Palm Springs, CA, USA
N21101
Cessna 172S
The certified flight instructor (CFI) and student were on a local instructional flight that included touch-and-go landings in the vicinity of the uncontrolled airport. The airplane took off to the west, returned, and performed a touch-and-go in the opposite direction, then made two sharp 90-degree turns to line up with the western runway again. The airplane did a touch-and-go, and appeared to climb at a very steep angle. Witnesses indicated that it appeared to be fully silhouetted in plan view against the sky when viewed from behind. The airplane subsequently turned to the right and dropped to the ground. The student pilot survived the accident, and said he was instructed by the CFI to fly down the runway just high enough so that the wheels would not touch. The student then pulled up to the appropriate takeoff attitude, but most likely failed to apply takeoff power, and the CFI failed to respond to the situation before the airplane was in a nose high, stalled condition in which there was not sufficient altitude to recover safely. The CFI's postmortem blood ethanol level was 0.31%, a level that would render a nontolerant individual unconscious, or nearly so. This level of tolerance suggests a minimum period of weeks or months of sustained increased alcohol intake, rather than a single binge event, particularly given that witnesses saw the instructor consume alcohol before the flight, a prior DUI conviction, and the liver cirrhosis found during the autopsy. The CFI's judgment and performance were undoubtedly impaired by alcohol. The CFI had reported to the FAA his prior DUI, but the FAA did not request details, nor require an additional substance dependence evaluation.
HISTORY OF FLIGHT On October 28, 2007, about 1730 Pacific daylight time, a Cessna 172S, N21101, collided with terrain immediately after takeoff from a touch and go, at Bermuda Dunes Airport, Palm Springs, California. The airplane was operated by the certified flight instructor (CFI) under the provisions of 14 Code of Federal Regulations Part 91. The CFI was killed and the student was seriously injured, and the airplane was substantially damaged. Visual meteorological conditions prevailed, and a flight plan had not been filed. The instructional flight originated at Bermuda Dunes Airport about 1715. Witnesses reported to the Safety Board investigator that they observed the airplane conducting touch-and-go landings, and operating in the vicinity of the airport. One witness relayed that he observed the airplane takeoff on runway 28, return and perform a touch-and-go on runway 10, then make two sharp 90-degree turns over the T-hangers to line up with runway 28. The airplane did a touch-and-go on runway 28, at which point another witness, who viewed the airplane from behind, looking down the runway, reported that the airplane appeared to climb out at a very steep angle, to a point where she could see the entire airplane silhouetted against the sky. The airplane subsequently turned to the right and dropped towards the ground. The student pilot stated to the Safety Board investigator that they had made two touch-and-go landings to runway 28, utilizing the normal landing pattern. At 500 to 600 feet above ground level (agl), the CFI told him to close his eyes. When he opened them they were set up for landing on runway 10. This time the CFI told him to hold the nose wheel off the ground during the landing roll, which he did. They took off, and at 200 feet agl the CFI "cut right" to line up for runway 28. The CFI gave him the controls while on final and told him to fly down the runway just high enough to keep the wheels off the ground. He performed this maneuver and then pulled the nose up to take off attitude. The airplane started losing speed and the CFI said "give me control." The last thing he remembers was that the airplane was in a "weird" attitude and he was looking at the ground. The Bermuda Dunes weather equipment recorded winds from the southeast at 2 to 4 knots for the time period between 1700 and 1800. PERSONNEL INFORMATION Certified Flight Instructor (CFI) The CFI, age 52, held a commercial pilot certificate with ratings for airplane single engine land, airplane multiengine land, and instrument (airplane), issued on January 12, 2005. He also held a flight instructor certificate (CFI) with a rating for airplane single-engine land, issued on June 23, 2006. He held a third class airman medical certificate issued on March 6, 2006, with the limitation that he wear corrective lenses for near vision. A review of his FAA airman records revealed that on January 9, 2006, his certificate was suspended for a period 45 days for operating an aircraft that had an expired annual inspection, and therefore was not considered airworthy. The pilot's log book was not located by the Safety Board investigator, however, on his last FAA medical application, dated March 6, 2006, he reported having accumulated 2,000 hours to date, and 500 hours in the previous 6 months. Additionally, on his August 3, 1998, FAA medical application he reported having had a driving while intoxicated conviction in 1990 or 1991, and his drivers license had been suspended for 90 days. The Sheriff-Coroner's report states that other pilots were aware that the accident pilot had a habit of being intoxicated during instruction and while flying. On the day of the accident, other pilots witnessed the accident pilot having drinks prior to the commencement of the flying lesson. Student Pilot The student pilot, age 18, held a student pilot certificate and third class medical certificate dated October 6, 2006. An examination of the student pilot's logbook revealed that he had accumulated 39.3 hours as of September 22, 2007, and had his initial solo endorsement dated on December 6, 2006. He had not flown within the last 30 days prior to the accident flight. He had flown with the accident CFI 38 times within the last year. AIRCRAFT INFORMATION The four seat, high wing, fixed landing gear airplane, serial number 172S9611, was manufactured in 2004. It was powered by a Lycoming IO-360-L2A, 180-hp engine, and equipped with a McCauley model 1A17OE fixed pitch propeller. Review of the maintenance logbook records showed an annual inspection was completed on February 1, 2007, at a recorded airframe and engine (Hobbs) time of 154.9 hours. On June 29, 2007, the starter was documented as replaced at 144.3 hours tach time. At the post accident wreckage exam the Hobbs meter read 0201.8, and the tach read 0162.3. WRECKAGE AND IMPACT INFORMATION The wreckage was located at the departure end of runway 28 approximately 3 feet to the north of the runway tarmac overrun. The terrain was flat, sandy soil, with spots of sage brush. The initial point of impact was denoted by an 18-foot long scrape mark in the sand ending in a 12-inch deep divot that contained fragments from the left landing gear fiberglass wheel fairing. The divot was 30 feet east of the nose of the airplane. The airplane was aligned on a magnetic bearing of 070. The entire airplane was inverted and contained within the immediate vicinity of the initial impact point. The wings, tail, and engine were in their normally configured location in relation to the fuselage. The left side of the engine compartment and cockpit was crushed inward at a 30-degree angle. The engine had been displaced up and left. The outer 4 feet of the left wingtip was bent upward, and the wing itself buckled in chordwise direction along the aileron-flap interface. The left lift strut was buckled outward at mid length. The outer 4 feet of the right wingtip was bent upwards and the outboard section of wing exhibited wing skin buckling and oil canning. The tail was relatively undamaged. The horizontal stabilizer and elevator were in place, and the elevator trim actuator measured 1.1 inches, which, according to the manufacturer, corresponded to 5 degrees tab down, and is equivalent to a slight nose up or take off trim setting. Primary and secondary control cable continuity was established from the control surfaces to the cockpit area, and no evidence of cable binding or jamming was identified. Although the airplane had remained inverted over night, once the airplane was positioned upright, a bluish fluid with a petroleum odor was collected from the wing tanks, and tested negative for water contamination using 'SAR-Gel.' Approximately 10 gallons of fuel was collected from the airplane. Blue fluid stains originating at the left fuel filler cap and wing root were also identified on the upper surface of the wing. The engine has been displaced upward and left. The engine exam revealed no evidence of mechanical failure or malfunction. The propeller, a McCauley fixed pitch propeller, was attached to the crankshaft flange. The outboard 12 inches exhibited leading edge polishing, forward s-bends, blade tip curling, and general twisting along the longitudinal axis. Additional information regarding the wreckage as examined on-scene is contained in the official docket of this accident investigation. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot November 7, 2008, by the Riverside County Coroner Forensic Pathologist. The autopsy findings include a blood ethanol level of 0.31%, and micronodular cirrhosis of the liver. The cause of death was listed as "multiple blunt force trauma." The FAA Forensic Toxicology Research Team performed toxicology analysis from specimens obtained during the autopsy. The results of the analysis were negative for carbon monoxide and cyanide. The results were positive for the following volatiles; 285 mg/dL ethanol detected in blood, 333 mg/dL ethanol detected in vitreous, 259 mg/dL ethanol detected in muscle, 265 mg/dL ethanol detected in brain, 3 mg/dL methanol detected in blood, and 4 mg/dL methanol detected in vitreous. The drug atropine was detected in blood. The FAA had been informed of the CFI's prior DUI and driver's license suspension in 1990 or 1991, but had not requested details of the offense. The Federal Aviation Regulations (FAR) states that to be eligible for an airman medical certificate that the applicant has no established medical history or clinical diagnosis of substance dependence, except where there is established clinical evidence, satisfactory for the Federal Air Surgeon , of recovery, including sustained total abstinence from the substance for not less than the preceding 2 years (4 CFR 67.107(a)(4)(ii), 67.207(a)(4)(ii), and 67.307(a)(4)(ii)). ADDITIONAL INFORMATION Regulations FAA regulation 14 CFR 91.17, alcohol or drugs, in part, stated: (a) No person may act or attempt to act as a crewmember of a civil aircraft -- (1) Within 8 hours after the consumption of any alcoholic beverage; (2) While under the influence of alcohol; (3) While using any drug that affects the person's faculties in any way contrary to safety; or (4) While having .04 percent by weight or more alcohol in the blood. The FAA defines substance (including alcohol) dependence as "evidenced by (A) increased tolerance, (B) manifestation of withdrawal symptoms, (C) impaired control of use, or (D) continued use despite damage to physical health or impairment of social, personal, or occupational functioning" (14 CFR 67.107(a)(4)(ii), 67.207(a)(4)(ii), and 67.307(a)(4)(ii)). FAA regulations cited above note that a history or clinical diagnosis of substance dependence is specifically disqualifying. The FAA requires that airmen report a history of substance (including alcohol) dependence on each application for airman medical certificate. The FAA additionally requires that airmen report any convictions involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug and performs a National Driver Register (NDR) inquiry for each application for medical certificate to verify that all such convictions are in fact reported. Once the initial conviction is reported, the FAA may or may not require a substance abuse evaluation.
The flight instructor's failure to maintain sufficient airspeed to avoid a stall during takeoff-initial climb, and his impairment from alcohol.
Source: NTSB Aviation Accident Database
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