WACO, TX, USA
N3020T
Cessna 320C
The pilot (plt) left his residence at 0500 & flew from San Antonio to Alamogordo. On the return flight (flt), he diverted to New Braunfels, due to weather (wx). After landing, he indicated that he needed fuel, but fuel was not available until the next morning. Reportedly, he slept in the aircraft (acft). Airport (arpt) personnel noted plt had departed without refueling & without a wx briefing. No record of en route communication or refueling was found. About 0600, wreckage was sited where acft had impacted in a level attitude near Waco Regional Arpt, about 0.89 mi from the VOR. Arpt elevation was 516 ft, minimum descent altitude (MDA) for the VOR approach was 880 ft. The VOR bearing selector was found at 142 deg (inbnd course was 141 deg). Waco wx was reported to be 300' ceiling, variable 100', visibility 1/2 mi with fog. No preimpact mechanical failure was found. Propeller damage & slashes marks indicated the engines were providing power during impact. Plt had been prescribed Wellbutrin (bupropion) for depression & anxiety. Toxicology tests of his blood showed 0.11 mcg/ml bupropion (antidepressant), 0.20 mcg/ml erythrodihydrobupropion, 0.94 mcg/ml threodihydrobupropion, & an unreported amount of tetrahydrocannabinol carboxylic acid (metabolite of marijuana). Tests of his urine showed 0.118 mcg/ml Phentermine (appetite suppressant/stimulant). Plt's prescription for bupropion had been refilled on 8/28/96. His son believed he was under stress from business & finances, & probably fatigued. Plt had urgent need to be at a real estate license renewal class in Ft Worth at 0900.
HISTORY OF FLIGHT: On September 19, 1996, at 0514 (based on the aircraft clock) central daylight time, a Cessna 320C, N3020T, registered to and operated by a private owner under Title 14 CFR Part 91, impacted terrain near the Waco Regional Airport, Waco, Texas. Instrument meteorological conditions prevailed and a flight plan was not filed for the cross country flight. The commercial/instrument rated pilot received fatal injuries and the airplane was destroyed by the impact and fire. The time that the flight originated from New Braunfels, Texas, was 0415 (based on ATC radar target track). During telephone interviews, conducted by the investigator-in-charge, airport fixed base operator (FBO) personnel reported the following information. The airplane landed at New Braunfels, Texas, approximately 1930 on September 18, 1996, after diverting from the intended destination of San Antonio, Texas, due to thunderstorms. The pilot reported that he had "10 gallons of fuel left" and requested refueling; however, line service personnel were gone for the day and the pilot was informed that fuel would be available the following morning at 0700 and local motels were available for the night. The pilot was further informed of 24 hour fueling service at Austin, Texas, (approximately 60 miles north of New Braunfels). Airport personnel departed the New Braunfels Airport for the evening. At 0640 the following morning, when an airport employee returned for work, the airplane was not at the airport. During telephone conversations, conducted by the investigator-in-charge, a flight instructor at the New Braufels Airport reported that he talked to the pilot at approximately 2200 and they looked at the weather on the computer at the Southern Wings Flight School. The instructor further stated that the pilot mentioned that he had 10 to 13 gallons in the main tanks, needed fuel and needed to go home; however, the pilot declined to siphon fuel from a flight school airplane into N3020T. During telephone interviews, conducted by the investigator-in-charge, and on the enclosed statement, the passenger, who deplaned at New Braunfels, Texas, reported that he and the pilot planned a round trip business flight from San Antonio, Texas, to Alamogordo, New Mexico, on September 18, 1996. The flight landed at the San Antonio International Airport at approximately 0815 on the morning of the 18th from Granbury, Texas. The pilot subsequently boarded the passenger and departed San Antonio between 0900 and 0930 for the flight to Alamogordo. During the departure climb they flew through some clouds; however, the en route flight was above the clouds. After conducting their business (during which time the airplane was refueled), they departed Alamogordo at 1730 for the return flight. En route the pilot overheard, on his airplane radio, conversations about thunderstorms in the San Antonio area, and the pilot decided to divert due to the thunderstorms. Subsequently, the airplane landed at New Braunfels. Local authorities and relatives reported the following information. The pilot departed his residence at approximately 0500 on September 18, 1996, and arrived at the Granbury Municipal Airport, Granbury, Texas, at approximately 0600. The pilot called from New Braunfels at approximately 2030 and reported to relatives that he would sleep in the airplane and fly home (Granbury, Texas) in the morning after refueling the airplane. The pilot was scheduled for a real estate class at 0900 at Fort Worth, Texas, on September 19, 1996, and that he had to make that class in order to renew his real estate license. At approximately 0920, on September 19, 1996, the land owner found the airplane in a plowed field near the Waco Regional Airport and called 911. Local authorities and witnesses reported fog reduced visibility in the area from midnight through 0730. A witness across the highway from the accident site reported to the local authorities that he went onto his porch about 0600 and saw the debris in the field; however, he thought it was a portion of a neighbor's barn that had blown there during the rain and windstorms which had occurred throughout the night. PERSONAL INFORMATION: During interviews, conducted by the investigator-in-charge, the pilot's son, who had previously flown with his father, stated the following information. The pilot had owned the airplane for approximately one year and flew approximately 40 hours per year; however, the pilot had flown in the military and had over 18,000 hours total flight time. The pilot normally checked the weather; however, he usually did not file a flight plan, fly in the clouds, or talk to ATC unless necessary for the flight. It was the son's opinion that the pilot was under stress from the business and finances and that he needed to make the deal at Alamodorgo to financially help the situation. The son stated that the pilot was in good health; however, the son felt that the pilot slept in the airplane due to finances and was probably fatigued from the day's activities. During interviews, conducted by the investigator-in-charge, the pilot's spouse stated the "pilot was no more stressed that any one else that had their own business." She further stated that the pilot "often slept in the airplane and in her opinion would not have been particularly tired from the trip or the weather." To date, the pilot's logbooks have not been made available to the Board. Therefore, the time of the pilot's last biennial flight review, instrument flight or instrument competency check is unknown. AIRCRAFT INFORMATION: The airplane was manufacturer in 1964. The airplane was registrated to the pilot on September 23, 1995. During telephone interviews, conducted by the investigator-in-charge, airport personnel at Granbury, Texas, Cleburne, Texas, and Sycamore, Texas, and relatives reported that the maintenance records should have been in the aircraft. An examination of the airplane did not reveal any remains of maintenance records. During a telephone interview, conducted by the investigator-in-charge, the mechanic at Sycamore, Texas, who performed the annual inspection, reported that the inspection was completed on August 1, 1996. Total time at the inspection was 2,626.3 hours on the airframe with a time of 287.7 hours since the engines were overhauled. At the time of the inspection, tachometer reading was 1,405.3 hours with engine S/N 138042-4-D installed at the left position and engine S/N 138039-4-D at the right position. Time since the annual inspection was 28.9 hours. METEROLOGICAL INFORMATION: Weather reports were reviewed by the investigator-in-charge. From 0234 through 0656, the local Waco weather station reported an airport visibility of 1/2 statute mile or less due to fog with ceilings 300 feet AGL variable to 100 feet AGL and a temperature/dewpoint spread of zero. The Area Forecast outlook for south central and north central Texas included thunderstorms and rain showers with visibilities reduced due to mist with an outlook for IFR weather through 1000. Airmet Sierra was valid until 1300 for low ceilings and visibility due to fog and precipitation. Numerous convective sigmets were issued for areas of Texas before and throughout the time of the accident. Convective sigmet 58C was valid until 0655 over central Texas for thunderstorms due to very moist and unstable atmospheric conditions. Area forecast for central Texas included IFR ceilings and fog. COMMUNICATIONS: A search of ATC facility data did not reveal any preflight or en route communications for said aircraft. AERODROME INFORMATION: Numerous airports are located along an en route flight from New Braunfels, Texas to Waco, Texas. Some of the airports had 24 hour fueling service and some had services upon request via telephone. The Waco Regional Airport (ACT), at an elevation of 516 feet and with an operating control tower Class D airspace effective 1200 - 0400 UTC, has 4 asphalt runways and is serviced with instrument approach procedures including a VOR 14 approach. During the hours of non tower operation the approach communication facility is the Fort Worth Center. The VORTAC is located 3 nautical miles northwest of the airport with an inbound altitude of 1,700 feet to the VOR, an inbound course of 141 degrees, and a minimum descent approach altitude of 880 feet MSL (364 feet AGL). WRECKAGE AND IMPACT INFORMATION: The wreckage distribution path of 776 feet was along a measured magnetic heading of 115 degrees with the final resting site in an open plowed field at an elevation of 572 feet, 4.2 nautical miles from the Waco Regional Airport and 0.89 nautical miles from the ACT VORTAC. The initial ground scar (North 31 degrees 39.48 minutes West 097 degrees 17.16 minutes) was two sets of ground scar slash marks and beyond the slash marks was a ground scar 43 feet 8 inches in width with portions of the left (red) wing navigation lens and the right (green) wing navigation lens near the respective outer limits of this ground scar. Components of the airplane (propellers, elevators, stabilizer, fuel tip tanks, and turbochargers) were found along the distribution path for the next 464 feet toward the main wreckage which came to rest at latitude North 31 degrees 39.44 minutes longitude West 097 degrees 17.12 minutes on a measured magnetic heading of 340 degrees with the wings and cockpit inverted. The engines were found beyond the main wreckage. See the enclosed diagram for additional details. Physical evidence of a post-impact fire was found in the vicinity of the left auxiliary fuel tank and portions of the cockpit. The integrity of the cockpit was destroyed by the fire, and extensive crushing and separation of components occurred throughout the airplane. All fuel tanks and lines were compromised; however, fuel caps were secure and there was no evidence of fuel leakage at the filler caps. The left wing fuel strainer screen was free of debris and the right fuel strainer screen was found destroyed. The cockpit magneto switches for the left engine were found in the "OFF" position and the right engine in the "ON" position. Flight control continuity was confirmed via the control cables. Shaft rotation was found in each of the turbochargers. The cockpit altimeter was destroyed. The bearing selector of the navigation equipment was found set at 142 degrees. Scoring was not found on the attitude indicator gyro rotor. The cockpit engine controls had the throttles and mixtures in the full forward position with the propeller controls between the low pitch and high pitch range. Alternate air controls were destroyed. The left fuel selector handle was in the "OFF" position on the selector indicator that was bent, twisted, and scratched. The right fuel selector was separated from the fuel system and its selector handle position could not be determined. Fuel boost pump was in the "ON" position for the left engine and in the "OFF" position for the right engine. The manifold pressure gauge indicated 58 inches for the #2 engine and 42 inches for the #1 engine with the RPM for both engines at 400 RPM's. The left engine, serial number 138042-4-D, crankcase halves remained intact. The left magneto, turbocharger, propeller, propeller governor, portions of the intake and exhaust pipes, and the oil cooler were separated from the engine. The right engine, serial number 138039-4-D, crankcase halves remained intact. The fuel pump, propeller, propeller governor, turbocharger, and portions of the intake and exhaust pipes were separated from the engine. The propeller blades for both engines were bent and twisted with gouges, striations, and scrapes. MEDICAL AND PATHOLOGICAL INFORMATION: The autopsy with autopsy toxicological screening for the pilot was performed by the Office of the Medical Examiner, Southwest Institute of Forensic Sciences at Dallas, Texas. The toxicological findings were positive for drugs in the following concentrations: O.11 mg/L bupropion; 0.20 mg/L erythrodihydrobupropion; and 0.95 mg/L threodihydrobupropion. Aviation toxicological testing was performed by the FAA Civil Aeromedical Institute (CAMI) at Oklahoma City, Oklahoma. The CAMI toxicological non quantified findings were positive for bupropion (antidepressant) in the urine and tetrahydrocannabinol (marihuana metabolite) in the blood and urine. The toxicology was also positive for 0.118 ug/ml, ug/g phentermine (anorexiant-diet pill) in the urine. According to Dr. Soper, CAMI, "putrefaction of the specimens may have lowered the levels of tetrahydrocannabinol carboxylic acid (marihuana metabolite) found in urine and blood." Neither bupropion nor phentermine is approved by the FAA for use while flying. See the enclosed toxicology report for additional details. Medical records for the pilot were reviewed by the investigator-in-charge, the NTSB Medical Officer, and the Regional Flight Surgeon for the FAA's Southwest Region. On March 4, 1996, the pilot discussed his stress level and depression with Dorris Morrissette, M.D., who prescribed Paxil 20 mg daily. On April 8, 1994, the dosage was reduced to 10 mg daily. August 29, 1995, during an appointment with Karen Jurgenson, M. D., the pilot reported taking the Paxil during the previous 6 to 8 months for depression. On March 29, 1996, due to a call from the pilot's spouse about the side effects with Paxil, Dr. Jurgenson changed the prescription to Wellbutrin (90 tablets 100 mg daily). During a telephone conversation, conducted by the investigator-in-charge, Dr. Jurgenson further stated that the patient was a business individual and described him as "110% go - go all the time and a risk taker professionally." The patient was last seen on July 2, 1996, and was reportedly doing well on the Wellbutrin; however, he had reported a shortness of breath at altitudes and requested a prescription for oxygen. Dr. Jurgenson prescribed the portable oxygen at 2L/minute as needed at altitudes greater than 10,000 feet; however, Dr. Jurgenson stated that she was not informed by the patient that he was a pilot until relatives notified her of the accident. Dr. Jurgenson stated that she had not prescribed the Phentermine for the patient. A review of the prescription data, by the investigator-in-charge, for the pilot revealed that the prescription for Wellbutrin was filled on March 29, 1996. The prescription was refilled on May 24, 1996, July 11, 1996, and August 28, 1996. TEST AND RESEARCH: The airplane was examined in October 1996 at Roanoke, Texas, under the surveillance of the investigator-in-charge. The gear actuator was in the retracted position. The left flap was in the retracted position and the right flap chain was separated from the actuator drive sprocket. The fuel system integrity was compromised by the separation of both tip tanks (mains), exposing of both auxiliary tanks, and crushing to each wing leading edges and fuel lines. The left fuel selector valve was in the auxiliary position and the right fuel selector valve was found centered between the auxiliary position and the cross feed position. Approximately 1/2 ounce of fuel was recovered from the left main tank fuel transfer pump. This fuel was "blue" in color and tested negative for water when tested by using Sar-gel Paste. Impact damage precluded a functional test for the left main fuel boost pump or transfer pump and the right main fuel transfer pump. The right main fuel tank boost pump functioned when power from a 12 volt battery was applied at the pump wiring. The left front seat was found with a portion of the right side of the seat belt attached. Shoulder harnesses were not installed in the airplane. The left engine (serial number 138042-4-D) crankcase was rotated and continuity was confirmed to all of the cylinders except the #4 cylinder that had the push rods bent. All pistons moved with the main oil pump and the scavenger pump rotating. Both vacuum pumps were disassembled and all internal components were found intact. The fuel pump drive coupling was intact. Damage precluded fuel pump rotation; however, no internal damage was found during the disassembly of the
VFR flight by the pilot into instrument meteorological conditions, and his failure to maintain sufficient altitude or clearance from the terrain. Factors relating to the accident were: inadequate preflight by the pilot, his failure to obtain a weather briefing, darkness, adverse weather conditions, lack of fuel to proceed to an alternate destination, pressure induced on the pilot by an urgent need to get to a real estate license renewal class, and pilot anxiety/depression.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
