N9196EMaule M-5-235C · 1977

On April 18, 2010, about 1915 eastern daylight time, a Maule M-5-235C, N9196E, operated by AirSign Inc. was substantially damaged when it impacted terrain after a loss of control during initial climb, from Orlando North Airpark (FA83), Zellwood, Florida. The certificated commercial pilot was fatally injured. Visual meteorological conditions prevailed for the flight destined for Dunnellon/Marion County Airport (X35), Dunnellon, Florida. A visual flight rules (VFR) flight plan was filed for the positioning flight conducted under Title 14 Code of Federal Regulations Part 91.

According to Air Sign Inc., the pilot of the accident airplane had flown a "banner towing job", over the Shingle Creek Golf Club in Orlando, Florida on the morning of the accident and was scheduled to fly another banner tow flight over the same golf course at approximately 1800 that evening. The operator cancelled the flight due to rain in the area. The pilot then advised the operator that he would therefore return to X35.

According to witnesses, at the time of the accident light rain was falling at FA83. After doing an engine runup, the pilot taxied on to the runway, and commenced his takeoff roll to the west. The airplane lifted off approximately 1/3 of the length down the runway. After liftoff, one witness thought she heard a "pop, pop", and the airplane immediately turned approximately 40 degrees to the right in the approximate direction of X35, which one witness stated was the pilot's usual practice. What appeared to one witness to be a thin trail of dark gray smoke, and to another witness as a larger amount of black smoke, was observed trailing from the airplane. The airplane then reached a height of approximately 60 feet above ground level, leveled off, and the smoke stopped. Upon approaching a tree line which ran perpendicular to the right side of the runway, the airplane was observed to climb. The airplane cleared the trees by approximately 50 feet turned to the west, rolled rapidly to the left, pitched nose down, and impacted the ground. Total flight time was approximately 15 seconds.

According to FAA and pilot records, the pilot held a commercial pilot certificate with ratings for airplane single-engine-land, multi-engine-land, and instrument airplane. He also held an airframe and powerplant mechanic certificate. The pilot had accrued approximately 673 total hours of flight experience. His most recent application for a FAA first-class medical certificate was on February 16, 2010.

The accident airplane was a steel-tube and fabric high-wing braced-monoplane with a cantilever tailplane with a single fin and rudder. It had a fixed-tailwheel landing gear, was equipped for banner towing operations, and was powered by a 235 horsepower Lycoming O-540-J1A5D engine.

The airplane had been involved in a previous accident on April 13, 1979, after accruing 1,326 total hours, when the airplane nosed over during landing in Lord Flat, Oregon. During the accident the airplane received substantial damage which required, replacement of the vertical stabilizer, rudder, both wings, both ailerons, both wing flaps, and the lift struts.

The airplane was donated to the owner specifically so the pilot could build flight time, and gain experience maintaining the airplane, to prepare him to become a missionary pilot.

According to Federal Aviation Administration (FAA) and airplane maintenance records, the airplane was manufactured in 1977. The airplane's most recent 100 hour inspection was completed on March 23, 2010. At the time of the inspection, it had accumulated 2,838.2 total hours of operation. The engine had accumulated 137 hours of operation since major overhaul.

A weather observation taken about 25 minutes prior to the accident, at Leesburg International Airport (LEE), located approximately 10 nautical miles northwest of the accident site included; wind at 160 degrees at 5 knots, visibility 10 miles, light rain, broken clouds at 7,000 feet, overcast at 8,500 feet, temperature 19 degrees C, Dew point 16 degrees C, and an altimeter setting of 29.91 inches of mercury.

According to the FAA's Airport Master Record, FA83 had one runway oriented in a 09/27 configuration. Runway 27 was asphalt and in good condition. The total length of the runway was 2,577 feet, and its width was 50 feet.

Obstructions existed on both sides of the departure end of runway 27. These included two rows of trees that ran perpendicular to the runway on both the north and south sides of the runway. A clear area (cabbage field) existed directly off the departure end of the runway.

The airplane came to rest in the cabbage field. Examination of the wreckage revealed that a postcrash fire had occurred. The fabric covering had burned away, and the tubular structure was exposed. The wreckage and ground scarring exhibited evidence that the airplane had been rotating about the longitudinal axis during impact. No evidence of any preimpact structural failure was discovered.

No preimpact failures or malfunctions of the primary or secondary flight controls were identified. Examination of the flight control system revealed impact damage and multiple separations of the cables that made up the system. The breaks in the flight control system were consistent with overload, and control continuity was confirmed from the ailerons, elevators, and rudder to the cockpit area. Continuity could not be established to the control yokes or rudder pedals due to fragmentation and crush damage.

Examination of the remains of the cockpit revealed that the instrument panel was heavily damaged due to the post impact fire. The magneto switch was in the "both" position, the mixture control was in the full rich position, and the propeller control was set to high RPM. The carburetor heat knob was in the off position. Further examination also revealed that the vertical speed indicator indicated an approximate 2,100 foot per minute rate of descent.

The airplane was equipped with a 2-blade, constant speed propeller. Examination of the propeller revealed that the pitch control mechanism was intact and the propeller blades had remained attached to their hubs. Both blades exhibited impact damage and chordwise scratching. One blade was bent back approximately 45 degrees at the 3/4 span position, and approximately 4 inches of its blade tip was missing. The other blade exhibited S-bending.

The propeller governor was still attached to the engine and it exhibited fire damage. Its drive shaft and coupling were intact. Examination of its casket screen revealed that it was clean and free of debris.

The engine was partially separated from its mounts. Examination of the engine revealed that the lower front section of the engine had sustained impact damage and the rear accessory section had been crushed against the airplanes firewall. The left rear engine cylinder had sustained impact damage to its pushrods. Fire damage was present throughout the engine; however the severity of fire damage was more severe on the left side of the engine. Oil was found to be present internally. A lighted borescope was used to examine the engine's internal top end components and no preimpact anomalies were revealed. Removal of the Nos. 2, 4, and 6, cylinders, and their respective valve assemblies was necessitated due to the fire damage so that a visual examination could be accomplished. Visual examination revealed that the parts most affected by the fire were the rocker arm bushings and valve guides. However, no evidence of lack of lubrication, unusual or excessive wear, or broken parts was discovered. The crankshaft was then rotated by hand, and no binding was noted. Internal gear, cam, and valve train continuity was confirmed. All of the cylinders on the right side of the engine (Nos. 1, 3, and 5.), which were unaffected by fire damage, produced compression.

The oil cooler was impact and fire damaged. Visual examination did not reveal any evidence of preimpact abnormalities or leakage. The oil suction screen and oil filter element were both clean.

The dual magneto ignition unit exhibited impact and fire damage and could not be tested. Visual examination revealed no evidence of preimpact malfunction and that the steel drive gears and drive coupling were still intact. All sparkplugs were removed for examination. Their electrodes were light gray in color.

Examination of the intake system revealed no blockages or debris. Examination of the exhaust system revealed that it was impact damaged. It exhibited multiple breaks, and fragmentation of the exhaust tubing. Further examination revealed that the interior of the tubing was light gray in color. No evidence of sooting or oil contamination was discovered inside the exhaust tubing.

Examination of the fuel system revealed no evidence of preimpact malfunction. All fuel filler caps were closed and fastened securely.

Examination of the carburetor did not reveal any evidence of preimpact failure or malfunction. The throttle plate was found to be full open and the throttle arm was in the full throttle position. Its fuel inlet screen was clean and free of debris. Internal examination revealed that it was fire damaged. Its plastic float was melted and the needle valve was heat damaged. The main fuel nozzle and internal passages were clear and free from obstructions.

The steel mechanical parts of the fuel pump were recovered intact and did not exhibit any evidence of preimpact failure or malfunction.

Fuel samples obtained from the fixed base operator where the airplane was fueled prior to the accident appeared to be bright, clear, and exhibited no visible contamination. When the fuel samples were applied to coupons containing water-finding paste, the paste did not change color, indicating that water was not present.

An autopsy was performed on the pilot by the State of Florida, District 5, Medical Examiner. The cause of death was multiple blunt force injuries.

Toxicological testing of the pilot was conducted at the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens were negative for carbon monoxide, cyanide, basic, acidic, and neutral drugs, with the exception of Naproxen, which is a nonsteroidal anti-inflammatory drug commonly used for the reduction of pain, fever, and inflammation.

Witnesses reported that they had observed smoke coming from the airplane during the takeoff which was reported as black or gray smoke and one of the witnesses thought that she may have heard a " pop, pop" when the airplane lifted off. Review of the Lycoming Operator's Manual revealed that black smoke could be caused by an overly rich mixture and gray smoke could be caused by burning oil. Inlet charge combustion (backfiring) could also be caused by an overly rich mixture. Examination of the engine however did not reveal any indication of sooty deposits on the spark plugs, nor was there any indication of sooty or black moist deposits in the exhaust pipe.

Review of maintenance records did not reveal any entries regarding adjustment of the fuel air mixture or excessive oil consumption. During the 100 hour inspection which occurred on March 23, 2010, the pilot conducted an oil change. Also, during a routine inspection by the pilot he discovered that the oil cooler had separated from its mounts. On April 2, 2010 (16 days before the accident), the oil cooler was replaced.

Overheating

According to the pilot's blog on his website, earlier in the month he had attempted to tow a 50 foot by 100 foot advertising banner. He reported that he was able to pick up the banner without a problem but the airplane was unable to climb properly and his cylinder head temperature began to rise dramatically,

As a result, during the examination of the engine, in addition to other failure modes, investigators looked for evidence of damage from overheating such as oxidized oil, varnish, darkening of the pistons, carbon buildup around the piston pins, scuffing of the cylinder barrels, dark burn lines down the outside of the cylinder barrels between the fins, darkening of the paint on the outside of the barrels, fading of the nitride stripes on the barrels, blistering of the barrels, and blueing of the cylinder barrels. Examination of the engine revealed however only evidence of thermal damage from the post impact fire.

In order to improve safety, AirSign Inc. issued Safety Memorandum 06-29-2010 requiring its pilots to:

1. Follow all standard traffic pattern procedures as published in the AIM.

2. Not depart the runway centerline until clear of the runway end with the airplane above 500 feet above ground level.

3. Not to attempt a banner pickup on the takeoff departure leg.