Aviation Accident Summaries

Aviation Accident Summary ERA09LA132

Hardin, KY, USA

Aircraft #1

N28RP

CESSNA 172

Analysis

The pilot arrived at the airport unannounced and rented the airplane with the stated intention to perform three takeoffs and landings to retain currency, and then fly the airplane to visit his daughter. The pilot subsequently called his daughter and stated that he was not going to make the flight. The pilot then departed the following morning, before sunrise. He flew approximately 50 nautical miles, and then turned around and flew back toward the departure airport. Approximately 10 miles from the departure airport, the airplane initiated a near vertical descent in excess of 6,000 feet-per-minute, and impacted the ground in a nose-low, wings-level attitude. Examination of the airplane and engine revealed no preimpact mechanical anomalies. Toxicological testing performed on the pilot revealed marijuana in the pilot's blood and lung tissue. The testing results suggested use of the illegal drug within about 3 hours of the accident, likely impairing him during the flight.

Factual Information

HISTORY OF FLIGHT On January 9, 2009, at 0600 central standard time, a Cessna 172F, N28RP, was substantially damaged while maneuvering in Hardin, Kentucky. The certificated private pilot was killed. Night visual meteorological conditions prevailed and no flight plan was filed for the flight that originated at Kyle-Oakley Field Airport (CEY), Murray, Kentucky. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the owner of the airplane, the pilot arrived unannounced at the airport on January 8, 2009, at 1800. He asked the owner if he could rent the airplane to perform three takeoffs and landings to retain currency, after which, he planned to fly to Marion, Illinois, to visit his daughter. The owner agreed to rent the airplane to the pilot and he assisted him in fueling the airplane with 22.7 gallons of fuel, topping off the tanks. The owner had no further contact with the pilot and assumed that he had flown the flight as planned. On the morning of the accident, the airport manager, who lived across the street from the airport, heard a Cessna 172 depart from the airport between 0500 and 0530. He reported that he also heard what he believed to be the accident pilot, on the night prior to the accident, performing takeoffs and landings. Two witnesses, who were on their front porch, witnessed an airplane in a nose-down attitude, continuously descending. The witnesses estimated the approach angle was too steep for a landing (greater than 30 degrees). They stated that the engine was running "smoothly," and the airplane had its lights on. The witnesses lost sight of the airplane behind a tree line, and shortly thereafter, they heard an impact. Air traffic control (ATC) information provided by the Federal Aviation Administration (FAA) revealed that the pilot of N28RP issued a "mayday" call at 0558. The call was heard on emergency frequency 121.5 by two separate airline crews and relayed to Memphis Center air traffic controllers. The airline crews reported the pilot of N28RP stated the "aircraft [was] out of control" and also mentioned his "elevator controls." The radio transmission by the accident pilot was not recorded. According to radar data, the airplane departed from CEY at 0438. It then proceeded north at an altitude of approximately 6,500 feet until it reached the area of DeKoven, Kentucky, where it turned around. The airplane continued back toward CEY at an altitude of approximately 6,800 feet. At 0556, the airplane was at an altitude of 7,100 feet and then initiated a rapid descent at rate of about 6,000 feet-per-minute, until it impacted the ground, about 10 miles north of CEY. PERSONNEL INFORMATION The pilot, age 50, held a private pilot certificate with a rating for airplane single-engine land, issued on November 28, 2007. His most recent FAA third-class medical certificate was issued on February 28, 2007. At that time, he reported 7 hours of total flight experience. Examination of the pilot's logbook revealed entries from January 3, 2007 to December 30, 2008. During this time, the pilot logged 102 hours of total flight experience, 63 of which were accumulated as pilot in command. In the preceding 90 days, the pilot logged 1.3 hours of flight experience. AIRCRAFT INFORMATION According to the airframe and engine logbooks, the most recent annual inspection was completed on September 24, 2008, at a total aircraft time of 6,400 hours, with no anomalies noted. The airplane had flown 69 hours since the last inspection, and no non-routine maintenance entries were noted in the logbook since the inspection. METEOROLOGICAL INFORMATION Weather, reported at Barkley Regional Airport (PAH), Paducah, Kentucky, 33 miles northwest of the accident site, at 0553, included calm winds, 10 miles visibility, clear skies, temperature -2 degrees Celsius (C), dew point -8 degrees C, and an altimeter setting of 30.08 inches of mercury. Weather, reported at Outlaw Field Airport (CKV), Clarksville, Tennessee, 50 miles southeast of the accident site, at 0552, included winds from 310 degrees at 4 knots, 10 miles visibility, clear skies, temperature 0 degrees C, dew point -8 degrees C, and an altimeter setting of 30.05 inches of mercury. According to recorded astronomical data, at the accident site location, sunrise occurred at 0706. There was no record of the pilot receiving a preflight weather briefing, in-flight weather briefing or filing a flight plan. WRECKAGE AND IMPACT INFORMATION Ground impact marks, and an examination of the wreckage and accident site by an FAA inspector, revealed that the airplane had impacted a field in a nose-low, wings-level attitude. According to the FAA inspector, it appeared the nosewheel impacted the ground first, followed by the engine/forward cowling, then the main wheels, and the leading edges of the wings. The airplane came to rest inverted, 105 feet from the initial point of impact. The leading edges of both wings displayed symmetrical crushing damage. All flight control surfaces remained attached and flight control continuity was established between the cockpit controls and each respective flight control surface. The elevator trim tab actuator was measured and corresponded to 3 degrees tab up. The flaps were in the retracted position and the flap jackscrew measurement corresponded to a flaps 0-degree setting. The throttle control was bent over in the idle position and the mixture was bent over in the full rich position. Examination of the tachometer displayed 6,469.18 hours of total time. A sample of fuel was drained from the right wing fuel tank, and no contamination was noted. The impact-damaged fuel selector was selected to the right tank; however, air could not be blown unrestricted through the valve to the right tank position. Disassembly of the valve revealed that an o-ring was loose inside the valve body and the actuating balls were riding high on the cam, which prevented the valve from opening. The o-ring was not damaged and the upper portion of the valve separated and was missing. The upper portion of the valve prevents the actuation balls from riding up on the cam. The engine was separated from the airplane and located about 250 feet from the main wreckage. The propeller was also separated from the engine and one of the blades was bent aft approximately mid-span. Most of the engine accessories were broken free from the engine assembly during the impact. Both magnetos were located and produced spark when rotated. The oil filter displayed no metal fragments, and the carburetor and gascolator had traces of fuel in them and displayed no anomalies. The vacuum pump remained attached to the crankcase and exhibited impact damage. The vacuum pump drive shaft was intact and turned freely when rotated by hand. Valve train continuity was confirmed to all cylinders by rotating the crankshaft at the vacuum pump accessory drive. MEDICAL AND PATHOLOGICAL INFORMATION The State of Kentucky, Office of the Chief Medical Examiner, performed an autopsy on the pilot on January 10, 2009. The cause of death was multiple blunt force injuries. The FAA Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma conducted toxicological testing on the pilot. According to the testing, 0.0075 ug/ml TETRAHYDROCANNABINOL (MARIHUANA) and 0.0291 ug/ml TETRAHYDROCANNABINOL CARBOXYLIC ACID (MARIHUANA) was detected in the pilot's blood. Additionally, 0.5387 ug/ml TETRAHYDROCANNABINOL (MARIHUANA) and 0.0201 ug/ml TETRAHYDROCANNABINOL CARBOXYLIC ACID (MARIHUANA) was detected in the pilot's lung. According to the Aerospace Medical Certification Division of the FAA, the pilot had two applications for medical certificates on file dated February 28, 2007, and December 7, 1990. On the 2007 application, the pilot noted 7 hours total flight time, with no entry for the last six months. That application indicated "No" for “Do You Currently Use Any Medication” and for all items under “Medical History,” including specifically “Substance dependence or failed a drug test ever, or substance abuse or use of illegal substance in the last 2 years” and “Alcohol dependence or abuse.” The application noted “No” to “History of any conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug…” and “No” to “History of non-traffic conviction(s) (misdemeanors of felonies).” The only other application was a limited electronic record of an application dated December 7, 1990, noting 10 hours total flight time with no entry for the prior 6 months. That record also noted "No" to all entries except for "Hay fever or allergy" and "Other illness, disability, or surgery," with no explanations in the electronic record. TESTS AND RESEARCH The fuel selector valve was sent to the NTSB Materials Laboratory for further examination. According to the Materials Laboratory Factual Report, the damage to the cam shaft was consistent with mechanical overload. Two washers were observed on the cam shaft below the o-ring that would seal up against the valve cover when the valve is assembled. The illustrated parts catalog for the airplane indicated only one washer in the illustration and accompanying parts list. The additional washer would locate the actuating cam slightly lower within the valve body. The actuating cam displayed a black colored smear on its lower portion, consistent with material transfer from the erroneous presence of a loose o-ring within the valve body. The illustrated parts manual incorrectly depicts the o-ring installed ahead of the retainer. To correctly assemble the valve, the retainer should be installed ahead of the o-ring. The o-ring found in the valve body was examined under stereo microscope and no discernible wear was observed. The condition of the valve's internal components and the loose o-ring found within the valve body did not provide adequate information to establish whether or not the valve was functioning properly prior to the accident. ADDITIONAL INFORMATION According to personnel at Williams County Regional Airport (MWA), Marion, Illinois (the pilot's reported destination), there was no record of the airplane making a stop on the night before or the day of the accident. The pilot's daughter reported that he called her on the night prior to the accident, at 1900. He stated he had just finished doing "touch and go's" and was thinking about coming to see her. She further stated that he subsequently called her back around 2200, and said he wasn't going to make the flight, as he was concerned that he may encounter winter weather. The pilot's daughter additionally reported that she lived near Chicago, Illinois, and not near Marion (280 miles to the southeast), as the pilot reported to the airplane's owner. According to 14 CFR Part 91.17, "No person may act or attempt to act as a crewmember of a civil aircraft…while using any drug that affects the person's faculties in any way contrary to safety."

Probable Cause and Findings

The pilot's failure to maintain aircraft control and his impairment from illegal drug use.

 

Source: NTSB Aviation Accident Database

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