2 fatalities

2 Feb 2011: POTEZ-AIR FOUGA CM 170 MAGISTER (N415FM) — Kissimmee, FL

Kissimmee, FL, United States

On 2 Feb 2011, a POTEZ-AIR FOUGA CM 170 MAGISTER (registration N415FM) was involved in an aviation accident near Kissimmee, FL. 2 people were killed. Investigators recorded the probable cause as: The pilot/mechanic's improper decision to continue a tight-turning landing pattern after a loss of hydraulic pressure, and his subsequent failure to maintain adequate airspeed during that pattern, which resulted in an accelerated maneuver stall. This summary draws on records from NTSB.

SourcesNTSBPrimary reportUpdated 1778583330Data APIEditorial standards

On February 2, 2011, a Potez-Air Fouga CM 170 Magister (N415FM) was substantially damaged after impacting terrain during a traffic pattern approach to landing at Kissimmee Gateway Airport, Florida. The two commercial pilots on board were fatally injured. The flight was a local maintenance test flight following hydraulic leak repairs.

History of Flight

On February 2, 2011, at approximately 1729 eastern standard time, a Potez-Air Fouga CM 170 Magister, registration N415FM, was substantially damaged when it struck terrain during a traffic pattern approach to landing at Kissimmee Gateway Airport (ISM), Kissimmee, Florida. The two certificated commercial pilots—the owner and a mechanic—were fatally injured. Visual meteorological conditions prevailed, and the flight was conducted under 14 Code of Federal Regulations Part 91 as a local maintenance test flight without a flight plan.

According to a work order, the flight followed repairs of multiple hydraulic leaks. Air traffic control transcripts and radar data were combined to reconstruct events. The pilot identified as the pilot/mechanic (based on voice recognition by a close friend) handled all radio communications. After taxi and takeoff from runway 24, the airplane flew southwest, maneuvered for about four minutes, then returned. The pilot reported a good check and requested landing. The controller cleared the airplane for a left break landing. Radar showed the airplane entered a left break from an overhead position. The pilot reported "three green" (landing gear down and locked) at 1728:35, after which no further transmissions were received. Radar data showed the airplane climbing briefly after the break, then descending. The last radar position was 2,700 feet from the runway threshold at 202 knots groundspeed. Witnesses observed the airplane in steep banks, pitching up, then losing altitude and impacting short of the runway.

Personnel Information

The pilot/mechanic, age 53, held a commercial pilot certificate with single-engine land, multi-engine land, and instrument ratings, plus FAA authorization for eight military aircraft including the CM 170. He also held an airframe and powerplants mechanic certificate with inspection authorization. His most recent second-class medical was issued September 9, 2010, reporting 8,300 total flight hours. Family members declined to provide his logbook despite requests.

The pilot/owner, age 61, held a commercial pilot certificate with single-engine land, multi-engine land, single-engine sea, multi-engine sea, and instrument ratings, and an FAA authorization for the CM 170. He also held a flight instructor certificate. His most recent second-class medical was issued January 9, 2009, reporting 1,500 total flight hours. His logbook could not be located.

Both pilots were ejected from the airplane; cockpit seat positions could not be determined from available evidence.

Aircraft Information

The CM 170 Magister, serial number 415, was manufactured in 1963 and registered to the pilot/owner in 2000. It was not equipped with an angle of attack indicator. The airplane was powered by two Turbomeca Marbore IIC turbojet engines. A fuel sample from the trailer-mounted bowser used by the pilot/owner was consistent with off-road diesel fuel, clear and absent of debris.

A discrepancy sheet found in the pilot/mechanic's truck listed ten items, including hydraulic leaks and a test flight.

Airport Information

Runway 24 at Kissimmee Gateway Airport is 5,001 feet long and 150 feet wide, with a magnetic heading of 243 degrees. Field elevation is 82 feet.

Meteorological Information

Weather at 1739: wind 240 degrees true at 3 knots, scattered clouds at 4,500 feet, visibility 10 statute miles, temperature 25°C, dew point 19°C, altimeter 30.11 inHg. The sun was 6.1 degrees above the horizon with an azimuth of 247.4 degrees.

Wreckage and Impact Information

The initial ground scar was in an open field at 28°17.79'N, 081°25.57'W, about 1,750 feet from runway 24 threshold at 060 degrees. Ground scars continued for about 175 feet on a heading of 225 degrees to the main wreckage. Red paint chips matching the wing tip tanks were found. A shallow impact crater contained a piece of windshield. Heavy debris including separated main landing gear was on the right side of the debris path.

The main wreckage comprised three sections: inverted cockpit, inverted tail, and center section with a relatively intact right wing and partial left wing. The outboard half of the left wing was separated. Crush damage indicated impact at 40-45 degrees left-wing down; the rear cockpit attitude indicator was jammed at 45 degrees left-wing down, 5 degrees nose-down.

All flight controls were present; continuity could not be confirmed due to damage. Landing gear levers were down; damage was consistent with gear extended at impact. Emergency airbrake selector was in "out" position; left airbrakes stowed, right airbrakes extended about 1 inch. Flap toggle switch centered; front cockpit flap gauge indicated 15 degrees, rear 20 degrees. Left wing flaps separated; right wing flaps full up.

Engine instruments: front cockpit showed right engine 19,200 rpm, left engine 7,500 rpm; rear cockpit showed about 9,500 rpm for both. Neither engine exhibited catastrophic failure. The left engine had compressor blade nicks but spool rotated freely. The right engine showed ingestion of sand and grass, with spool rotation difficult due to debris.

Medical and Pathological Information

Autopsies listed cause of death for both pilots as multiple traumatic injuries. Toxicological testing found no anomalies for the pilot/mechanic; for the pilot/owner, hydrochlorothiazide and salicylamide were detected in blood and urine, and valsartan in blood.

Additional Information

Excerpts from the Fouga CM 170 Crew Manual describe the hydraulic system, landing gear, flaps, airbrakes, aileron servo control, and emergency procedures. The manual notes that in a turn, stall features a sharp rolling movement preceded by light buffeting. It also details procedures for landing gear emergency extension, airbrake emergency operation, and flap-up landing patterns. An FAA handbook describes accelerated maneuver stalls, noting they occur at higher airspeeds and may be unexpected.

Contributing factors

Causes

PilotAirspeed — Not attained/maintained

Other contributing factors

Hydraulic power system