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CEN14FA265
TheNationalTransportationSafetyBoarddeterminestheprobablecause(s)ofthisaccidentasfollows:
Thepilotslossofcontrolandsubsequentaerodynamicstallduetospatialdisorientationinnightinstrumentmeteorologicalconditions.Contributingtothe
accidentwasthepilotsdistractionduetohiscellphoneusewhilemaneuveringatlowaltitude.
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travel.Theleftaileroncontrolcablewascontinuousfromtheyoketotherespectivebellcrank.Therightaileronactuationcableseparatedintensionoverloadattheright
wingroot.Theaileroncarrythroughcablewasseparatedintensionoverloadattherightwingroot.Theelevatorandruddercableswerecontinuousfromthecontrol
yokeandtherudderpedalstotherespectivecontrolsurfaces.Theelevatortrimsettingwasnearneutral.Thetrimwheelchainwasoffthetrimwheelinthecockpit.The
fueltankscontainedseveralgallonsoffuel.Neitherfueltankwasbreachedduringtheaccidentsequence.Thefuelcapswereinplaceandthechainlanyardswere
attachedtothecaps.ThefuelselectorvalvewasinanintermediatepositionbetweenOFFandON.Thefuelstrainerbowlwasfracturedandthescreencontained
minimaldebris.Therightmainlandinggearremainedattachedtotheairframe.Theleftmainlandinggearandthenoselandinggearseparatedandexhibitedimpact
damage.Thepitottubewasintactandremainedattachedtotheleftwing.Theleftseatseparatedfromtheseatrailsandwasoutsidethefuselage.Therightseat
remainedattachedtotheseatrails.Thelapbeltsremainedlatchedandseparatedfromthefuselage.Theonlyseatbeltthatremainedattachedtothefuselagewasthe
rightseatsoutboardbeltsection.Theaftfuselageseparatedfromtheforwardfuselageattheaftcabinarea.Thetailconewasbentandtwistedtotheleft.The
emergencylocatortransmitter(ELT)wasfoundinthearmedpositionandremainedattachedtotheantenna.NoreportsofELTtransmissionswerereported.The
tachometerread7,062.85hours.
Thecrankshaftdisplayedcracksconsistentwithimpactdamage.Ahandtoolwasusedtorotatethepropellerflange.Continuitywasestablishedbetweenthecrankshaft,
camshaftandassociateddrivetraincomponents.Thetopsparkplugswereremovedandallfourcylindersproducedcompressionandsuctionwhenthecrankshaftwas
rotatedbyhand.Allfourcylinderswereexaminedusingaborescopeandeachdisplayednormaloperatingsignatures.Thebottomsparkplugswereremovedandeach
displayednormaloperatingsignatures.Bothmagnetoswereactuatedwhenthecrankshaftwasrotatedbyhandandalloftheterminalsproducedaspark.Theoilsump
wasimpactdamagedandbreached.Theoilfilterwasremovedfromtheengineandcutopennometalcontaminantswerefoundinside.Thecarburetorbrokefreefrom
theintakesystemandsustainedimpactdamage.Themixturecontrolarmbrokefreefromthecarburetorandthethrottlecontrolcablerodendsbrokefreefromtherestof
thecontrolcable.Thethrottlemovedfreelywhenactuatedbyhand.Thecarburetorwasdisassembled.Thefuelinletscreenwasfreeofcontaminantsandallinternal
componentsdisplayednormaloperatingsignatures.Thevacuumpumpbrokefreefromtheengineandaportionofthecrankcaseremainedattachedtoit.Thevacuum
pumpdriveshaftwasintact.Theshaftwasrotatedandexhibitedsomeresistance,butwasabletoberotatedbyhandandpumpedresidualoil.Thevacuumpumpwas
disassembledandrevealednormaloperatingsignatures.
Thepropellerremainedattachedtothepropellerflange.Thefirstbladewasmostlystraightwithminortwistingdeformation.Thesecondblade,whichwasbentaftand
underthewreckage,displayedtwistingdeformationandthecamberedsidedisplayedpolishing.
MEDICALANDPATHOLOGICALINFORMATION
AnautopsywasperformedonthepilotattheAdamsCountyCoroner'sOffice,Brighton,Colorado,onJune2,2014.Thecauseofdeathwasmultiplefracturesand
internalinjuriesduetoblunttraumaandthemannerofdeathwaslistedasanaccident.TheFAACivilAerospaceMedicalInstitutecompletedaFinalForensic
ToxicologyFatalAccidentReport,whichwasnegativeandnotestedfordrugsweredetected.
ADDITIONALINFORMATION
14CFRPart91.155BasicVFRWeatherMinimums
Theregulationstates,"Exceptasprovidedinparagraph(b)ofthissectionandSec.91.157,nopersonmayoperateanaircraftunderVFRwhentheflightvisibilityisless,
oratadistancefromcloudsthatisless,thatthatprescribedforthecorrespondingaltitudeandclassofairspace."
(b)ClassGAirspace.Notwithstandingtheprovisionsofparagraph(a)ofthissection,thefollowingoperationsmaybeconductedinClassGairspacebelow1,200feet
abovethesurface:
(2)Airplane,poweredparachute,orweightshiftcontrolaircraft..Ifthevisibilityislessthan3statutemilesbutnotlessthan1statutemileduringnighthoursandyouare
operatinginanairporttrafficpatternwithinonehalfmileoftherunway,youmayoperateanairplane,poweredparachute,orweightshiftcontrolaircraftclearofclouds.
ClassGdistancefromcloudnightminimumswerelistedas:3statutemilesvisibility,500feetbelow,1,000feetabove,and2,000feethorizontal.
14CFRPart61.57Recentflightexperience:Pilotincommand
(b)Nighttakeoffandlandingexperience.(1)Exceptasprovidedinparagraph(e)ofthissection,nopersonmayactaspilotincommandofanaircraftcarrying
passengersduringtheperiodbeginning1houraftersunsetandending1hourbeforesunrise,unlesswithinthepreceding90daysthatpersonhasmadeatleastthree
takeoffsandthreelandingstoafullstopduringtheperiodbeginning1houraftersunsetandending1hourbeforesunrise,and
(i)Thatpersonactedassolemanipulatoroftheflightcontrolsand
(ii)Therequiredtakeoffsandlandingswereperformedinanaircraftofthesamecategory,class,andtype(ifatyperatingisrequired).
(c)Instrumentexperience.Exceptasprovidedinparagraph(e)ofthissection,apersonmayactaspilotincommandunderIFRorweatherconditionslessthanthe
minimumsprescribedforVFRonlyif:
(1)Useofanairplane,poweredlift,helicopter,orairshipformaintaininginstrumentexperience.Withinthe6calendarmonthsprecedingthemonthoftheflight,that
personperformedandloggedatleastthefollowingtasksanditerationsinanairplane,poweredlift,helicopter,orairship,asappropriate,fortheinstrumentrating
privilegestobemaintainedinactualweatherconditions,orundersimulatedconditionsusingaviewlimitingdevicethatinvolveshavingperformedthefollowing
(i)Sixinstrumentapproaches.
(ii)Holdingproceduresandtasks.
(iii)Interceptingandtrackingcoursesthroughtheuseofnavigationalelectronicsystems.
TETSANDRESEARCH
OnboardImageRecorder(GoPro)Summary
GOPR0016.MP4Daylight
PilotandPassenger#1adjustandfastentheirseatbelts.Thepilotmadesomekeyboardentriestohiscellphoneandreachedtothebackcompartmentoftheairplane
tograbanotepad.Recordingends.
GOPR0017.MP4Daylight
TaxiingwithPassenger#1fromthepreviousfile.Theairplanetaxiedtowardanunknownrunwayviamultipletaxiways.Thepilotmaderadiocallsandattimes,
adjustmentstodevicesinthevicinityoftheinstrumentpanel.ThepilotandPassenger#1spokeinalanguageotherthanEnglish.Thepilotappearedtoperforman
enginerunupduringthetaxi.Later,theATCcontrolleraskedthepilotifhewantedtodoarunup.Thepilot'sresponseismuffledbytheenginenoiseontheaudiotrack
andhisactionsareconsistentwiththepilotindicatingthathesaidhehadalreadycompletedit.Thevideorecordingendsbeforethepilotreachestherunway.
GOPR0018.MP4Daylight
Videostartsattakeoffroll.ThepassengerisstillPassenger#1fromthepreviousvideofiles.Theairplanetookoffanditappearedthatthepilotflewalargerightpattern
fortheactiverunway.Thepilottookafewselfphotographsusingthecellphone,onbasenearfinalandpossiblyalsoonfinal.Thepilot'scellphonescreenisseenin
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cameramode.Passenger#1wasalsotakingselfphotographsandforwardfacingphotographswithhisowncellphoneforaboutthelasttwominutesofvideo.Thepilot
madeanuneventfullanding.Passenger#1appearedtobeginrecordingashortvideo.ThepilotclearedtherunwayandreceivedtaxiinstructionsfromATCandthe
videoends.
GOPR0019.MP4Daylight
Thevideobegannearthehangararea.Anewpassenger(Passenger#2)isseeninthecockpitwiththepilot.Thepilotdidnotappeartodoapretakeoffcheckinthe
timecapturedbythevideorecording.Thepilottaxiedtotherunwayandisclearedfortakeoff.Thepilotmadeanuneventfultakeoff.Passenger#2followsthepilot'sflight
controlmanipulationsonthecontrolyokeforthedurationoftheflightbutitappearedthatPassenger#2wasnotactivelymanipulatingthecontrols.Thepilotmadesome
slightnegativeGcontrolmovementsandPassenger#2wasentertained.Thepilottooksomeselfphotographsonwhatappearstobethedownwindleg.Thepilotmade
anuneventfullanding,taxiedbacktothehangarareaandpicksupanewpassenger(Passenger#3)withoutshuttingdowntheengine.Passenger#3fastenedtheir
seatbeltandputonaheadset.Passenger#3usedhiscellphonetotakemultipleselfphotographsduringtaxi.Thepilotlistenedtothetailendoftheairport'sautomatic
weatherrecording"InformationLima"andthenmadeaninputtoadeviceneartheinstrumentpanel.Thepilotappearedtomakesomekeyboardentriesonhiscell
phoneduringtaxi.Theuseofachecklistorpreflightcheckwasnotseenintherecording.TheairplanetookoffwhilePassenger#3appearedtoberecordingavideo
usinghiscellphone.ThepilotmovedPassenger#3'scellphoneoutofhislineofsightatonepoint.Later,thepilotcanbeseentakingselfphotographsduringtheclimb
outportionoftheflight.Passenger#3isusinghiscellphonetotakemoreselfphotographsduringtheflight.Thevideosegmentedtonewchapterrecording(nextfile,
GP010019.MP4)astheairplaneturnedtocrosswindleg.
GP010019.MP4,ContinuationofGP010019.MP4Daylight
Passenger#3continuedtousehiscellphonetotakeselfphotographsandwhatappearedtobeavideorecording.Thepilotcanbeseenmakingkeyboardentriesto
hiscellphoneduringportionsoftheflight.ThepilotconductssomemildandslightnegativeGmanipulationsofthecontrolyoke.Theairplanelandeduneventfullyand
thepilottaxiedbacktothehangararea,Passenger#3continuedtousehiscellphonetotakeselfphotographs.Thepilot'sassociatesandpreviouspassengerswalked
totheairplanetogreetPassenger#3.Thegroupusedtheircellphonestotakephotos.Passenger#4enteredthecockpitandthevideorecordingended.
GOPR0020.MP4Daylight
TherecordingbeganasthepilotandPassenger#4appearedtobebacktaxiingtoarunway.ThepilotwasclearedfortakeoffonRunway08andinstructedtomake
rightclosedtraffic.Thepilotperformedanuneventfultakeoff.Duringtheclimboutphase,thepilotwasseenmakingkeyboardentriestohiscellphoneandadditional
keyboardentriesonaportionofflightconsistentwiththedownwindleg.Duringthattime,thepilotmadethreedistinctandseparateinteractionswithhiscellphone.The
pilotperformedsomesmallwingrocksduringthedownwindleg.Passenger#4isseentakingselfphotographsandvideosthroughoutthelandingportionoftheflight.
Thepilottaxiedbacktothehangarareaandshutdowntheengineontheramp.AlanguageotherthanEnglishisheard.Thevideofileended.
GOPR0021.MP4Night
Videorecordingbeganatthehangararea.Anewpassenger,Passenger#5wasinthecockpitwiththepilot.Thepilot'sassociateswereseenstandingnearthehangar
behindtheairplane.Asoundsimilartothepilotpumpingtheairplane'sfuelprimerisheard.Thepilotstartedtheengine.ThefollowingATISrecordingwasheard
throughtheGoPro'sinternalmicrophone:
DenverFrontRangeAirportautomatedweatherobservationzerosixzerofive(0605)Zulu:weatherwindcalm,visibility[seven],ceilingthreehundred(300)overcast,
temperatureonefour(14)Celsiusdewpointonethree(13)altimeterthreezerotwozero(30.20).
Thepilottaxiedtoarunway.Itappearedthatthepilotconductedanenginerunupduringthetaxi.Thepilotwasseencheckingforfreedomofcontrolmovementinthe
controlyokeduringtaxi.Thepilotbeganthetakeoffrollanddepartedtherunway.Duringtheclimboutportionofflight,thepilotuseshiscellphonetotakeaself
photograph.Thecamera'sflashwasactivatedandilluminatedthecockpitarea.Thepilot'scellphoneappearedtobeonauserscreenconsistentwithacamera
application.Thepilotlandedandcanbeseenusinghiscellphoneduringthelandingrollout.Therecordingappearedtohaveendednormally.
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