Aviation Accident Summaries

Aviation Accident Summary SEA97LA104

MITCHELL, OR, USA

Aircraft #1

N3152J

Cessna T188C

Analysis

While the pilot was on the ground surveying area of land that he intended on spraying, the airplane was loaded with a pesticide in preparation for an aerial application flight. The pilot then boarded, started, and taxied the airplane for takeoff with no problems noted. He took off to the east, leveled off between 25 and 50 feet above the ground, commenced a steep bank turn to the left, flew over a target field located adjacent to the airstrip, and continued to bank steeply toward the west. The airplane aerodynamically stalled while in a steep turn and suddenly descended into terrain in a steep nose-down attitude. Most of the witnesses did not perceive any unusual engine noises prior to impact. The airstrip was surrounded by rising terrain. The flaps were in the fully retracted position. An examination of the engine, airframe, and systems did not reveal any evidence of preimpact mechanical deficiencies, except for the seat restrain systems. The shoulder harness belt, which was original equipment, was severely deteriorated and had failed during the impact. No evidence of pilot incapacitation was found.

Factual Information

On May 10, 1997, about 0900 Pacific daylight time, N3152J, a Cessna T188C, operated by Precision Applicators, Inc., collided with terrain while maneuvering after takeoff near Mitchell, Oregon, and was destroyed. The commercial pilot, the sole occupant, was fatally injured. Visual meteorological conditions prevailed and no flight plan had been filed. The aerial application flight was conducted under 14 CFR 137. According to the operator (statement attached), the pilot flew from Madras, Oregon, to an airstrip near Mitchell on the morning of the accident. The operator stated that the aircraft was empty of any chemicals during that flight, and had been full of fuel at departure. He stated that the flight to Mitchell would have consumed about 10 to 15 gallons of fuel. The operator, who was at the airstrip, observed the pilot circling around Mitchell to familiarize himself with the area before landing. The operator stated that the pilot had planned to spray a 40-acre area located about one mile downstream and to the north of the river that paralleled the airstrip. After landing, the pilot got out of the airplane and rode with a farmer to view the target fields that the operator had been contracted to spray. While the pilot was gone, the aircraft was loaded with 140 gallons of a pesticide mix known as Furadan. The operator stated that the mix consisted of 4.5 gallons of Furadan and 135 gallons of water. When the pilot returned from viewing the target fields, he got into the airplane, started it up, and back taxied to the west end of the airstrip for a takeoff to the east. The operator observed the takeoff. He stated: "[The pilot] was airborne in approximately 900 [feet and] climbed to about 25 [feet above the ground,] leveled out and then turned to the north. Approximately one minute later he crashed while turning to the west." The operator also stated that he heard the engine until impact, and that he did not perceive any problems with the engine. According to a representative of the Wheeler County Sheriff's Office (report and witness statements attached), one witness observed that the airplane was headed in a northwesterly direction after it departed from the airstrip, banked right, and then "went down." The witness further stated that the airplane was no more than 50 feet above the ground when it began to go down. Another witness stated that the airplane was "extremely low" while it was "banking to turn." This witness stated that the airplane suddenly "slipped into a nose dive" while it was banking, and then "skipped on its nose." Another witness, who lived near the airstrip and who initially notified local authorities of the accident, stated that she looked out her window and saw the airplane flying "real low" by her house. She stated that the airplane was "...going east up the river and made a left banking [turn] north....it still was real low [and] it kept banking until it was going west...then all at once the plane just went down...." A forth witness stated that she was in the yard of her home, located near the airstrip, when she saw the accident. She stated that the airplane crossed the river, was turning, and was headed toward her. She stated that she heard the engine change in pitch and "perhaps die," at which time the airplane suddenly entered a vertical dive and impact terrain. According to Federal Aviation Administration (FAA) records and the operator, the pilot, age 27, held an FAA Commercial Pilot certificate with ratings for airplane single engine land, airplane single engine sea, airplane multiengine land, and instrument airplane. He was also a certified flight instructor and held a current, valid FAA Second Class Medical Certificate with no limitations or waivers. According to the operator, the pilot had accumulated a total of 1,636 hours of flight time, including 520 hours in type, and 50 hours in type during the previous 30 days of the accident. The airstrip consisted of a paved 2,800-foot runway at a field elevation of 1,560 feet. The area around the airstrip was surrounded by rising terrain. Weather conditions included clear skies, nearly calm winds, and a temperature of about 60 degrees F. The airplane, a 1980 Cessna model T188C "AG husky", was powered by a single, turbocharged, 310-horsepower, Continental TSIO-520-T(1) engine. Its certificated maximum gross weight is 4,400 pounds. The airplane has a fuel capacity of 54 gallons (324 pounds), and a published maximum hopper load of 1,900 pounds. The weight of the airplane at the time of the accident is estimated to be about 3,850 pounds. The airplane's published indicated stall speed, flaps up, wings level , maximum gross weight, is 73 miles per hour (mph). This stall speed increases to 103 mph in a 60-degree bank. An examination of the maintenance records revealed that the airplane had received an annual inspection on December 19, 1996, and there were no unresolved discrepancies noted. The examination also did not reveal any evidence indicating that the seat restraint system had ever been inspected and/or replaced in accordance with Cessna Service Bulletin SEB94-20 (attached), which addressed "Seat Belt and Shoulder Harness Inspection and Replacement." According to an FAA aviation safety inspector from Hillsboro, Oregon, the airplane had impacted terrain vertically, and was found in a nose down attitude. The three-blade propeller was sheered off the crankshaft and embedded into the ground; its plane of rotation was parallel to the ground. The airframe was resting straight up on its engine/nose about ten feet from the propeller. Fuel was found leaking from the right wing only. Liquid pesticide was also leaking from the airplane. The leading edges of both wings were crushed aft. There was more damage to the left wing than the right wing. The nose of the airframe, including the engine, was crushed rearward to the main landing gear attach fittings. The instrument panel and cockpit area was intact. The flaps were found in the retracted position. The pilot was found inside the cockpit; he was wearing a crash helmet and a four-point harness seat restraint system. The front rollers on the pilot's seat remained intact. The rear rollers were off of the their tracks. The shoulder harnesses were cut by rescue personnel to remove the pilot. The pilot's crash helmet was intact and undamaged. The empty space surrounding the rudder pedals, seat cushion, seat back, control stick, throttle quadrant, and instrument panel was sufficient to contain an object with the same shape and dimensions of the body of a "standard man." The wreckage was removed from the accident site and examined in detail by representatives of the FAA, the Cessna Aircraft Company, and Teledyne Continental Motors (report attached) on May 22, 1997, in Redmond, Oregon. No preimpact mechanical malfunctions were found with the engine, airframe, or systems. The seat restraint system consisted of a four-point harness, with two lap belts and two shoulder belts that connect into a central attach point at the pilot's torso. The two shoulder belts were tied into a single belt that emanated from a single inertial reel attached to the top of the cockpit cage structure. The inertial reel remained intact and secured to the undamaged structure. The inertial reel was functionally tested and operated normally. The single shoulder harness belt, however, had separated along the width of the belt, with one end secured to the inertial reel and the other end leading to the two shoulder harness belts. The separated ends were stretch and frayed; the belt had failed in tensile overload and exhibited evidence of severe deterioration and over-exposure to ultraviolet radiation. An examination of the tag numbers on the seat restraint system revealed that the belts were originally installed on the airplane. An autopsy was performed on the pilot by Dr. Edward F. Wilson, MD, on May 18, 1997, at the Oregon State Medical Examiner's Office, Portland, Oregon. According to the report of autopsy, the cause of death was "head and neck injuries." Specimens taken from the pilot were analyzed by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma. According to their report (attached), no carboxyhemoglobin, cyanide, or drugs were detected. The report also states: "1.000 (mg/dL, mg/hg) Acetaldehyde detected in Blood" and "20.000 (mg/dL, mg/hg) Ethanol detected in Urine." No ethanol was found in the blood or vitreous fluids, and the samples were deemed to be putrified. Specimens taken from the pilot also underwent toxicological analysis by the Oregon Department of Human Resources with the specific goal of detecting Carbofuran and its metabolite (Carbofuran is the active ingredient in the pesticide formulation that was loaded on the airplane at the time of the accident). According to their final report (attached), no Carbofuran or Carbofuran metabolite were detected.

Probable Cause and Findings

The pilot's failure to maintain adequate airspeed while maneuvering, which led to a stall. A factor contributing to the accident was the lack of adequate altitude to effect a successful stall recovery.

 

Source: NTSB Aviation Accident Database

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