NTSB Incident Report on the Mankovich Sonerai at Jeffersonville, IN (CHI96FA322)
NTSB Identification: CHI96FA322.
The docket is stored in the (offline) NTSB Imaging System.
Accident occurred AUG-30-96 at JEFFERSONVILLE, IN
Aircraft: Mankovich SONERAI, registration: N7037J
Injuries: 1 Fatal.
The pilot's airplane was #2 in a 4-airplane ferry formation of Formula V Class racing airplanes. The #3 pilot said that the #2 pilot's flying was erratic during the flight. "He had a hard time staying in position. He would fly ahead, then drop back." The witness said when they were within a mile of the landing airport, [the pilot] "pulled straight up, pulled left to the east at full power, then went into a slight descent." The witness said that he flew up along side of the pilot's airplane to try and get his attention. "I couldn't get his eye. He would not even look at me. I chased him about 5 miles before I lost sight of him. The last time I saw him, he was below 500 feet." Examination of the wreckage revealed that the adhesive resin which bound the rubber stripping forming the firewall lower seal was missing. The airplane had been involved in 2 earlier landing accidents, and had been repaired/inspected by pilots/mechanics of the racing association. The pilot/mechanic performed the annual inspection on 5/1/96. Two days before the accident flight the pilot said that he experienced smoke in the cockpit. He also said that the temperature was "185 degrees" and that he was very hot. The results of FAA toxicology specimens from the pilot revealed a carboxyhemoglobin saturation of 41.000 percent in the blood; loss of consciousness is attained at approximately 30.000 percent.
inadequate maintenance and inspection of the airplane by the pilot/owner and other airframe and powerplant mechanics, which failed to assure adequate sealing of the engine firewall, and led to the pilot's incapacitation due to carbon monoxide.
HISTORY OF FLIGHT
On August 30, 1996, at 1230 eastern daylight time (edt), a Mankovich Revenge, N7037J, operated by an airline transport pilot, was destroyed when during descent for landing, the airplane departed controlled flight. The airplane subsequently impacted in a corn field 4 miles northeast of Jeffersonville, Indiana. Visual meteorological conditions prevailed at the time of the accident. The business flight was part of a ferry formation to an airshow performance with three other Formula V class airplanes being conducted under 14 CFR Part 91. No flight plan was on file. The pilot sustained fatal injuries. The flight originated at Seymour, Indiana, at 1210 edt.
According to officials in the Formula V Air Racing Association, two days of practice and race familiarization flights for new Formula V air racing pilots were held at Freeman Municipal Airport, Seymour, Indiana, beginning on August 28, 1996. At the practice sessions, the pilot, a new Formula V air racing pilot, was to demonstrate competency in the maneuvers required by the Formula V Air Racing Association to compete in air races.
According to one witness who spoke to the pilot several times on August 28, 1996, the pilot said that he experienced smoke in the cockpit and had to cut short a qualifying flight where he was required to demonstrate 180-degree rolls to inverted flight, both to the left and right. He did not accomplish the maneuvers.
The pilot told the witness that there was a small hole in the firewall and with the help of some of the other air race pilots, he changed a hose. He also told the witness that the temperature in the cockpit was 185 degrees and that he was very hot.
The witness spoke to the pilot again on August 29, 1996. The pilot told the witness that during one of his practice flights, he ran out of fuel and had to perform a dead-stick landing on another runway. The pilot accomplished the landing without incident. The pilot again mentioned that the cockpit was extremely hot and that he was very uncomfortable.
A witness, who was the lead airplane in the formation flight said that prior to the flight, the four pilots held a pilot briefing and went over emergency procedures. They had planned the route of flight to follow Interstate 65 south to Clark County Municipal Airport, Jeffersonville, Indiana at 2,000 above ground level. "Our route was going to take us over Scottsburg airport, so if anyone had a problem, they could land there. It was half-way down." The witness said that they all refueled at Freeman Municipal Airport, Seymour, Indiana, prior to the flight and had plenty of fuel to make the flight. "We took off in a wide echelon. I gave [the pilot] big hand signals from the cockpit; we wanted to be spread out. We climbed out at 120 miles per hour, turned [south], and followed the interstate down." The witness said that the pilot's flying was erratic. "He [the pilot] passed me up, then fell back. When we got to Scottsburg, everything looked okay. I looked back, everyone was there. As we got to Clark County, I didn't see him. I didn't see [the pilot] pull up and away. I didn't even find out about the accident until I was on the ground."
A witness who flew in the formation flight as the number three airplane said that the pilot's flying along the route was erratic. He said that, "he had a hard time staying in position. He would fly ahead, then drop back." The witness said, "We were one mile north of the field, heading southbound, when [the pilot] pulled straight up, pulled left to the east at full power, then went into a slight descent." The witness said that he flew up along side of the pilot's airplane to try and get his attention. "I couldn't get his eye. He would not even look at me. I chased him about 5 miles before I lost sight of him. The last time I saw him, he was below 500 feet."
Another witness who flew in the formation flight as the number four airplane said that before they took off, the pilot expressed concern to the witness about his fuel. The witness said that he checked the pilot's airplane. "It [the fuel level] was halfway below the top where it should be, about 8 to 9 gallons." The witness said that they "took off around noon and headed south east until we intercepted the interstate." The witness said that during the first couple of minutes of the flight, the pilot made some altitude deviations. At the halfway point on the route, the witness said that he saw the pilot pull ahead, then return to the formation. The witness said that he only saw the pilot do this the one time. "As we got close to Clark County airport, we began to drift the formation further left toward the airport. As we were just getting to the airport, I saw a Sabreliner cross in front of us. He was a long way off and heading down in a big hurry. I knew he wasn't going to be a conflict. Just as I saw the Sabreliner ahead, [the pilot] pitched up sharply, about 30 degrees, and began a slow left turn followed by a gentle descent. He continued the descent until I lost sight of him. We went into the airport and landed. Five minutes after we landed, we found out that something had gone wrong."
The pilot held certificates as an airline transport pilot, a certified flight instructor in single and multi-engine instrument airplanes, and an airframe and powerplant mechanic. The pilot also held a Statement of Aerobatic Competency card and a certificate authorizing aerial pesticide application.
According to the pilot's logbook, the pilot had 8,831.6 total flying hours; 8,290.7 hours in single engine land airplanes; and 7,826.9 hours as a flight instructor.
The pilot's business partner said that when she spoke to the pilot the day prior to the accident, the pilot said that he had to bring his logbook up to date so that he could meet show requirements. This required putting flight time in his logbook.
According to the pilot's logbook and two witnesses, one who was the pilot's business partner, the pilot had logged approximately 4.0 total hours in the Revenge airplane.
The Formula V Air Racing Association had a Letter of Formula V Air Race Pilot Competency, dated August 29, 1996, on file for the pilot.
The airplane was a homebuilt kit constructed by Stanley J. Mankovich, Jr. The airplane was issued a special airworthiness certificate, experimental, amateur-built airplane, on March 16, 1989. According to the aircraft logbook, the airplane made its first flight on April 2, 1989.
According to the builder, the airplane was built and used predominantly for air racing in the Formula V air racing category. The builder flew the airplane in air race competitions between 1989 and 1993. In 1993, the builder decided to discontinue air racing and put the airplane up for sale. During 1994, the airplane continued to be flown in Formula V class air races, by other air racing pilots.
According to a witness who was responsible for transporting the airplane to airshows during the 1994 Formula V air racing season, the airplane was involved in two incidents where the airplane sustained substantial damage and required major repair. Neither accident was reported to the National Transportation Safety Board. The first accident occurred on September 9, 1994, at Virginia Beach, Virginia, when during landing following a qualifying air race, the airplane was ground looped. The witness said that the tail wheel was broken, the left wing tip was bent up and the main landing gear spar box was bent. The witness stated that members of the Formula V Air Racing Association grouped together to repair the airplane. The second accident occurred on October 9, 1996, at Myrtle Beach, South Carolina, when on landing from a race, the airplane was ground looped again. The witness stated that the pilot "stepped on the brakes and one grabbed sooner than the other. The airplane spun around and stood on its nose damaging the spinner and breaking off one of the propeller blades." The left wing was bent. "A couple of the ribs in the wing tip were bent. The left main landing gear was bent underneath the airplane." The airplane sat in the witness' garage for several months before an airframe and power plant mechanic, who was also a Formula V racing pilot, came to retrieve the airplane and fix it.
Another witness, a Formula V air racing pilot, who observed the incident at Myrtle Beach, South Carolina, said that the left wing outer skin panel, ribs and spar were bent back. The witness stated that the airplane did not participate in the 1995 Formula V air racing season.
A third witness, an airframe and powerplant mechanic and Formula V air racing pilot, who observed the incident at Myrtle Beach, South Carolina, confirmed that the airplane had been ground looped and confirmed the damage to the airplane's wing and landing gear. The witness said that after the incident, he installed another landing gear on the airplane.
According to his wife, the airplane was purchased by the pilot-owner on April 25, 1996. The airplane was first flown by the pilot-owner on May 1, 1996. The airplane's last recorded annual inspection was performed on May 1, 1996, by the pilot- owner, who was also an airframe and powerplant mechanic. Previous to that inspection, the last annual inspection was performed on August 8, 1995. No record of major repairs during 1994 or 1995 was found in the aircraft logbook. The aircraft logbook indicated that as of July 10, 1996, the airplane had logged 89.6 hours.
WRECKAGE AND IMPACT INFORMATION
The NTSB on site investigation began on September 30, 1996 at 0800 edt.
The accident site was located on the edge of a cornfield 25 feet west of Bud Prather Road, a winding, predominately north-south running paved road. The cornfield was slightly rolling in feature. At the time of the accident the corn stalks were approximately 4 feet in height. Examination of the accident site revealed one single ground scar in the center of a 30 foot diameter flattened area. The scar was approximately three feet in length and was oriented east to west. The scar was approximately 5 inches wide at the center, and 4 inches in depth.
The area was significantly eroded since the accident. A 4 foot high north-south running bob-wire fence lined the east side of the accident site. At the time of the accident, the fence was damaged when the right wing of the airplane struck it. Small pieces of fuselage fabric and fiberglass from the cowling was still evident at the site.
The wreckage had been moved into a warehouse at M & K Aviation in Jeffersonville, Indiana. The main wreckage included the fuselage aft of the firewall, both wings and the empennage.
The engine cowling, fiberglass fuselage forward of the cockpit, and the canopy were broken into several large pieces. The plexiglass which made up the bubble-windscreen was broken out. Several pieces of the plexiglass were missing.
The forward landing gear legs, main wheels and gear mounting box were intact and had separated from the fuselage metal frame tubing. The mounting box was bent to the left approximately 25 degrees.
The metal frame tubing which made up the cockpit area of the fuselage was bent to the left approximately 10 degrees. The floor of the fuselage was broken out. The fabric which made up the skin around the cockpit area was torn and twisted. The instrument panel was cracked and bent aft and down. The engine instruments were destroyed. The fuel tank was still strapped to the frame forward of the instrument panel. The bottom of the fuel tank was torn open and separated. Fuel stains and a faint smell of fuel were noticed in the fabric along side and beneath the fuel tank. The fuselage aft of the cockpit was bent to the left approximately 30 degrees. There was some minor skin wrinkling just behind the cockpit area.
The underside of the fuselage, just aft of the cockpit was crushed upward approximately 3 inches. The remaining fuselage aft to the empennage was intact. The horizontal stabilizer, vertical stabilizer, elevator and rudder were undamaged. The fuselage skin, 1/2-inch forward of the rudder hinge line had a 1 and 1/4 inch puncture where the upper elevator pulley had punched through. A part of the pulley was observed in the skin puncture. Flight control continuity to the elevator and rudder were confirmed. The tail wheel of the airplane was bent upward.
The left wing was still attached to the fuselage at the forward spar box and the aft attach pin. The forward third of the left wing tip was broken off. The left wing was crushed aft from the leading edge to the main wing spar, and crushed up approximately 30 degrees from underneath along the lateral span of the wing. The upper wing surface was opened up longitudinally along the center rivet line, 14 inches aft from the leading edge. The upper wing skin showed a 30 degree longitudinal buckling from the wing root outboard and aft to the aileron hinge line. The inboard 6 inches of the left wing leading edge was bent laterally inward approximately 60 degrees. The underside of the wing surface was buckled upward and aft. The left aileron was positioned 80 degrees up from the neutral position. The aileron was bent upward approximately 30 degrees at mid-span and was buckled just outboard of the wing root. The left counterweight was bent inboard. Flight control continuity to the left aileron was confirmed.
The right wing was still attached to the fuselage at the forward spar box and the aft attach pin. The upper wing surface was bent upward and slightly aft, and was wrinkled along the entire span. The upper skin was separated from the main wing spar along a 9 inch section beginning at the wing root and running outboard along the rivet line. The inboard 7 inches of the left wing leading edge was bent laterally inward approximately 55 degrees. The right wing tip was cracked longitudinally along the outboard edge. The tip was partially separated from the wing skin along a 12 inch rivet seam beginning at the leading edge of the wing and moving aft. The right aileron trailing edge was in the neutral position. The aileron was bent slightly upward approximately 3 inches outboard of the wing root. Flight control continuity to the right aileron was confirmed.
The engine, propeller and firewall had separated from the forward fuselage just forward of the instrument panel. The engine was examined and showed no anomalies. The engine was turned and exhibited rotation and proper valve action. One blade of the wooden propeller was predominately intact and still attached to the hub. The blade was cracked slightly aft, 7 inched out from the hub. The other blade had broken off at the hub and was split in half. The blade tip was missing. The metal spinner was bent aft and outward. The spinner exhibited conformity with the propeller hub. Impressions from the propeller mounting bolts and safety wires were observed in the metal. There were no rotation signatures on the propeller blades or the spinner. Three of the four engine mounts were broken. The firewall remained attached to the mounting frame. Heat discoloration was observed on the lower firewall metal, engine-side, near the exhaust manifold. The insulation around the lower firewall at the firewall lower seal was charred and melted. The adhesive resin which bound together two pieces of rubber stripping forming the firewall lower seal between the engine and the cockpit was missing. The outboard rubber strip was stiff and showed signs of charring. The inboard strip was clean of resin and showed some minor charring. The fiberglass inside the underside fuselage panel containing the exhaust port showed charring and delamination.
MEDICAL AND PATHOLOGICAL INFORMATION
An autopsy of the pilot was performed on August 30, 1996, by the Clark County, Indiana, Medical Examiner, in Jeffersonville, Indiana.
The results of Federal Aviation Administration (FAA) toxicology specimens from the pilot revealed a carboxyhemoglobin saturation of 41.000 percent in the blood. The Manager of the FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma stated that loss of consciousness is attained at a carboxyhemoglobin saturation of approximately 30.000 percent.
TESTS AND RESEARCH
The Formula V Air Racing Association publishes several documents which provide standardization for technical inspections of the airplanes, and competency of the air racing pilots.
In the Formula V Procedural and Safety Rules Guide, it states that "a competing aircraft must possess a valid certificate of airworthiness or equivalent of the country of origin and must pass the technical inspection."
The Formula V Guide for New Race Pilots states that the technical inspection will be performed "before flying. The inspection will be performed by the Formula V Technical Inspection staff." The pilot will "be required to uncowl [the] engine." And, "a new competitor's aircraft will receive a more careful scrutiny than other aircraft which have raced regularly."
The Formula V Aircraft Technical Inspections Guide states, "Materials and workmanship (going into the airplane) must conform to aircraft standards or equivalent. The Technical Committee is empowered to refuse permission to fly, attempt to pass flight test, or to qualify an aircraft, which in their opinion, is not up to reasonably safe standards in either materials, workmanship, detail design, or condition. This applies to new, modified, repaired, or damaged aircraft."
A witness said that when technical inspections are performed may vary. "Sometimes they are done every race. They are done whenever there is a protest." The witness said that one person in the Formula V Air Race Association does all the technical inspections. The witness also said that the race pilot does not receive any documentation that an airplane meets Formula V technical specifications.
According to the Formula V Air Racing Association Procedural and Safety Rules Guide, for a pilot to be eligible to compete in Formula V air racing, he/she must meet a list of specified qualifications. The qualifications include possessing a current private pilot's license, a current medical certificate, a pilot logbook with current biennial endorsement and a letter of Formula V air racing competency. The pilot must have a minimum of 200 hours pilot-in-command time in a fixed-wing airplane, a minimum of 10 hours in the specific Formula V airplane to be raced or 25 hours in any Formula V, Formula One or Sport Biplane race type, a minimum of 5 take-offs and landings in any Formula V race plane type during the previous 90 days, and a minimum of 1 hour in the specific Formula V airplane to be raced during the previous 30 days or a minimum of 10 hours in any aircraft type during the previous 30 days. The pilot must also demonstrate in his/her airplane before a Formula V Safety Officer, an abort from a simulated racing start, a take off at full throttle without veering more than 10 feet to either side of a straight line, three 180-degree turns at race speed without appreciable loss of altitude, a slow roll in each direction without loss of altitude exceeding 50 feet or stalling, and execute a half roll (to the inverted position) then reverse roll in each direction without exceeding 50 feet or stalling. Lastly, the pilot must demonstrate flight around the race course including a racing takeoff, 10 laps of the race course at racing speed, passing another airplane, being passed by another airplane, a race finish and landing.
A witness stated that a simulated dead-stick landing was also required of the participants, and that new Formula V air racing pilots were considered on probation for their first couple of air racing competitions.
A party to the investigation was the Federal Aviation Administration Flight Standards District Office, Indianapolis, Indiana.
All wreckage was released and returned to a representative designated by the pilot's family.