Bryan, TX, USA
N1041J
ROCKWELL 112
A review of the pilot's logbooks revealed that he had flown two flights in the airplane several days before the accident flight for a total of 2.8 flight hours. The airplane was not refueled after those flights. About 1.4 hours after takeoff on the accident flight, the pilot reported that he was "running out of fuel," and the airplane subsequently started descending. A witness reported seeing the airplane at a low altitude and then suddenly turn and depart controlled flight, indicating than an aerodynamic stall had occurred. The airplane impacted terrain in the parking lot of an apartment complex in a congested urban area. Engine data monitor information for the accident flight showed that, for most of the flight, the airplane had an average fuel flow of about 14.7 gallons per hour. The airplane had a total useful fuel capacity of 62 gallons. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. It is likely that the pilot improperly planned how much fuel he would need for the accident flight and that the airplane ran out of fuel, which resulted in a loss of engine power due to fuel exhaustion. The pilot's medical records revealed a diagnosis of major depression, and toxicology testing found medications in the pilot's body consistent with the treatment of this condition. The pilot's depression had been documented and treated since 1989, but the treatment and medications were inadequately reported to the Federal Aviation Administration on the pilot's recent airman medical applications and would have disqualified him from obtaining an airman's medical certificate. The pilot's depression and the medications he was taking would have significantly degraded his cognitive abilities, including executive functioning and judgment, and likely led to his failure to recognize the fuel shortage earlier and his improper decision to fly with disqualifying medical conditions.
HISTORY OF FLIGHT On May 28, 2011, at 2044 central daylight time, a Rockwell 112, single engine airplane, N1041J, impacted terrain during a forced landing at Bryan, Texas. The pilot and passenger were fatally injured. No persons on the ground were injured. The airplane sustained substantial damage. The airplane was registered to a private individual and was being operated by another private individual for the 14 Code of Federal Regulations Part 91 personal flight. Dusk visual meteorological conditions prevailed and a flight plan had not been filed. The flight had originated from Fort Worth Spinks Airport (FWS), Fort Worth, Texas, about 1922 and was en route to Scholes International Airport (GLS), Galveston, Texas. A witness statement and fueling records show that the airplane was last refueled on May 25, 2011. Other records showed that the pilot made two flights of 1.4 hours each, totaling 2.8 hours, on May 26, 2011. Another witness reported the pilot may have made two other local flights on either May 26, or May 27, 2011, and records show the airplane was not refueled after any of those flights. On the day of the accident the airplane was in cruise flight about 9,500 feet mean sea level (msl) when the pilot advised the controller that he wanted to make a fuel stop at Easterwood Field Airport (CLL), College Station, Texas. The airplane then made a right turn of about 90 degrees and began descending toward CLL. Several minutes later the pilot reported that he was "running out of fuel". When the airplane was at 600 feet msl the pilot reported that he would not make the airport. A witness at an apartment complex reported seeing the airplane flying "extremely low" and parallel to the road when he saw it suddenly turn right and head toward the witness's location. The airplane struck terrain and an unoccupied automobile in the parking lot of the apartment complex and came to rest upright; 47 feet from the initial impact point. PERSONNEL INFORMATION The 57-year old pilot held a private pilot certificate issued by the Federal Aviation Administration (FAA) with ratings for airplane single engine land and instrument airplane. The pilot's flight review requirement was successfully completed on May 18, 2010. A third class medical certificate was issued by the FAA on July 1, 2010. As of May 26, 2011, the pilot had logged a total of 460.6 hours of flight experience, with 259.6 of those hours in the accident airplane make and model; 18.2 of those hours were in actual instrument conditions, an additional 49.9 of those hours were in simulated instrument conditions, and a total of 18.8 hours of night flight time. AIRCRAFT INFORMATION The four-seat, low-wing, retractable gear airplane, serial number (s/n) 41, was manufactured in 1973. It was powered by a 200-hp Lycoming IO-360-C1D6 engine, serial number L-9193-51A, which drove a Hartzell 3-blade metal alloy controllable pitch propeller. The engine was equipped with a pilot controlled manual waste gate turbo-normalized system manufactured by RCM Normalizing Inc., installed under FAA Supplemental Type Certificate Number SE5203NM. The airplane had fuel tanks in each wing which had a total useful fuel capacity of 62 gallons. The aircraft maintenance logbooks were not available for examination. However, the pilot's aircraft usage spreadsheet, pilot's personal logbook, and several individual flight planning documents were found in the wreckage. The investigator-in-charge (IIC) reviewed those documents and estimated that the most recent annual inspection was completed on May 24, 2011, at a tach time of 2,937.18 hours, which is the IIC's estimate of the aircraft total time. METEOROLOGICAL INFORMATION The closest official weather observation station was CLL, located 2 nautical miles south of the accident site. The elevation of the weather observation station was 320 feet msl. At 2053, the automated weather observing system at CLL reported wind from 170 degrees at 13 knots, visibility of 10 miles, clear of clouds, temperature 29 degrees C, dew point 21 degrees C, with an altimeter setting of 29.71 inches of Mercury. Data from the U. S. Naval Observatory showed that moonset occurred at 1648, sunset occurred at 2021, and the end of civil twilight occurred at 2048. COMMUNICATIONS AND RADAR The airplane was in cruise flight about 9,500 feet mean sea level (msl) and the pilot was receiving flight following from the Houston Air Route Traffic Control Center (ARTCC). At 2029, when the airplane was about 25 miles northeast from CLL, the pilot advised the ARTCC controller that he wanted to make a fuel stop at CLL. The ARTCC controller instructed the pilot to contact the tower controller at CLL. The airplane then made a right turn of about 90 degrees and began descending toward CLL. At 2035:30 the airplane was at 7,000 feet msl and about 11 miles from CLL when the pilot made his initial radio contact with the tower controller at CLL and he reported that he had to make a "fuel stop". At 2036:40 the pilot advised the controller that he was "running out of fuel". At 2037 the controller advised the aircraft rescue and firefighting (ARFF) unit of an Alert 2. At 2040:32 the airplane was at 3,000 feet msl and about 4 and 1/2 miles from CLL when the pilot reported that he had the airport in sight and would be landing on runway 16. At 2043:40 the airplane was at 600 feet msl when the pilot reported that he would not make the airport. There were no further communications from the pilot and last radar return was at 2043:46. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was located in the parking lot of a large apartment complex about 2 miles north of CLL. The area from the northwest through the southwest for a distance of over three miles was a congested urban area. The initial impact crater was about 47 feet from the main wreckage final resting location. Debris and ground scars led from the crater on a direction of 235 degrees to the main wreckage which came to rest about 45 feet from the nearest building of the apartment complex. The nose of the airplane's upright fuselage was oriented to 358 degrees. Aircraft debris and all portions of the airplane were found at the scene within a radius of about 100 feet from the final resting location. There was impact damage to the leading edges of both wings and to the engine and forward fuselage. Both wings exhibited aft accordion crushing along their leading edges with corresponding impact scars on the ground. The right wing was bent up and aft at mid-span. Both wings remained attached to the fuselage and no hydraulic deformation was observed to either wing. No fuel was detected in the fuel tank in either wing. The left and right wing flaps remained attached. Both ailerons remained attached or partially attached. The left and right main landing gear were impact damaged, but observed to be retracted and still in the gear wells. The nose gear was impact damaged and was protruding slightly out of the nose gear well. The rear empennage remained attached to the fuselage and was bent slightly over the top portion of the fuselage in scorpion tail fashion. The elevator trim tab was observed in the neutral position. The elevator and rudder remained attached with no significant damage noted. The engine remained attached to the fuselage and the propeller remained attached to the engine. The bottom of the engine cowling displayed impact and crushing damage and the engine mount was bent slightly up. The upper engine cowling was detached and found with other debris near the main wreckage. The gascolator was examined and had a small amount of clean aviation gasoline. The fuel screen was clear. The flow divider was opened and examined and no fuel was seen. The three-blade propeller displayed impact damage on the forward face of one blade which was bent aft about 90 degrees at mid-span. The other two propeller blades displayed superficial damage. The propeller spinner had crushing damage, but there was no evidence of rotation at impact. The lower portion of the forward fuselage was crushed up and aft. The cockpit area had crushing damage that reduced the occupiable space for the front seat occupants. The fuel selector valve handle was observed in the BOTH position. A J.T. Instruments EDM-700 engine data monitor and a Fujitsu Stylistic Tablet PC electronic flight bag computer were removed from the wreckage and sent to the National Transportation Safety Board's (NTSB) vehicle recorder division for examination. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the Travis County Office of the Medical Examiner in Austin, Texas. The cause of death was listed as blunt force injuries. Forensic toxicology was performed on specimens from the pilot by the FAA, Aeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated: NO CARBON MONOXIDE detected in Blood; NO CYANIDE detected in Blood; NO ETHANOL detected in Vitreous; Fluoxetine detected in Blood and Urine; Norfluoxetine detected in Urine and Blood; Quinine detected in Urine. The NTSB Chief Medical Officer reviewed the IIC's narrative, the autopsy report, the toxicology results, the pilot's FAA airman medical certification file, and the pilot's personal medical records. The toxicology evaluation identified quinine, fluoxetine, and its primary metabolite, norfluoxetine, in urine, and fluoxetine (1.515 ug/ml), and norfluoxetine (1.036 ug/ml) in cavity blood. Therapeutic levels for fluoxetine are 0.09 to 0.40ug/ml but it can become concentrated in cavity blood post mortem. Quinine is an antimalarial drug which is also found in tonic water. At usual doses, it does not affect performance. Fluoxetine, marketed under the trade name Prozac, is an atypical antidepressant in the class of selective serotonin reuptake inhibitors. Fluoxetine carries official FDA warnings: "Side effects of fluoxetine include insomnia, anxiety, and headache; manic behavior and suicidal ideation have also been reported. Warnings - may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." Prescription bottles were found in the wreckage. There were bottles with the pilot's name for fluoxetine, Abilify (aripiprazole), Tramadol (ultram), Lyrica (pregabalin), and simvastatin. Aripiprazole is used to treat bipolar disease and as an adjunct in major depression which is non-responsive to first line treatments. It carries a specific FDA warning, "use caution when operating machinery." Ultram is a synthetic opioid pain reliever used to treat moderate to severe pain. Concomitant administration of ultram and selective serotonin reuptake inhibitors has been demonstrated to increase the risk of seizure and serotonin syndrome. In addition, ultram carries a specific FDA warning, "may impair the mental and physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery". Pregabalin is indicated as treatment for pain and to prevent partial complex seizures. It carries a specific FDA warning: "may cause dizziness and somnolence and impair patient's ability to drive or operate machinery". The FAA's toxicology lab does not test for pregabalin. The ultram was an "as needed" medication and may not have been taken recently. The dosing regimen for the aripiprazole had been increased by the physician only a few weeks before the crash. According to the pilot's personal medical records, the pain medications were prescribed for a nerve impingement syndrome in his neck and shoulder. Records show intermittent use of antidepressants and anxiety medications from 1989 forward. In January 2011, although he was already taking fluoxetine, the pilot suffered a recurrence of major depression and required escalating doses of fluoxetine and the addition of aripiprazole. At the time of the fatal crash the medical records showed the pilot's depression had improved, but not resolved, and his mediations were still being adjusted. A review of the FAA airman medical certification file revealed the pilot's first medical certificate was issued in 1978 and was re-issued without limitations or deferment periodically until 1989 the pilot reported a DUI conviction and both a hospitalization and medication use for depression. His application was deferred and multiple documents were requested by the FAA. In November, 1990, the pilot's application for a medical certification was denied. In 1992, the pilot reapplied and, after supplying documentation of resolution of his major depression and reporting that he was off all medications, he was issued a third class certificate. This contained a request that when he reapplied for a medical certificate, he include a current status report from the treating physician. The pilot failed to provide the status report on his re-examination in 1994 and his certificate was deferred. By May 1995, the necessary report (demonstrating stability) had been provided and the medical certificate was issued. The pilot next applied for a medical certificate in 2008 and was issued a third class certificate after reporting he was taking Zocor and that all of his previous issues were "previously reported, no change". The pilot's most recent medical certificate (third class) was issued on July 1, 2010, with a limitation "must have available glasses for near vision". The only medication then reported by the pilot was simvastatin (marketed under the trade name Zocor). TESTS AND RESEARCH Wreckage examination: The wreckage was moved to another location and examined. The engine and cowling were still attached. The wings had been cut at the root and the tail section had been removed to facilitate transport. All components of the airplane were present. Both wings were examined and neither wing had any blue fuel staining or displayed any hydraulic deformation. Both wing fuel tanks were opened and examined. Both fuel tank transmitters were examined and a resistance test was performed on the transmitters, it was noted that the left wing transmitter functioned nominally, the right wing transmitter was observed to indicate the aircraft right side fuel gauge would read "empty" when there were approximately five gallons remaining in the tank. All three primary flight controls were examined. Control cable continuity was confirmed from the main wing spar aft for the Rudder and Elevator. Aileron flight control continuity was verified from the fuselage to wing mate cut lines to both the left and right ailerons. The engine was removed from the airplane and the engine and all components were examined. Approximately one quarter of an ounce of aviation fuel was recovered from the inlet fuel screen housing of the fuel injector. The fuel sample tested negative for the presence of water. No other fuel was observed in the engine. An unmeasured amount of oil was observed in the oil sump and there was no evidence noted of thermal distress or lubrication distress. The postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Examination of devices containing non-volatile memory (NVM): The airplane was equipped with a J. T. Instruments EDM-700 engine data monitor (EDM) which records several engine parameters including fuel flow, exhaust gas temperature (EGT). The EDM device was examined at the NTSB vehicle recorder division in Washington, D.C., and data was extracted. EDM data for the accident flight showed that fuel flow increased to about 20 gallons per hour about nine minutes after the start of data at an estimated takeoff time of 1922. About 22 minutes later the fuel flow decreased, and for about the next 50 minutes it remained at an average of about 14.7 gallons per hour. During that time the EGT was operating at an average temperature above 1,200 degrees F. At an estimated time of 2032, about one hour and 20 minutes after the start of data, the fuel flow decreased to about 13 gallons per hour, and the EGT then reduced about 200 degrees. Four minutes later, at
The pilot's inadequate fuel planning, which resulted in a loss of engine power due to fuel exhaustion, and his improper control inputs following the loss of engine power, which resulted in an aerodynamic stall and subsequent loss of control. Contributing to the accident was the pilot's impaired judgment, which led to his failure to recognize the fuel shortage earlier and his improper decision to fly with disqualifying medical conditions.
Source: NTSB Aviation Accident Database
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