NATIONAL 

TRANSPORTATION 

SAFETY 

BOARD 

WASHINGTON, D.C. 20594 

AIRCRAFT ACCIDENT REPORT 

THURMAN L. MUNSON

CESSNA CITATION 501, N15NY

NEAR CANTON, OHIO 

AUGUST 2,1979 

UNITED STATES GOVERNMENT 

NTSB-AAR-80-2
. Report No. 2.Government Accession No. 

I. Title and Subtitle 

NTSB-AAR-80-2

Aircraft Accident ReportThurman L. Munson Cessna Citation 501, N15NY, Near 

Canton, Ohio, August 2, 1979 

7. Author(s) 

9 . Performing Organization Name and Address 

National TransportationSafety Board 

Bureau of Accident Investigation 

Washington, D.C. 20594 

12.Sponsoring Agency Name and Address 

NATIONAL TRANSPORTATIONSAFETY BOARD 

Washington, D.C. 20594 

3.Recipient's Catalog No. 

5.Report Date 

6. Performi ng Organ i za t ion 

8.Performing Organization 

April 16, 1980 

Code 

Report No. 

10. Work Unit No. 

11.Contract or Grant No. 

13.Type of Report and 

Period Covered 

August 2, 1979 

2917 

Aircraft Accident Report - 1 .Sponsoring Agency Code 

17. Key Words CessnaCitation 501; stall; multiengine aircraft; 

undershoot; wing flap position; airspeed control; power 

management; approach profile; standard procedures and 

practices; angle-of-attack system; turbojet engines; pitch 

attitude; general aviation; pilot training; checklist; 

survivability; shoulder harness; fire 

Ig.Security Classification 20.Security Classification 

(of this report) (of this page) 

UNCLASSIFIED UNCLASSIFIED 

15.Supplementary Notes 

but ion Statement 

This document is available

to the public through the 

National Technical Information Service, Springfield, 

Virginia 22161 

21.No. of Pages 22.Price 

28 

16.Abstract 

About 1602 e.d.t., on August 2, 1979, a Cessna Citation piloted by Mr.Thurman L. 

Munson crashed short of runway 19 at the Akron-Canton Airport near Canton, Ohio. The pilot 

was practicing touch-and-go landings during a local flight with two passengers aboard. The 

aircraft first touched down in a relatively level, clear area about 870 f t short of the runway. 

The aircraft slid through a small clump of trees, hit a large stump, and came to rest on a road 

adjacent to the airport boundary fence. Fire erupted immediately after the aircraft came to 

rest. The two passengers escaped from the wreckage; the pilot was killed. 

The National Transportation Safety Board determines that the probable cause of the 

accident was the pilot's failure to recognize the need for, and to take action to maintain, 

sufficient airspeed to prevent a stall into the ground during an attempted landing. The pilot 

also failed to recognize the need for timely and sufficient power application to prevent the 

stall during an approach conducted inadvertently without flaps extended. Contributing to the 

pilot's inability to recognize the problem and to take proper action was his failure to use the 

appropriate checklist and his nonstandard pattern procedures which resulted in an abnormal 

approach profile. 
This document was converted to text using Optical Character Recogntion procedures. 

Every effort has been made to ensure integrity; however, minor differences may exist 

between this and the original printed version.

CONTENTS 

SYNOPSIS ........................... 1

1. FACTUAL INFORMATION .................. 1 

1.2 Injuries to Persons ..................... 6 

1.3 Damage to Aircraft ..................... 6 

1.4 Other Damage ....................... 6 

1.5 Personnel Information .................... 6 

1.6 Aircraft Information .................... 7 

1.7 Meteorological Information. ................. 7 

1.8 Aids to Navigation ..................... 7 

1.9 Communications ...................... 7 

1.10 Airport Information ..................... 7 

1.11 Flight Recorders ...................... 8 

1.12 Wreckage and Impact Information ............... 8 

1.13 Medical and Pathological Information ............. 9 

1.14 Fire ........................... 10 

1.15 Survival Aspects ...................... 10 

1.16 Tests and Research ..................... 11 

1.16.1 Powerplants ........................ 11 

1.16.2 Entry Door. ........................ 11 

1.17 Additional Information. ................... 11 

1.17.1 Aircraft Performance .................... 11 

1.17.2 Angle-of-Attack Indicator .................. 12 

1.17.3 Pilot Training ....................... 13 

1.17.4 Pattern Procedures ..................... 14 

1.17.5 Crew Seat Strength ..................... 14 

1.18 New Investigative Techniques. ................ 14 

1.1 History of the Flight .................... 1

2. ANALYSIS. ........................ 14 

3. CONCLUSIONS. ...................... 21 

3.1 Findings.. ........................ 21 

3.2 Probable Cause. ...................... 22 

4. RECOMMENDATIONS. ................... 22 

5. APPENDIXES ....................... 25 

Appendix A-Investigation and Hearing. ........... 25 

Appendix B-Pilot and Passenger Information ......... 26 

Appendix C-Aircraft Information. ............. 27 
NATIONAL TRANSPORTATION SAFETY BOARD 

WASHINGTON, D.C. 20594 

AIRCRAFT ACCIDENT REPORT 

Adopted: April 16, 1980 

THURMAN L. MUNSON 

CESSNA CITATION 501, N15NY 

NEAR CANTON, OHIO 

AUGUST 2, 1979 

SYNOPSIS

About 1602 e.d.t., on August 2, 1979, a Cessna Citation piloted by Mr. 

Thurman L. Munson crashed short of runway 19 at the Akron-Canton Airport near 

Canton, Ohio. The pilot was practicing touch-and-go landings during a local flight 

with two passengers aboard. The aircraft first touched down in a relatively level, 

clear area about 870 f t short of the runway. The aircraft slid through a small 

clump of trees, hit a large stump, and came to rest on a road adjacent to the 

airport boundary fence. Fire erupted immediately after the aircraft came to rest. 

The two passengers escaped from the wreckage; the pilot was killed. 

The National Transportation Safety Board determines that the probable 

cause of the accident was the pilot's failure to recognize the need for, and to take 

action to maintain, sufficient airspeed to prevent a stall into the ground during an 

attempted landing. The pilot also failed to recognize the need for timely and 

sufficient power application to prevent the stall during an approach conducted 

inadvertently without flaps extended Contributing to the pilot's inability to 

recognize the problem and to take proper action was his failure to use the 

appropriate checklist and his nonstandard pattern procedures which resulted in an 

abnormal approach profile. 

1. FACTUAL INFORMATION 

1.1 History of the Flight 

About 1430 e.d.t., 1/ on August 2, 1979, the pilot of N15NY, a Cessna 

CE-501 "Citation," invited two associates to accompany him on a local flight at 

Akron-Canton Airport near Canton, Ohio. Both associates of the pilot were 

certificated pilots; however, neither had flown in turbojet-type aircraft. One of 

them had been the pilot's flight instructor in the Beech aircraft model BE-60. He 

had flown with the pilot for about 100 to 150 hrs. He boarded N15NY and sat in 

the right front seat next to the pilot. The other associate boarded the aircraft and 

sat in an aft-facing passenger seat behind the right cockpit seat. The pilot closed 

the cabin entry door. The passengers were not briefed regarding the location of 

shoulder harnesses, the operation of emergency exits, or procedures to follow in an 

emergency. The passenger who was seated in the cabin said that he left his 

seatbelt fastened loosely so he could turn to his right and face partially forward to 

view the cockpit. 

1/All times herein are eastern daylight based on the 24-hour clock. 
-2-

According to the passengers, the pilot turned on the electrical power 

and checked his fuel quantity, which was about 900 pounds per tank. The pilot then "referred to a little booklet" and calculated his reference speeds for landing 

approaches. He set the "bug" 2/ on his airspeed indicator at 93 kns. The passenger 

in the right cockpit seat then set the bug on the right side airspeed indicator at 93 

kns. 

The passengers said that they were not aware of the pilot's intentions 

for the flight until he requested and received clearance to remain in the traffic 

pattern for practice landings. The pilot used a headset and a microphone button 

located on his control yoke for radio transmissions. The pilot started the engines, 

checked the ATIS, 3/ and at 1536 was cleared to taxi to runway 23. The flight was 

cleared for takeoff on runway 23 at 1541:36. Three touch-and-go landings were 

conducted on runway 23 before anapproach was flown to runway 19.

The following account of the sequence of events preceding the accident 

was supplied by the two passengers aboard Nl5NY and by other persons who 

witnessed the flight and the crash: 

The initial takeoff was normal and the aircraft was turned to enter a 

left traffic pattern for a touch-and-go landing on runway 23. Downwind 

airspeed was about 200 kns indicated airspeed (KIAS) for a short time and

then the aircraft was slowed below the gear-down limit (174 KIAS). 

Altitude on the downwind leg was about 2,500 ft mean sea 

level 4/ (airport elevation was 1,217 ft). Power was reduced abeam midfield 

on downwind, the landing gear was lowered, and the approach flaps were 

extended. A normal touch-and-go landing was accomplished on runway 23. 

The flaps were raised to takeoff position and thrust was applied for takeoff. 

During the climbout, the landing gear and flaps were retracted, and 

then the pilot pulled the right throttle back to demonstrate the single-engine 

climb capability. The right throttle was then returned to normal thrust 

position and a left traffic pattern was flown. One passenger said that the 

aircraft was "as high as 3,000 ft" on downwind. The other passenger was not 

positive, but believed the altitude was about 2,800 ft. 

During the downwind leg of the second landing, the pilot advanced the 

throttles and demonstrated how rapidly the aircraft would accelerate. The 

passengers did not state what airspeed was reached during the acceleration, 

but they did recall that the pilot then used the speed brakes to reduce the 

2/ Movable pointer which is set at the desired reference speed on the airspeed 

indicator. 

3/ Automatic Terminal Information Service-recorded information regarding local weather and airport conditions. 

4/ All altitudes herein are mean sea level unless otherwise specified. 
-3-

airspeed below maximum gear-lowering speed (174 KIAS). The pilot then 

lowered the landing gear, extended approach flaps, and retracted the speed 

brakes. A second normal touch-and-go landing was made, and the aircraft 

was flown for a third left traffic pattern for runway 23. 

After turning to the crosswind leg for the third pattern, the pilot 

invited the right seat passenger to take the control yoke and acquaint himself 

with the control responsiveness. The passenger turned the aircraft left to a 

downwind leg. The pilot then invited the passenger to fly a zero flap 

approach. The pilot mentioned that the aircraft would float considerably 

unless flaps were used during the landing. The passenger flew the aircraft at 

170 KIAS on downwind leg. He said the pattern was considerably wider- than-normal to dissipate some altitude, but he did not recall what altitude 

was flown. He said the final approach was flat, and somewhat below the 

VASI. 5/ 

The passenger who was flying the aircraft said that the pilot did not 

recommend a final approach airspeed; however, he recalled that the speed 

flown was "considerably faster than the reference speed (bug) on the airspeed 

indicator." He said the pilot was handling the throttles and made a few 

power adjustments during the approach. The passenger flying the aircraft 

said he was only handling the control yoke and trim. 

The landing touchdown was long (about midpoint of the runway) and 

preparation for takeoff was begun immediately. The passenger who was 

flying the aircraft said the aircraft suddenly floated into the air about 5 to 10 

ft. He said he was surprised until he realized that the pilot had lowered the 

flaps to the takeoff position causing the aircraft to "balloon." The pilot 

applied takeoff thrust and took control of the aircraft. 

During the fourth takeoff, the tower advised Nl5NY to enter a right 

pattern for runway 19 because of other traffic. A right downwind leg was 

entered at 3,500 f t and 200 KIAS. While on downwind, the pilot reduced the 

throttles to dissipate airspeed and altitude. The passengers recalled that the 

throttles were reduced to a point where the landing gear warning horn 

sounded and that the pilot silenced the horn. One passenger stated, " . . . I 

know that when we were at 3,500 ft, those throttles were pretty much all the 

way back." 

A t 1559:33, the tower controller advised N15NY to extend the down- wind leg for about 1 mile, because of traffic landing on runway 19 and 

departure traffic on runway 23. At 1559:55, the controller advised N15NY to 

begin its base turn "anytime now." The aircraft was turned immediately onto 

base leg. The passengers reported that they did not recall the pilot using the 

speed brakes and that he did not lower the landing gear or extend the flaps on 

downwind.

5 / Visual Approach Slope Indicator--provides visual glide slope guidance to the 

pilot to assist in preventing undershoots and overshoots. 
-4-

The passengers recalled that the turn to base leg was made with about 

30° of bank and with the nose slightly low. One passenger said that about 

1,000 f t of altitude was lsot in the base leg turn. The turn to final was 

estimated by the passengers to have been about 20° to 30° of bank with the 

nose still slightly low. 

The passenger in the right seat stated that he noticed the VASI as the 

turn to final was begun, and the aircraft was just about on the desired 

glidepath He noticed that the landing gear had not been lowered so he said, 

"I don't think you want to land this airplane with the gear still up." The pilot 

then lowered the landing gear. The aircraft had now drifted slightly left of 

centerline for runway 19, and it had begun to settle below the VASI glidepath. 

The passenger in the right seat said he recalled that the altimeter indicated 

1,700 ft when he advised the pilot about the landing gear. He said that when 

the aircraft went below the VASI glidepath, he cautioned the pilot about 

being below the VASI and about possible downdrafts near the approach end of 

runway 19. The passenger did not recall altimeter indications after the

landing gear was lowered, because he was watching the VASI and using 

outside references. He said he recalled sensing that the aircraft was "settling in." He said he could "just feel it." He recalled saying to the pilot,

"we're sinking." 

At that point the pilot started to apply power. The aircraft was aligned 

with the runway centerline but was below the VASI glidepath and descending. 

The passenger in the cabin recalled that the power application was relatively 

slow because the pilot "sort of inched them (throttles) forward." The 

passenger in the right front seat said he noticed the angle-of-attack indicator 

was in the caution range (yellow). At that time, the sink rate was beginning 

to increase and power was being applied gradually. 

The passenger in the cabin said he did not watch the VASI, but he could 

"sense" the sink rate was "pretty strong." He said, "I could see in his face 

(the pilot's) that h e felt there was something wrong of course." He also said, 

"I sensed the airplane sinking and I could sense through the expression in 

Thurman's face that the aircraft was out of control."

Neither passenger could recall seeing a vertical speed indication 

regarding the descent rate while on base leg or on final approach. The 

passenger in the right front seat stated he was sure the airspeed was "nailed 

right on the bug" (93 KIAS) during the final approach. 

The passengers said they never felt a sensation of acceleration from the 

power application by the pilot during the last portion of the approach. The 

passenger in the cabin said he felt the left wing drop slightly as they were 

sinking and he saw the pilot suddenly push the throttles "to the firewall," that 

is, full forward. The passenger in the right front seat recalled feeling slight

airframe buffet just before impact. He said it was not pronounced--just a 

shudder before impact. The other passenger said he did not recall a shudder 

or buffet; rather he turned around and faced rearward in his seat, because he 

believed the aircraft was going to crash. He said he "kept waiting for that 

acceleration to pull us out of what I felt . . . was pretty excessive sink rate." 
-5-

The passenger in the right front seat said, "I was trying to convey to 

him (the pilot) my discomfort with the fact that we were getting a little bit 

low and that I was uncomfortable with the sink rate. . . . I didn' t want to 

come out and say ' I don't like this approach; please add power.' I was trying 

to feed that information to him in that fashion because, again, I had no 

experience in this type of aircraft." He said the pilot seemed calm and not 

rushed in his activities. 

Neither passenger saw the pilot use a checklist during the flight. One 

passenger recalled the pilot saying something during the flight such as, "You 

have to pay attention to what you're doing, because the aircraft will descend 

rapidly." The passenger said, "I remember him saying, 'You have to stay on 

top of it--pay attention.'"

Neither passenger recalled the pilot saying he was going to make a zero 

flap landing. The passenger in the right front seat said he just assumed the 

pilot was conducting a zero flap approach because he didn't follow the same 

sequence as before. Neither passenger saw the pilot attempt to lower the 

flaps during the last approach. 

When the aircraft touched the ground, the passengers said they felt a 

series of bumps and then they came to a sudden halt. The passenger in the 

cabin said he thought they hit a "ditch or hill or something." 

A passenger in an automobile traveling southeasterly on Interstate 77, 

3,300 ft from the threshold of runway 19 and along the extended centerline of 

runway 19, stated that the aircraft crossed from left to right in front of the 

automobile. He first saw the aircraft to his left about 400 to 500 f t away. 

He then saw it about 150 to 200 f t directly in front of his automobile and 50 

to 75 ft above the ground. He next saw it to his right, just skimming the 

trees and then disappearing from view. He then saw red flames and black 

smoke. The witness stated that the aircraft was in a gradual descent, 

extremely low, and barely clearing the tree tops. He said, "The aircraft was 

going very slowly, resembling the landing speed of a light small aircraft." He 

said he saw the right wing "wobbling" as it passed in front of his position 

The controller working the local control position in the Akron-Canton 

Tower saw the aircraft only from the time it was on short final approach 

until it disappeared below the level of the approach end of the runway. He 

sounded the crash alarm. No other controllers reported seeing the aircraft 

during this approach. 

The aircraft touched down about 870 ft short of the runway on slightly 

rising terrain at an elevation of about 1,160 f t (runway touchdown zone elevation is 

1,217 ft). The aircraft rolled across rough terrain and struck a 2.5-ft-deep ditch 

where the nose gear separated from the aircraft. I t continued sliding until it 

passed through a clump of small trees and struck a large stump. The aircraft spun 

around and came to rest on a road, about 270 ft from the initial touchdown point 

and about 600 ft from the runway threshold. A fire erupted immediately after the 

aircraft came to rest. 
-6- 

The aircraft crashed about 1602 during the hours of daylight. The 

coordinates of the accident site are 40°55' N and 81° 27' W at an elevation of about 

1,180 ft.

1.2

1.3 

1.4

Injuries to Persons 

Injuries - 

Crew Passenger 0ther 

Fatal 1 0 

Serious 0 2 

Minor/N one 0 0

0 

0 

0

Damage to Aircraft

The aircraft was destroyed by ground impact and postcrash fire. 

Other Damage 

A few small trees were destroyed. The asphalt surface of a roadway on 

which the aircraft came to rest was damaged by heat and fire. 

1.5 Personnel Information 

The pilot, who also owned N15NY, was trained and certificated in 

The pilot's logbook revealed that he began flight training on

accordance with current regulations. (See appendix B.) 

February 27, 1978, in a Cessna 150 aircraft. He continued flight training in 

single-engine Cessna aircraft until April 10, 1978, at which time he also began 

training in the Beech BE-60, "Duke," twin-engine aircraft. The pilot completed 

successfully his private pilot checkride on June 11, 1978, in a Cessna 172. His

logbook showed that he had logged 25.0 hrs pilot-in-command and 65.2 hrs dual

when his Private Pilot Certificate was issued. The pilot received his multiengine

rating on June 15, 1978, in a BE-60 aircraft, He had logged 23.8 hrs in the BE-60 

and had logged 97.2 hrs total flight time when he took his multiengine checkride. 

On February 10, 1979, at a total logged flying time of 330 hrs, the pilot 

purchased and began flying a Beech E-90 "King Air." His logbook revealed that he 

flew this aircraft until July 6, 1979, when he purchased the Cessna Citation, 

N15NY. His total logged flying time on July 6 was about 480 hrs, which included 

428 hrs of multiengine time. His total time was broken down into 165 hrs dual and 

315 hrs pilot-in-command. 

The pilot flew N15NY with a flight instructor for 10 flights before 

receiving his type-rating in the aircraft on July 17, 1979. He had logged 21.7 hrs 

and 24 landings in the aircraft before his checkride, which was 1.5 hrs long and 

included 8 landings. The checkride was flown in N488CC, another Cessna CE-501 

Citation. 

In the 16 days following the type-rating checkride, the pilot logged 10.6 

hrs in the Citation (N15NY). He logged 4.1 hrs of this time as pilot-in-command, 

single pilot. The pilot's total logged flying time at the time of the accident was 

516.2 hrs, 33.8 hrs of which were logged in the CE-501 model aircraft. 
-7-

The passenger in the right front seat had been the pilot's flight 

instructor for a period of time in 1978. He had flown with the pilot in a Beech 

aircraft BE-60 "Duke" for about 100 to 150 hrs, during which time the pilot trained 

for and completed his instrument rating. The passenger was not rated in turbojet 

aircraft and had not flown previously in the Cessna Citation model aircraft. He 

was not trained or qualified to act as the pilot's instructor for the accident flight. 

According to his statement, he was a friend of the pilot and was aboard the 

aircraft solely as an observer. 

The passenger in the cabin was also a certificated pilot. However, he 

was not rated in turbojet aircraft and had never flown in a Cessna Citation. 

1.6 Aircraft Information 

N15NY, a Cessna CE-501 Citation, serial No. 501-0110, was certifi- cated, maintained, and equipped in accordance with current regulations. (See 

appendix C.) The CE-501 is a single-pilot version of the original Cessna Citation 

CE-500, which was certificated on September 9, 1971, with a minimum crew of a 

pilot and a copilot. The CE-501 was certificated on January 7, 1977. 

1.7 Meteorological Information 

on August 2, 1979, was as follows: 

The surface weather observation for the Akron-Canton Airport at 1556 

Sky condition -- 3,000 f t above ground level, scattered clouds, 

estimated 4,000 feet a.g.l. broken clouds; visibility -- 10 miles; 

temperature -- 76°F; dewpoint -- 62° F; wind -- 280° at 9 kns; 

barometric pressure -- 29.97 inHg.

A special weather observation for Akron-Canton Airport taken at 1604 

Sky condition -- 3,000 f t a.g.l. scattered clouds, 4,000 f t a.g.l.

broken clouds, visibility -- 10 miles; temperature -- 77°F ; dew- point -- 63°F; wind -- 280° at 11 kns; barometric pressure -- 29.97 inHg. 

on August 2, 1979, was as follows: 

1.8 Aids to Navigation 

Not applicable. 

1.9 Communications 

There were no reported com municat ions difficulties. The 

Akron-Canton Airport is served by a Federal Aviation Administration (FAA) 

control tower. 

1.10 Airport Information 

surface runways; runway 19 is the longest, 6,397 ft long by 150 ft wide. 

The Akron-Canton Airport, elevation 1,217 ft, consists of three hardThe 
-8-

approach end of runway 19 had previously been extended toward the north by using 

fill dirt. The pierlike approach end of the runway is about 50 f t higher than the 

terrain immediately to the north of it. 

Runway 19 is equipped with a two-bar VASI to assist pilots with 

maintaining a 3° glide slope during Visual flight rules (VFR) operations. When the 

aircraft is positioned on the glide slope, the bar light closest to the aircraft 

displays a white indication, while the bar light farthest from the aircraft displays a 

red indication. When the aircraft is positioned below the glide slope, both bars 

display a red indication. The VASI glide slope provides for a touchdown point about 

1,000 f t from the runway threshold. 

1.11 Flight Recorders 

data recorder, and neither recorder was required. 

The aircraft was not equipped with a cockpit voice recorder or a flight 

1.12 Wreckage and Impact Information 

The aircraft first touched down about 870 f t from the threshold of 

runway 19. Marks in the foliage and dirt revealed that the aircraft first touched on 

its left main landing gear and then on its right main gear about 70 f t farther. The 

terrain was fairly level, open, and uncultivated. The aircraft rolled on its landing 

gear for about 150 f t from initial contact until i t struck a 2.5-ft-deep trench 

where the nose gear separated from the aircraft. The aircraft continued for about 

70 f t before it entered a stand of small trees. It passed through the trees and hit a 

large tree stump 5 f t in diameter and 4 f t high. The lower portion of the nose 

beneath the pilot's seat and the left wing root leading edge hit the stump, and the 

aircraft again became airborne for a short distance. It came to rest on Greenburg 

Road, which is located about 8 ft above the terrain on which the trees were 

located. When the aircraft hit the trees and stump, it rotated clockwise 180°. The 

crash path was oriented southerly along the extended centerline of runway 19. 

The left wing root area and lower left side of the fuselage were 

extensively damaged by impact. The skin was buckled beneath the left windshield 

and the nose of the aircraft was crushed slightly downward and buckled aft about 5 

ft. The right wing and the lower right side of the fuselage were damaged 

extensively by impact. The skin on the bottom of the fuselage was distorted and 

crushed upward slightly along the full length of the fuselage. Both wing fuel cells 

were opened during contact with the trees, and fuel stains were found on 

surrounding foliage. The right wing and the entire right side of the fuselage were 

damaged extensively by fire. The left side of the aircraft sustained moderate fire 

damage. 

The empennage was extensively burned. The engines were burned away 

from their attachments and were found in the debris of the empennage. 

Examination of the wreckage revealed that the flaps were up and the 

speed brakes were stowed at impact. Continuity of the flight control mechanisms 

was established with no evidence of preimpact malfunction or failure. 
-9- 

The cockpit interior showed little evidence of impact damage, except 

for the left side. The pilot's control yoke was broken in half just above the midcolumn. The instrument panel was dented and pushed forward. The floor structure 

beneath the pilot's seat was disrupted. About 2 f t of the floor structure, including 

the pilot's left seat floor track, was disrupted, crushed aft, and buckled by impact

from below. Although the right floor track for the pilot's seat was relatively

undamaged, the seat had become detached from the floor track and was found 

loose in the cockpit. 

The pilot's seat had sustained impact damage. The left front corner of 

the seat pan was bent downward about 4 in. The seat pan had contacted the seat 

base in this area. The seat base and other supporting structures were bent and 

twisted. The lap buckle was found fastened and the webbing near the left seat 

attach point was burned away. There was no evidence that the attach point for the 

shoulder harness lapbelt insert had been fastened to the lapbelt buckle. The inertia 

reel assembly for the pilot's single-strap diagonal shoulder harness was found with 

the webbing burned within the reel assembly housing. The inertia reel housing is 

mounted above and behind the pilot's left shoulder, and it is attached to the wall 

behind the pilot's seat. The right front seat was found firmly fastened to the floor 

with no impact damage. 

The cabin was severely burned. The cabin seats were in place with no 

evidence of impact damage. The right emergency exit door was open, and the door 

was inside the cabin. The main cabin door on the left side was closed and jammed. 

The skin on the forward lower corner of the door was found bent and curled aft and 

the exterior door handle was missing. 

1.13 Medical and Pathological Information 

A postmortem examination of the pilot, performed by the Summit 

County Coroner's Office, revealed no evidence of preexisting pathology which 

would have impaired his ability to conduct the flight safely. 

The autopsy revealed congestion and edema in the tracheobronchial 

tree, and the laryngeal airway contained considerable edematous fluid. There were 

flecks of carbonaceous material scattered throughout the edematous fluid. The 

autopsy also revealed a dislocation of the atlanto-occipital and atlanto-axial joints, 

where the cervical spine joins the lower back part of the head. Examination of the 

spinal cord revealed a "severe contusion, hemorrhage and necrosis of the cervical 

spinal cord." This injury was beneath the area of the dislocation. The lower aft 

portion of the brain (cerebellar tonsillar) was displaced downward from its normal 

position. The coroner concluded that the pilot died from "asphyxiation due to 

acute laryngeal edema and due to inhalation of superheated air and toxic 

substances.'' 

The Summit County Forensic Toxicology Laboratory in Akron, Ohio, the 

Ohio State University Toxicology Laboratory in Columbus, Ohio, and the FAA Civil 

Aeromedical Institute Laboratory in Oklahoma City, Oklahoma, conducted 

toxicological examinations of the pilot. Levels of carbon monoxide and cyanide 

were insignificant. Findings for alcohol and drugs were negative. 
-10-

The two passengers suffered second- and third-degree burns to exposed 

areas of their bodies--face, neck, and hands. They did not sustain serious impact 

in juries. 

There was no evidence of in-flight fire. There were about 1,500 pounds 

of jet A-1 fuel aboard the aircraft when it crashed. All fuel cells were ruptured as 

the aircraft slid on the ground and when it hit the trees. A severe fire erupted 

when the aircraft came to rest. Several ignition sources were present--electrical, 

hot-engine components, and friction. 

1.14 Fire 

- 

The left side of the aircraft was upwind from the smoke and fire, which 

was intense and concentrated on the right side of the fuselage. The passengers' 

only escape route was through the emergency exit on the right side of the cabin. 

When the emergency exit was opened, fire and smoke propagated rapidly into the 

cabin requiring both passengers to exit immediately. 

Immediately after the accident, the Green Township Fire Department 

and the airport fire department were notified via the Tower "hot line." Units were 

on scene in 8 minutes and the fire was extinguished. The first firefighters on the 

scene reportedly saw someone with a crowbar or tire iron near the aircraft. It was

not determined if the bar was used to attempt to open the entry door. One

firefighter said he attempted to open the entry door from the outside and the 

handle reportedly came off in his hand with little effort. 

1.15 Survival Aspects 

Neither cockpit occupant wore his available shoulder harness. The 

passenger in the cabin seat did not have a shoulder harness available. 

After the aircraft stopped, the passenger in the right cockpit seat said 

he unbuckled his lapbelt and attempted to extricate the pilot from his seat. He 

said the pilot was pinned between his seat and the instrument panel. He tried 

several times to pull the pilot out by his shoulders. 

The passenger in the cabin unbuckled his lapbelt and attempted to open 

the left entry door. He said he rotated the handle from the locked position to the 

horizontal position (open) and back to the stowed position but the door would not 

open. The other 

passenger then came aft and attempted to open the door. He said he kicked the 

door, but it would not open. By this time, black smoke was beginning to enter the 

cabin and the passenger, who had been riding in the cabin, looked out the right 

emergency door window and saw flames. He said he located the emergency exit 

handle and "cracked" the exit open. As flames began to enter the cabin, both 

passengers made a final attempt to extricate the pilot, but without success. The 

passenger from the cabin then returned to the emergency exit, opened it, and 

exited immediately. The passenger in the cockpit said he was still trying to pull 

the pilot out when the aircraft began to fill rapidly with smoke. He said when he 

turned around he could not see the emergency exit. He tried once more to 

extricate the pilot and then moved aft and went out the emergency exit. 

He attempted to open the door two times without success. 
-11- 

Ground witnesses near the accident site said the fire propagation was 

rapid with heavy dense smoke. They said the heat was so severe that they could 

not approach the burning aircraft after they saw the two survivors run away. 

1.16 Tests and Research 

1.16.1 Powerplants 

On August 14 and 15, 1979, Safety Board investigators examined both 

engines from N15NY at the manufacturer's facility--Pratt and Whitney Aircraft of 

Canada, Ltd., Lonqueuil, Quebec, Canada. The total time on each engine was 

43.1 hrs; each engine had been operated through 45 flight cycles. 

Both engines had been subjected to moderate impact damage and 

moderate to severe fire damage. The damage precluded functional tests of the 

fuel control and fuel pump assemblies from both engines. Disassembly and 

inspection of these components revealed no evidence of preimpact failure. 

The fan blades were bent and twisted severely. Blade bending in both 

engine fan sections was opposite the direction of normal rotation. Small pieces of 

wood and wood ash deposits were found in both engines in various locations 

throughout the engine airflow areas. The disassembly and examination of both 

engines revealed no evidence of preimpact failure or malfunction. 

1.16.2 Entry Door 

Examination of the entry door revealed that a linkage tube was broken 

in the latch mechanism. The broken tube prevented two latching pins from 

retracting from the door frame when the handle was rotated to the open position. 

The door structure adjacent to the broken tube had a compression buckle, and the 

two latching pins were jammed in the door sill. 

The broken linkage tube was examined at the Safety Board's metallur- gical laboratory to determine the mode of failure. The examination revealed that 

the tube failed in tension overload and that the tube material met the 

manufacturer's strength specifications. 

1.17 Additional Information 

1.17.1 Aircraft Performance 

The performance of N15NY during the final landing attempt was 

calculated using the following conditions: 

Field elevation - 1,217 ft

Barometric pressure - 29.07 inHg

Pressure altitude - 1,170 f t

Temperature - 77° F 

Density altitude - 2,700 f t

Aircraft gross weight - 8,750 pounds 
-12-

The gross weight was estimated to be 8,750 pounds using the aircraft 

basic empty weight (6,741) plus estimated passenger weights (510) and the 

estimated weight of fuel onboard (1,500), minus the probable amount of fuel burned 

during the flight (300). 

Using these data and the CE-501 Flight Manual Performance Charts, a 

normal landing configuration (full-flap) stall speed of 74 KIAS was calculated with 

aerodynamic buffet beginning at 79 KIAS. A reference speed (Vref) for this 

configuration would have been 95.5 KIAS, based on the charts. 

Based on the above conditions and the Flight Manual Performance 

Charts, a no-flap stall speed of 82 KIAS was calculated with aerodynamic buffet 

beginning at 92 KIAS. Vref for the no-flap configuration was calculated to be 106.6 

KIAS. 

The CE-501 Flight Manual specifies that a no-flap approach must be 

conducted at the flaps-extended Vref speed + 20 kns, which would be 115.5 KIAS 

for the assumed conditions (Vref of 95.5 KIAS + 20 kns). 

The Safety Board could not determine how the pilot calculated a Vref 

of 93 KIAS before takeoff. Although witnesses stated that he used the CE-501 

checklist quick-reference chart for his calculation, 93 KIAS is not one of the 

speeds printed on the chart. The quick-reference chart shows the following 

weights and recommended Vref speeds: 

(GEAR DOWN-FULLFLAPS) VREF

Weight 7500 8500 9500 10000 10500 11000 11350 

Speed 89 92 94 97 99 101 102 103 104 106 107 108 

Using the chart, a Vref of 97 KIAS should have been selected for the 

fuel weight described by the passengers, if the pilot accurately estimated the 

aircraft gross weight. 

1.17.2 Angle-of -Attack Indicator 

A key performance instrument available to the pilot of N15NY was the 

angle-of-attack indicator and its associated displays. The angle-of-attack system 

derives its input from a sensor which detects the direction of airflow at the side of 

the fuselage. The system is totally independent of the pitot-static system and 

displays performance information (angle-of-attack) to the pilot in three ways. 

First, a three-color vertical display unit, mounted on the glareshield, shows an 

amber, green, and red light in descending order. This unit provides a "heads-up" 

source of information with respect to deviation from the approach reference speed. 

The correct reference speed is displayed as a green light.

The second angle-of-attack display is a fast-slow pointer located on the 

flight director, and the third display is an instrument located on the left upper 

portion of the instrument panel. The third display depicts "lift" information on a 

scale from zero (0) t o one (1.0). Zero represents zero lift and 1.0 represents 100 

percent lift, or stall. The display is valid for all flap positions. 
-13- 

An angle-of-attack indication of 0.6 indicates that the aircraft is 

operating at the maximum lift/drag ratio and equates to 1.3 x Vso 6/ or Vref. That 

indication is the maximum endurance reference and is also used for maximum angle 

of climb. A yellow area (caution) on the angle-of-attack indicator begins adjacent 

t o the 0.6 index and continues toward the stall warning area. Flight in the caution 

area is less than 1.3 Vso (Vref) and is near the prestall buffet regime. Flight in the 

caution zone on the angle-of-attack indicator (less than lift/drag maximum) 

requires more power to sustain steady flight than is required at an indication of 

0.6. Similarly, any increase in angle of attack during flight in the caution zone 

produces proportionately more drag than lift achieved--"the area of reverse 

command." Considerably more power is required to overcome the additional drag 

produced for the relatively small amount of lift gained. 

1.17.3 Pilot Training 

According to the staff of Flight Safety International (FSI) located at 

Wichita, Kansas, FSI was initially requested to provide an instructor pilot for 

pilot-service to fly with the new pilot/owner of N15NY. It was later requested 

that the pilot-service include instruction to prepare the pilot for a type-rating in 

the Citation. An instructor pilot employed by FSI was provided and instruction 

began on July 7, 1979. 

According to the instructor, the entire FSI ground school curriculum 

was completed between July 7 and July 15, 1979. He said 4 to 6 hrs per day were 

devoted to ground training. The instructor stated that i t was evident to him that 

the pilot had spent considerable time studying the aircraft before taking delivery 

of N15NY. This portion of the ground school training was completed in conjunction 

with flight training. The flight training was conducted during cross-country flights 

to Oakland, Seattle, Kansas City, and Wichita. Local training flights were made at 

Oakland and Seattle. 

The flight training record completed by the pilot's instructor showed 

five flights for a total of 11.1 hrs flight time. He stated that additional training 

was conducted during cross-country flights. 

On July 17, 1979, the pilot received 4 hrs in the Citation simulator at 

FSI. He reportedly conducted the simulator time as a single pilot. The instructor 

reported the pilot's knowledge and performance in the simulator as "above 

average." The instructor also stated that "from the onset to completion of training 

Mr. Munson displayed well above average skills and judgment as a pilot. H e was 

very knowledgeable of the Operators Manual and the Flight Manual." 

The pilot received his type-rating from an FAA-designated pilot 

examiner employed by FSI. He reportedly had no difficulty during the checkride. 

According to the records, the pilot was trained and certificated in accordance with 

provisions of 14 CFR 61. 

6/ The stall speed or the minimum steady flight speed in the landing configuration. 
-14- 

According to flight instructors who had flown with the pilot and who 

had given him instruction for his various certificates and ratings, they considered 

the pilot above average in operation and knowledge of the aircraft they observed 

him fly. 

1.17.4 Pattern Procedures 

The FSI training material used for the pilot's training contains a 

diagram for recommended VFR pattern airspeeds, altitudes, and configuration. 

The recommended downwind airspeed was 150 KIAS at 1,500 f t a.g.l. with the flaps 

extended to "approach." The landing gear should be lowered opposite to the 

planned touchdown point. The recommended airspeed during base turn was 

Vref + 20 kns with approach flaps extended and landing gear down. Minimum 

altitude on base leg was 1,000 ft a.g.l. The recommended final approach airspeed 

was Vref to Vref + 10 kns and back to Vref once the landing is assured. 

Regulation 14 CPR 91.70 specifies that a turbine-powered aircraft must 

be restricted to 200 KIAS maximum in the airport traffic area, providing that the 

operational requirements of the aircraft permit that speed. 

Regulation 14 CFR 91.87 specifies that turbine-powered aircraft must 

maintain at least 1,500 f t a.g.l. entering the airport traffic area and while in the 

pattern until final descent for landing is required, at airports with an operating 

control tower. 

1.17.5 Crew Seat Strength 

The Citation crew seats were designed to comply with the strength 

requirements of 14 CFR 25.785. That rule specifies that the seats must withstand 

an ultimate inertial load of 4.5 g's downward, 9.0 g's forward, and 1.5 g's sideward, 

as set forth in 14 CFR 25.561. Cessna personnel stated that the seat was designed 

and tested to withstand these ultimate inertial loads. In fact, the seat was tested 

to failure at a combined resultant ultimate design load of 10.5 g's (9 g's forward, 3 

g's sideward, and 4.5 g's downward); the sideward load was twice that required by 

the FAA so that the seats would meet more stringent foreign certification

requirements. This test was conducted based on a 170-lb occupant and a 32-lb 

seat. 

1.18 New Investigative Techniques 

None. 

2. ANALYSIS 

The Accident 

The pilot was properly certificated and had received the training 

prescribed by applicable regulations. There was no evidence of preexisting medical 

problems which could have affected the pilot's performance. 
-15-

The aircraft was certificated, equipped, and maintained in accordance 

with applicable regulations. The aircraft gross weight and center of gravity were 

within prescribed limits. Meteorological conditions were not a factor in the 

accident. Although density altitude was higher than field elevation, it was not high 

enough to affect adversely the aircraft or engine performance to a point to be 

considered a factor in the accident. 

Based on the evidence, the Safety Board's investigation concentrated on 

three possible areas of causation: (1) flap system or pitot-static system malfunction or failure, (2) engine malfunction or failure, and (3) pilot action or inaction. 

Flap System or Pitot-Static System Malfunction or Failure 

The Safety Board's investigation revealed no preimpact mechanical 

problems with the flap system. This finding is supported by passenger statements 

confirming that the pilot did not attempt to actuate the flap control switch to 

lower the flaps during the last landing attempt. Additionally, during the flight the 

pilot did not mention problems with the flap system nor did the passengers observe 

any difficulties with this system. 

Impact and fire damage precluded a functional test of the pilot's

airspeed indicating system, the most critical pitot-static instrument in this case. 

However, the Safety Board does not suspect a problem with this system for several 

reasons. Three successful takeoffs and landings were accomplished with no 

reported difficulties. If erroneous airspeed indications were a problem during the 

flight, the pilot and possibly the passengers would have likely sensed low airspeed 

cues, such as airframe buffet and flight control unresponsiveness. In fact, if 

erroneous airspeed indications were a problem, they would have been more 

noticeable during the earlier approaches and landings where the aircraft was 

slightly heavier and low airspeed problems would have been more pronounced. 

The passengers' description of the aircraft performance during the last 

approach is consistent with that calculated from the aircraft performance charts. 

That is, the onset of aerodynamic buffet and the rapid sink rate in the configura- tion and at the airspeed being flown was normal and predictable. 

Finally, the angle-of-attack indicator was observed to be in the caution 

zone during the last approach at 93 KIAS. Since the angle-of-attack indicator 

receives inputs for its display from a source totally independent of the pitot-static 

system and since the "caution" indication on the indicator is the proper reading for 

the airspeed and configuration being flown, the airspeed indicator obviously was 

showing the proper indication. 

Therefore, the Safety Board concludes that neither the flap system nor 

the pitot-static system failed or malfunctioned. Additionally, the investigation 

revealed no other aircraft system or airframe problems which could have caused 

the accident. 
-16- 

Engine Malfunction or Failure 

Disassembly and examination of the engines revealed no evidence of 

preimpact failure or malfunction. Additionally, both engines were found to be 

capable of normal operation and were developing considerable power at impact. 

Rotational damage to the engine fan assemblies and the presence of wood particles 

and burned wood residue throughout the engine interiors support this conclusion. 

Debris would not be distributed through the engine air passages if the engines were 

operating at low power. Passenger statements further support the conclusion that 

the engines were functioning properly before the crash. Apparently, the pilot did 

not advance the throttles full forward until just before impact. He gave no 

indication to the passengers that he was experiencing engine problems, and they did 

not recall sensing any visual or audible indications of engine malfunction. 

Pilot Action or Inaction 

This undershoot accident involved a high sink rate and a descent below 

the glidepath which continued unrecognized and unchecked until contact with the 

ground was unavoidable. Wing flap position, airspeed control, power management, 

the approach profile, and standard procedures and practices, all are important 

aspects in the cause of this accident. These aspects are dependent upon one 

another in effecting a safe, stabilized approach and landing. 

The Safety Board could not determine positively whether the pilot 

inadvertently flew the last approach without flaps, or did so intentionally but at 

the wrong airspeed. The Safety Board believes that the pilot most likely forgot to 

lower the flaps. According to the passengers, the pilot held the selected "bug" 

airspeed, which suggests that he was monitoring the airspeed indicator. Moreover, 

the airspeed indicator is a primary performance instrument and is readily in view 

of the pilot. Further, it is the most important cue available and used during 

approach and landing. The flap handle and flap position indicator are not primary 

flight performance cues and are checked only during the "before landing" and 

"landing" checklists. According to the passengers, the pilot did not refer to a 

checklist during the flight. The passenger in the right front seat reminded the pilot 

to lower the landing gear, but he did not mention the flaps because he was not 

totally aware of the pilot's intentions and was not familiar with the proper airspeed 

to be flown. Consequently, an oversight was made and the pilot forgot to lower the 

flaps. He flew the approach at a normal (full-flap) approach speed, about 20 kns 

below that required for a no-flap approach. The aircraft entered a high sink rate 

and continued below the glidepath without adequate and timely corrective action 

by the pilot. 

The 4-kn difference between the full-flap Vref speed (93 KIAS) selected 

by the pilot and the proper speed (97 KIAS) was not a major oversight. However, it 

does reflect adversely on the pilot's attention to detail while computing the 

aircraft gross weight and the proper Vref. 

The Safety Board could not determine why the pilot did not monitor the 

angle-of-attack system, which obviously would have given him a "slow" indication. 

Since he had not flown other aircraft equipped with this system, he may not have 

been fully familiar with it, or may not have developed a habit of including it in his 

scan during approach and landing. 
-17- 

The pilot's management of power during the approach is also related to 

the cause of the accident. Passenger statements indicate that the pilot did not 

advance the throttles full forward until just before impact. The technique 

described by the passengers regarding the pilot's "inching the throttles forward" is 

typical of pilot technique in a propeller-driven aircraft, the type aircraft with 

which this pilot was more familiar. Power response in turbojet engines is generally 

less rapid than in propeller-driven aircraft engines, thus requiring the pilot to 

anticipate his power requirements with timely throttle application. Additionally, 

in propeller-driven aircraft, the increased air flow from the propeller(s) over the 

aircraft wings and control surfaces generally improves the aircraft performance. 

This does not occur in turbojet aircraft. 

In addition, for turbojet engines, the greatest percentage of thrust 

available is gained in the top range of engine rpm. The power response in 

propeller-driven aircraft is more linear throughout the power range in relation to 

throttle position. Therefore, the pilot's action of "inching the throttles forward" 

would not have enabled him to gain appreciable added thrust until he reached the 

top range of engine rpm. In the accident situation, where considerable power was 

required to overcome the high descent rate and to avoid contacting the ground, 

rapid and full throttle movement was needed to attain maximum engine response. 

Although rapid throttle movement is not recommended as a routine practice in jet 

aircraft, it can be accomplished without engine damage if the fuel-control system 

is calibrated properly. 

The pilot's throttle technique further compounded his situation because 

the aircraft was flying at an airspeed below the maximum lift/drag ratio. Flight in 

this manner is generally referred to as "the area of reverse command." In this 

condition, any attempt to arrest the rate of descent by increasing pitch attitude 

(angle of attack) will produce proportionately more drag than lift. Therefore, 

additional power, beyond that required to decrease the descent rate, would be 

required to overcome the added drag. The amount of power the pilot added during 

the last approach may have been sufficient for previous approaches flown at the 

proper airspeed for the configuration. In fact, he may have added the amount to 

which he was accustomed on previous occasions; however, that was not sufficient 

for the last approach. In order to maintain the "bug" speed he selected, altitude 

had to be sacrificed, and as a result the rapid descent rate continued. Rapid and 

full throttle advancement was the only alternative available to the pilot. 

The Safety Board believes the pilot failed to apply sufficient power in a 

timely manner because he did not realize or sense that power was required. The 

pilot was probably bewildered by the unexpected response of the aircraft; the high 

sink rate and the different "feel" of control responsiveness at the low airspeed 

probably confused him. When he monitored his airspeed indicator, which he 

assumed was showing the "correct" airspeed for the conditions, the pilot probably 

became even more bewildered by the aircraft reaction. His bewilderment or 

concern was described by one of the passengers, who said he could "sense the 

problem" by the expression on the pilot's face. The pilot's lack of action regarding 

power management in a serious life-threatening situation confirms that he did not 

diagnose properly the problem confronting him and failed to take timely and 

effective action. 
-18- 

Another matter which contributed to the pilot's confusion during the 

last approach involves the manner in which he conducted the previous patterns. 

Normal practice and procedure dictate certain traffic pattern criteria, such as 

recommended airspeeds and altitudes and setting aircraft configuration at selected 

phases of the pattern. These criteria aid a pilot in establishing habit patterns 

during approaches and landings in order to fly in a consistent manner and to create 

a normal approach profile so that abnormal situations will be more recognizable. 

The description of the accident flight, as related by the survivors and 

other witnesses, shows a general lack of adherence to "standard practice" regarding 

airspeed and altitude management on the part of the pilot. Also, he was not 

consistent in establishing the aircraft configuration. This failure to establish a 

normal flight profile set the stage for the pilot's problem when he was requested to 

fly a pattern to a different runway. 

The first three approaches were in a left-hand traffic pattern which is 

easier to fly in aircraft with side-by-side cockpit arrangements because the pilot 

has a better view of the airport. In right-hand patterns, visibility to the runway 

from the left seat is restricted and hinders the pilot. The right-hand pattern to 

runway 19 was "nonstandard" to the pilot, who had not yet flown a "normal" flight 

profile for a left-hand pattern to runway 23. His erratic airspeed and altitude 

control and the extended downwind leg put him in an unfamiliar situation. Any 

habit pattern he may have developed regarding gear and flap lowering was broken. 

Even though his former instructor reminded him about the landing gear, the 

situation had developed to a stage where only positive action by the right-seat 

passenger or by the pilot could have prevented the accident. 

In order to initiate the last approach, the pilot reduced power, silenced 

the gear warning horn, and lowered the nose. Once the descent was established and 

he was reminded about the landing gear, he lowered it, but the normal landing habit 

pattern had been broken. The added drag of the gear, the reduced power, and the 

reduced lift available without flaps extended, placed the aircraft in a dangerous 

situation. The pilot obviously did not recognize his plight because of previous 

nonstandard practices. 

The Safety Board believes there are other reasons beyond the circum- stances of the last approach which caused the pilot to forget to extend the flaps 

and to fail to recognize the need for rapid power application. General aviation 

flying is generally conducted under less stringent rules and procedures than 

commercial or corporate/executive operations. However, general aviation flying 

does have rules, procedures, and common practices which a pilot must follow in 

order to develop good habit patterns and to produce safe flight. The pilot of 

N15NY did not fully comply with these essentials during the accident flight. 

First, the pilot allowed his right-seat passenger to make a no-flap 

approach and landing despite the fact that the pilot was not a qualified flight 

instructor and the right-seat passenger was not qualified in this type aircraft. 

Moreover, although a certificated pilot, the right-seat passenger had not met 

recency of experience requirements of 14 CFR 61.57, which requires three takeoffs 

and landings in the 90 days preceding the flight. Further, the pilot of N15NY did 

not brief the right-seat passenger regarding airspeeds associated with the 
-19- 

 maneuver nor who would operate certain controls. The Safety Board does not 

believe the pilot's actions were prudent under any circumstances and reflect 

adversely on his judgment. 

Second, although the pilot of N15NY was certificated to carry 

passengers, the carriage of passengers during practice landings can expose them to 

unnecessary risks, especially with a recently qualified pilot. The pilot was required 

by 14 CFR 91.199 to brief his passengers before takeoff on the location and usage 

of seatbelts and shoulder harnesses and on procedures to be followed in an 

emergency, including the location and means for opening the entry door and 

emergency exits. According to the passengers, he failed to do so. 

Third, the pilot did not comply with generally accepted and required 

traffic pattern procedures. Besides the previously mentioned benefit of developing 

good habit patterns and a normal pattern profile, standard patterns also provide for 

proper spacing and separation from other traffic. This is beneficial to all aircraft

in the pattern as well as to the tower controller. None of the patterns on the 

accident flight were flown at the "recommended" airspeeds or altitudes. The pilot 

of N15NY was certainly aware of standard pattern procedures from his previous 

flying experience, and especially since he had been trained recently in the CE-501 

and had demonstrated his ability to fly standard patterns during a checkride. 

Fourth, the pilot failed to use a checklist. The routine of lowering 

landing gear and flaps on downwind leg was followed on the first three approaches 

even though he did not use a checklist. However, these "natural" actions were not 

performed for the last approach because the habit pattern was broken. The habit 

pattern was broken by the changed landing pattern and a wider- and higher-thannormal base leg entry. The Safety Board believes that if the landing checklist had 

been followed by the pilot, the accident could have been prevented. 

In summary, the Safety Board concludes that the pilot's conduct of the 

flight set the stage far oversight and confusion. His disregard for standard 

practices, procedures, and regulations created an atmosphere in which he could not 

recognize a worsening situation. Perhaps a more experienced pilot would have 

recognized the dangerous situation more readily and may have taken proper and 

timely action. However, the pilot had received more training than the minimum 

specified by the Federal Aviation Regulations. Also, he recently had been certified 

as competent in the aircraft, reportedly was well qualified, and had demonstrated "above average" skill. He certainly would not have been certificated and described 

as above average if he had flown the aircraft during training and his checkride in 

the manner described by the passengers for the accident flight. Therefore, the 

Safety Board concludes that the manner in which the pilot conducted this flight 

was the primary factor which precipitated the accident sequence, not his training 

and experience. 

Survivability Aspects 

The crashworthiness of the aircraft was a significant factor in the 

survival of the two passengers because a livable environment for the occupants was 

maintained throughout the crash sequence; there was no appreciable collapse of the 
-20- 

airframe in the occupiable areas. However, the floor structure beneath the pilot's 

seat was disrupted severely. The damage included the seat floor track and the

floor and its substructure. This localized damage reduced the effectiveness of the

pilot's restraint system and the seat-to-floor attachments, permitting him and his 

seat to pitch forward into the control yoke and instrument panel during the abrupt 

deceleration. The other occupants' restraint systems were not compromised. 

Even though the pilot's seatbelt was fastened, it was ineffective 

because it was anchored to the seat structure rather than to airframe structure. 

When the seat became detached from the floor, the seatbelt was useless. This type 

installation is acceptable to the FAA as long as appropriate strength requirements 

of 14 CFR 25.785 are met. 

The pilot and the right front seat passenger were not wearing their 

available shoulder harnesses. Thus, the pilot, as a required crewmember, was in 

noncompliance with 14 CFR 91.7. The Safety Board believes that had the pilot 

been wearing his harness, his injuries may not have been as severe. With the seat 

free from its floor attachments, longitudinal decelerative forces could not be

transmitted through the seat structure into the floor. However, the shoulder 

harness, which was anchored to the aft cockpit wall, would have attenuated some 

of the decelerative force even though the shoulder harness might have been 

overloaded by the deceleration of the combined weight of the pilot and the seat. It 

is also possible that the single diagonal-strap shoulder harness would have acted as 

a pivot point about which the pilot and seat would have rotated. In this case, the 

pilot would have been thrown into the control column and surrounding structure 

producing injuries; however, the shoulder harness may have attenuated sufficient 

decelerative forces to have lessened the extent of the injuries. 

The complex crash sequence, the number of unknowns, and the number 

of assumptions required precluded calculations of the probable magnitude of the 

crash forces using the equations of motion. The damage to the pilot's seat 

indicates that relatively high vertical g-forces were transmitted through the 

airframe structure to his seat. The impact damage to the pilot's control yoke and 

instrument panel was indicative of relatively high longitudinal g-forces. These 

forces were a result of the localized impact with the tree stump and were confined 

to the left front seat area of the aircraft. 

Although the exact magnitude of the crash forces experienced by the 

pilot's seat could not be calculated, certain information can be derived from the 

known conditions. That is, in view of the manufacturer's combined loading test of 

the crew seats and the fact that the pilot's seat structure in the accident aircraft 

bent, but did not completely fail, the loads experienced by the pilot and seat were 

probably in the range of 3.5 g's downward and 8 g's forward. These inertial forces

certainly are within the limits of human tolerance for a restrained occupant. The 

localized impingement of the tree trunk destroyed any load attenuation capability 

of the restraint system allowing the pilot to impact the aircraft structure. The 

damage to the control column and to the instrument panel is consistent with the 

level of g's believed to have been sustained by the pilot and his seat. 

The pilot's injuries prevented him from extricating himself. Moreover, 

the passengers were unable to remove the pilot before the cockpit and cabin 
-21- 

environment became intolerable. Since the pilot's lapbelt buckle was found 

fastened after the accident and because of the nature of the fire damage to the 

lapbelt, the difficulty encountered by the passengers in attempting to pull the pilot 

out may be attributed to the restriction of the lapbelt and the additional weight of 

the seat. The pilot's injuries were the result of contact by his body and head with 

the control column and the instrument panel. The evidence indicates that the 

injuries to the pilot's head and neck were caused by the pilot's head striking the 

instrument panel while the neck was hyper-extended (aft). This caused the 

dislocation of the cervical vertebrae and consequent spinal cord damage. 

Postcrash fire also was a major survivability factor. The two 

passengers had limited time to attempt to extricate the pilot and to escape. Their 

efforts were further complicated by the jammed main entry door on the left side of

the fuselage where the fire and smoke initially were less severe. The main entry

door would not open because of impact damage and a tube in the linkage of the 

door latch mechanism was broken, leaving two door latching pins engaged in the 

door sill. The pins were jammed because of the buckling in the door structure and 

the structure beneath the door. 

Metallurgical examination of the failed linkage tube in the main entry 

door's latching mechanism revealed that it failed in tension overload and that the 

material met Cessna's strength specifications. Impact forces and resultant damage 

could not have generated sufficient tensile loads to fail the tube. The only way the 

tube could fail in tension is from an excessive force on the door handle in an 

attempt to open the door. The Safety Board could not determine whether the tube 

was broken as a result of the passengers' or rescuers' attempts to open the door. 

3. CONCLUSIONS 

3.1 Findings 

2. 

1. The pilot was properly certificated and trained. 

The aircraft was properly certificated, equipped, and maintained. 

3. There was no evidence that aircraft structure, systems, or powerplants malfunctioned or failed. 

4. The pilot did not comply with recommended or standard traffic 

pattern altitudes and airspeeds. 

5. The pilot had to be reminded to lower the landing gear during the

last landing attempt. 

6. The pilot forgot to extend landing flaps during the last landing 

attempt. 

7. The pilot did not use a checklist during the flight. 
-22- 

8. The aircraft was flown about 24 kns below the desired no-flap 

reference speed during the last final approach. 

9. The pilot did not add sufficient power to arrest the descent rate. 

10. Although a pilot, the right-seat passenger was not qualified to 

assist the pilot. 

11. Neither the pilot nor the right-seat passenger was wearing the 

available shoulder harnesses. 

12. Longitudinal and vertical crash loads were estimated to be 8 and 

3.5 g's, respectively. 

13. The pilot's restraint system was rendered ineffective by the 

localized damage to the seat track and supporting floor structure. 

14. A severe postcrash fire erupted when fuel was spilled during the 

crash sequence. 

15. The pilot sustained severe traumatic injuries from contact with 

the control column and instrument panel. 

16. The pilot died from the effects of fire. 

17. The two passengers sustained no serious impact injuries, but were 

burned severely during evacuation. 

18. The main cabin door was jammed. 

19. The two passengers were not familiar with the operation of the 

main door and the emergency exit and had not been briefed by the 

pilot before takeoff. 

3.2 Probable Cause 

The National Transportation Safety Board determines that the probable 

cause of the accident was the pilot's failure to recognize the need for, and to take 

action to maintain, sufficient airspeed to prevent a stall into the ground during an 

attempted landing. The pilot also failed to recognize the need for timely and 

sufficient power application to prevent the stall during an approach conducted 

inadvertently without flaps extended. Contributing to the pilot's inability to 

recognize the problem and to take proper action was his failure to use the 

appropriate checklist and his nonstandard pattern procedures which resulted in an 

abnormal approach profile. 

4. Safety Recommendations 

None. 
-23- 

BY THE NATIONAL TRANSPORTATION SAFETY BOARD 

/s/ JAMES B. KING 

Chairman 

/s/ ELWOOD T. DRIVER 

Vice Chairman 

/s/ PATRICIA A. GOLDMAN 

Member 

G.H. PATRICK BURSLEY, Member, did not participate. 

FRANCIS H. McADAMS, Member, filed the following concurring and 

dissenting statement: 

The majority concludes that the cause of the accident was the failure of the 

pilot to recognize the need for, and to take action to maintain, sufficient airspeed 

to prevent a stall, and the reason for the pilot's failure was the fact that he did not 

use the checklist and used nonstandard pattern procedures. This equates to 100 

percent "pilot error," but the majority has made no attempt to determine why the 

pilot failed to take adequate action. 

In my opinion, the Board should have cited as a contributing factor the fact 

that the pilot lacked sufficient flight experience in the aircraft, and further he 

may have lacked adequate basic training. The Citation is a high-performance 

aircraft and, although the pilot had the minimum number of hours (approximately 

30 hours), I believe that with more experience in the aircraft he would have 

arrested the high sink rate and approach to stall by immediately adding thrust. 

In addition, the Board report should have addressed the fact that all of the 

pilot's checks--private, multiengine, instrument, and type ratings--were given by 

designated examiners. I t is interesting to note that during 1978 only 1percent of 

private pilot certificates were issued by FAA inspectors; all of the remainder were 

by designated flight examiners. In this connection, the disapproval rate by 

designated flight examiners was 6 percent whereas for FAA inspectors it was 28 

percent. By addressing this situation, the Board might have been able to 

recommend that the FAA review the procedures for designating examiners. 

April 16, 1980 

-25- 

5. APPENDIXES 

APPENDIX A 

INVESTIGATION AND HEARING 

1. Investigation 

The Safety Board was notified of the accident about 1700 c.d.t. on 

August 2, 1979. Investigators from the Safety Board's Chicago Field Office and 

Washington, D.C. headquarters were sent to the scene. Two working groups- powerplants and human factors-were established to assist the 

investigator-in-charge. 

Participants in the investigation were the Federal Aviation 

Administration, Cessna Aircraft Corporation, and Pratt & Whitney Division of 

United Technologies Corporation. 

2. Public Hearing Public Hearing 

No public hearing was held and no depositions were taken. 
-26- 

APPENDIX B 

PILOT AND PASSENGER INFORMATION 

- Pilot 

Thurman L. Munson, age 32, held a Second-class Medical Certificate 

issued February 1, 1979, with no limitations. He possessed a Private Pilot 

Certificate for Airplane Single-Engine Multiengine Land with an Airplane 

Instrument Rating. He received a type rating in the CE-501 on July 17, 1979, 

which satisfies the requirements of a Biennial Flight Review. Mr. Munson was a 

professional baseball player and was employed by the New York Yankees Baseball 

Team. 

Right Front Seat Passenger 

Mr. David L. Hall, age 32, held a First-class Medical Certificate issued 

April 24, 1979, with no limitations. He possessed an Airline Transport Pilot Rating 

for Airplane-single- and multiengine land, an Airplane Instrument Rating, and a 

Flight Instructor Certificate for Airplane-single- and multiengine land. He also 

held a Ground Instructor's Rating for advanced and instrument instruction. On his 

last medical certificate application, dated April 24, 1979, Mr. Hall listed 6,723 

total flight hrs and 512 hrs in the previous 6 months. He had no flying time in the 

Cessna Citation model aircraft. 

Cabin Passenger 

Mr. Jerry D. Anderson, age 31, had a medical certificate pending. He 

held a Private Pilot Certificate for Airplane-single-engine land. 
-27- 

APPENDIX C 

AIRCRAFT INFORMATION 

The aircraft, a Cessna Citation Model 501, N15NY, serial No. 501-0110, 

was issued a Standard Certificate of Airworthiness on June 25, 1979. The 

pilot/owner took delivery of the aircraft on July 6, 1979. The aircraft had 

accumulated 43.1 hrs flight time since new. 

The .engines were maintained in accordance with applicable regulations 

and procedures. Pratt and Whitney of Canada engines, model JT-15D-1A, were 

installed on N15NY. Serial No. PCE 77064 was installed in the left position and

PCE 11067 was installed in the right position. The engine times since new (TSN) 

and cycles since new (CSN) were as follows: 

PCE 77064 43.1 hrs 45 hrs 

PCE 77067 43.1 hrs 45 hrs