternoon..

My one and only ride on a Tri-Motor was in 1968, end of air show "Send all the cadets down for a quick trip around the pattern" offer.
_________________
Bernard J. Wilson, Major, CAP

Mitchell 1969; Earhart 1971; Eaker 1973. Cadet Flying Encampment, License, 1970. IACE New Zealand 1971; IACE Korea 1973.

CAP has been bery, bery good to me.

a2capt

The Reno Air race crash happened where some prior unit members would have probably been in the shrapnel range, as they typically attended and had floor seats in that area, but did not go that year. :|

..and that would be the Flying-M Ranch, owned by Barron Hilton :)

Eclipse

This is why it infuriates me when members treat operations, especially those involving aircraft in any way,
without the seriousness they deserve, or with a casual attitude of "I got this."

I'm as much an advocate of "Safety 3rd" as anyone.  CAP's check-box mentality is too much a swing in the wrong direction,
but for heaven's sake...

...we're putting our people in Yugos with garage doors stapled to them and pointing industrial salad shooters at them,
not the mention the 100 other ways people can get hurt between the bookends of "Watch this..." and "It seemed like a good idea at the time..."

Life has risk, helping people and being involved in aviation increases that from the general norm, that's a given,
but check twice and don't assume.

"That Others May Zoom"

Max Rockatansky

Quote from: Cindi on February 19, 2014, 07:57:57 PM
QuoteOn the pass that N928CP crashed, witnesses stated the aircraft was in a large clockwise orbit, and was noticeably lower than 300 to 500 feet agl. A sputtering noise was heard by one witness, and another stated there was no engine sound at all just before she observed the aircraft depart normal upright flight. From an altitude of about 120 to 150 feet agl, she saw the aircraft simultaneously nose over vertically and commence a right half roll into the terrain.

Non-pilot witnesses are notoriously unreliable.  "Sputtering noises" and "no engine sound" don't mean anything since pilots know we change power settings quite a bit during some operations.  Wind can carry away sound so that none is heard even if the engine is running at full power.

That part aside, even a non-pilot can recognize an aircraft nosing over at low altitude (although I'd question their ability to judge altitude) and a roll left or right.  As pilots, we know that is indicative of a stall.  If it was a stall, we can wonder why, but the results are the same tragic truth; the loss of three CAP volunteers.