Aviation Accident Summaries

Aviation Accident Summary CHI08FA135

Stevens Point, WI, USA

Aircraft #1

N1813T

PIPER PA-28-140

Analysis

The airplane was taking off and experienced a loss of engine power during the initial climb. Witnesses on the ground observed smoke off of the end of the runway from the postimpact fire. An examination of the accident scene showed a ground scar containing green glass pieces from the right navigation light and pieces of the right wing tip. A nearby ground depression was consistent with the shape of the engine cowling. An examination of the propeller showed damage signatures consistent with the engine at low power. No preimpact anomalies were revealed with the airplane during the investigation.

Factual Information

HISTORY OF FLIGHT On May 12, 2008, about 1700 central daylight time, a Piper PA-28-140, N1813T, owned and piloted by a private pilot, sustained substantial damage when it impacted terrain south of runway 12 (3,635 feet by 75 feet, dry, asphalt) at the Stevens Point Municipal Airport (STE), near Stevens Point, Wisconsin. A post-impact fire occurred. The personal flight was operating under 14 CFR Part 91 and no flight plan was on file. Visual meteorological conditions prevailed at the time of the accident. The pilot and passenger were fatally injured. The flight was originating from STE at the time of the accident and was destined for the J. Douglas Bake Memorial Airport (OCQ), near Oconto, Wisconsin. A refueling receipt showed that the airplane was serviced with 27.4 gallons of "auto" fuel at OCQ on May 12, 2008, prior to its departure to STE. A witness at the fixed base operator (FBO) at STE recalled that the pilot and passenger checked the weather computer prior to their departure from STE. Another witness flying on downwind for runway 12 said that he heard a pilot announce on the common traffic advisory frequency a takeoff from runway 12. He heard no further transmissions as he turned base on approach to runway 12. He saw smoke off the departure end of runway 12 and advised the FBO of a possible airplane down. He flew over the area and observed the accident airplane. The airplane's center section was "engulfed in fire." The pilot radioed the FBO and confirmed that it was a "downed" airplane. Review of a video record from a ramp camera at STE showed an airplane was departing runway 12 about 1659. About 1700, a plume of smoke is observed in the recording. PERSONNEL INFORMATION The 56 year old pilot held a Federal Aviation Administration (FAA) private pilot certificate with a single-engine land airplane rating. A review of a copy of the pilot's logbook indicated that his most recent flight review was completed on July 27, 2007. The last recorded entry was dated April 20, 2008, and the logbook showed that the pilot had accumulated 278.2 hours of total flight time. The following medical information was extracted by the National Transportation Safety Board (NTSB) Medical Officer from records maintained on the pilot by the FAA Aerospace Medical Certification Division: 11/1/04 - An application for 3rd class Airman Medical Certificate indicates "Yes" for "Do you currently use any medication" and notes the use only of atorvastatin. The application notes "Yes" to "Diabetes" and "No" to all other items under "Medical History." Under "Comments on History and Findings" is noted, in part, "... Recent diagnosis of Type II diabetes, recently started on Actos [pioglitazone] and glyburide. Random sugar today 250 mg%. ..." Total pilot time is noted as 67 hours with 2 hours in the previous 6 months. Also noted is "No Certificate Issued - Deferred for Additional Evaluation." 11/3/04 - Personal physician's note indicates, in part, that the pilot "...works as a truck driver and is also pursuing a pilot's license and he saw [another doctor] for a DOT exam 2 days ago, who called me indicating he was off his meds and his nonfasting glucose was 500. ... he has been pulled off the road for now." 12/7/04 - A letter from the Manager of the Aerospace Medical Certification Division notes, in part, "We have received FAA Form 8500-8, Application for Airman Medical Certification, dated November 1, 2004. For further consideration regarding your diabetes mellitus requiring oral hypoglycemic medication for control, please submit ... A current status report from your treating physician regarding your diabetes mellitus in accordance with the enclosed specification sheet. Upon receipt of this information, we will notify you regarding your eligibility for medical certification." 1/14/05 - A letter from the Manager of the Aerospace Medical Certification Division notes, in part, "A careful review of your application and physical examination performed on November 1, 2004, discloses that you do not meet the medical standards ... By virtue of your failure to provide requested information as outlined in our letter dated December 7, 2004 ... we have no alternative except to deny your application for Aerospace Medical Certification." 1/9/06 - Personal physician's note indicates, in part, that the pilot "... has a history of poor compliance. Note when last seen in June his hemoglobin A1c was elevated and I increased his glyburide ... and he was told to return for a recheck in 3 months which he did not do. He states his Accu-Checks typically range 180 to 210. He states that when he gets a low reading in the 120s his feet will sting or tingle. ... He gets no regular exercise ... has apparently been unable to fly because of his poorly diet controlled diabetes ...Have tried again to emphasize the necessity of good diabetic control ... emphasized the fact that his diabetes has never been well controlled. ..." 2/15/06 - An internal FAA electronic memo from the Manager of the Aerospace Medical Certification Division (AMCD) notes, in part, "I see that the airman's treating physician mentions history of poor control but based on the hemoglobin A1c levels given to AMCD he can be issued a time-limited certificate and a 6 year Authorization." 2/23/06 - An Authorization for Special Issuance of a Medical Certification from the Manager of the Aerospace Medical Certification Division notes, in part, "I have reviewed the information submitted by you in support of your request for an airman medical certificate. The medical information reveals a history of diabetes mellitus requiring oral hypoglycemic medication. You are ineligible for medical certification .... I have determined, however, that you may be granted an Authorization for special issuance of a third-class airman medical certificate ... Enclosed is your medical certificate with the restriction 'Not valid for any class after November 30, 2006.' You must promptly report any adverse changes in your medical condition to the AMCD at the above address. ... Because of your history of diabetes mellitus, operation of aircraft is prohibited at any time new symptoms or adverse changes occur or if you experience side-effects from, or require a change in medication." 3/19/07 - A letter from the pilot's personal physician notes, in part, that the pilot "... was last seen by me on March 5, 2007. He continues to take glyburide 5 mg tablets one twice a day, Actos 45 mg every day, Byetta [exenatide] 10 micrograms twice a day. Reviewing his Accu-Check readings the 14 and 28 day average is 129. He has had no significant hypoglycemic episodes and has been instructed on how to deal with these should they occur, always have some type of sugar available. His hemoglobin A1c was 7.0 which is considerably improved from his previous Hemoglobin A1c of 10.2 on December 4, 2006. There is no evidence of any cardiovascular, neurologic, renal, or ophthalmologic complications. I note that his most recent diabetic eye examination was on February 24, 2006 ... and there was no background retinopathy noted at that time. ..." 3/30/07 - The pilot's most recent application for 3rd class Airman Medical Certificate indicates "Yes" for "Do you currently use any medication" and notes the use of pioglitazone, atorvastatin, exenatide, and glyburide. The application notes "Yes" to "Diabetes," "Admission to hospital," and "Other illness, disability, or surgery." Under "Comments on History and Findings" is noted, in part, "... shoulder surgery ... good control of Type II diabetes ..." Height is noted as 70 inches and weight as 223 pounds. Total pilot time is noted as 231 hours with 17 hours in the previous 6 months. 5/11/07 - A letter to the pilot from the Manager of the Aerospace Medical Certification Division notes, in part, "Our favorable review of your interim follow-up reports regarding your history of diabetes has established that you are eligible for continued Authorization for Special Issuance of a third-class airman medical certificate ... The certificate issued by your AME is "Not valid for any class after March 31, 2008". ... Please be advised, you must demonstrate more consistent glycemic control on future evaluations. Failure to do so may jeopardize continued special issuance medical certification. ... Because of your diabetes, operation of aircraft is prohibited at any time new symptoms or adverse changes occur or if you experience side effects, or require a change in medication, or for 2 hours after use of the medication Byetta. ..." AIRCRAFT INFORMATION N1813T, a 1971 Piper PA-28-140, serial number 28-7125165, was a single-engine, low wing, four-place airplane, with fixed tricycle landing gear. The airplane was powered by a 150-horsepower Lycoming O-320-E2D engine, serial number L-21766-27A, which was a four-cylinder, normally aspirated, reciprocating engine. Its propeller was a fixed pitch, two-bladed, Sensenich 74DM6-0-58, with serial number K31196. Review of the maintenance logbooks indicated the airplane's most recent annual inspection was completed on May 15, 2007. The entry for that inspection showed that the airplane had accumulated 3,185.35 hours of total time and that the engine had accumulated 1,061.35 hours since major overhaul. METEOROLOGICAL INFORMATION At 1655, the recorded weather at STE was: Wind 180 degrees at 7 knots; visibility 10 statute miles; sky condition clear; temperature 17 degrees C; dew point 0 degrees C; altimeter 29.91 inches of mercury. AIRPORT INFORMATION The airport elevation at STE was 1,110 feet above mean sea level. STE was an uncontrolled airport with two runways, 3/21 and 12/30. Runway 3/21 was 6,028 feet by 120 feet wide. Runway 12/30 was 3,635 feet by 75 feet wide. Both runways' surfaces were composed of asphalt. The airport listed a Unicom frequency of 122.7 megahertz as its common traffic advisory frequency. WRECKAGE AND IMPACT INFORMATION The airplane was found about 250 yards south of the departure end of runway 12. Its fuselage, empennage, and left wing came to rest upright on about a 15-degree magnetic heading. The right wing was detached from the fuselage and it was found inverted. An aileron control cable was found intact between the right wing and fuselage. The fuselage was melted, deformed, charred, and consumed consistent with a ground fire. The wings, cowling, and engine sustained fire damage consistent with a ground fire. A ground scar was found 60 feet from the center of the fuselage. Green glass like media was found in the area of that scar. A depression consistent with the frontal shape of the cowling was found 38 feet from the center of the fuselage. The magnetic heading from that scar and that depression to the center of the airplane's fuselage was 270 degrees magnetic. Control cables were traced from the flight controls in the cockpit to their respective flight control surface. All breaks in the cables were consistent with overload. The engine control cables were traced from the cockpit to the engine. Engine control and flight control continuity was established. The flap handle position was found near the first notch of flaps. The flap handle was not engaged in that first notch. A cabin door hinge was found intact. The cabin door latch was found intact and extended in the locked position. The propeller remained attached to the engine's crankshaft propeller flange. One propeller blade was bent rearward and the other blade did not reveal any damage. The propeller flange was bent rearward on the same side that the propeller was. Removal of the propeller allowed the engine crankshaft to be rotated. The top sparkplugs were removed and they exhibited no anomalies. Each cylinder produced a thumb compression when the crankshaft was rotated. Valve rockers operated when the crankshaft was rotated. Disassembly of the carburetor and fuel pump revealed no anomalies. Both magnetos sustained fire damage and did not produce a spark when they were rotated. Examination of the muffler's baffles revealed that they were intact. The fuel selector valve allowed air pressure to flow through the fitting for the right fuel tank and the air was felt discharging from the valve's fitting to the engine. Air pressure was applied to the valves fitting for the left fuel tank and no air was felt at the fitting to the engine. No pre-impact airframe or engine anomalies were detected. MEDICAL AND PATHOLOGICAL INFORMATION The Office of Coroner, Portage County, Wisconsin, performed an autopsy on the pilot. The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report. The report stated: PIOGLITAZONE detected in Blood PIOGLITAZONE detected in Urine The following medical information was extracted by the NTSB Medical Officer, from the report of autopsy: Cause of death is noted as "Massive Blunt Force Chest Trauma." Under "Gastrointestinal Tract" is noted, in part, "The stomach contains approximately 100 cc of a partially digested food matrix with tan-white fragments of unrecognizable food particles admixed with a brown yellow-tan mucoid matrix." An e-mail from the coroner notes, in part, that the pilot was "a type II insulin dependent diabetic and in his medical records described as being 'poor controlled.' Was last seen Dec. 07, 2007 and was started on a long acting insulin (U-100)."

Probable Cause and Findings

The partial loss of engine power for undetermined reasons.

 

Source: NTSB Aviation Accident Database

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