Cold Springs, NV, USA
N9831V
CESSNA R172K
The pilot, who held an instrument rating, was flying the airplane for the owner, who did not hold an instrument rating, from the departure airport, where instrument meteorological conditions (IMC) prevailed, to another airport, where visual meteorological conditions prevailed. Forecast weather conditions along the route of flight called for areas of mountain obscuration and precipitation, including snow. The pilot filed an instrument flight rules (IFR) flight plan, and he was issued an IFR clearance. About 44 minutes into the flight, the pilot canceled the IFR clearance and continued the flight under visual flight rules (VFR). About 16 minutes later, the pilot amended the flight’s destination to an airport that was along the route of flight, but closer than the original destination, and about 19 minutes after that, the air traffic controller told the pilot that radar service was terminated. About 1.5 hours after radar service was terminated, the airplane impacted mountainous terrain at an elevation of about 6,400 feet mean sea level (msl). The wreckage was confined to the impact area, and the damage was consistent with controlled flight into terrain. The accident site was located along the route of flight beyond the amended destination and about 20 miles short of the original destination, indicating that the pilot had over flown the amended destination and may have been attempting to reach the original destination. About 30 minutes before the accident, light rain and mountain top obscuration were reported in the vicinity of the original destination airport. At the time of the accident, the original destination airport was reporting cloud layers with bases about 6,300 and 6,800 feet msl. Given the forecast and reported weather conditions, it is likely that the pilot encountered IMC and was unable to see the terrain prior to the airplane colliding with it. The toxicology report for the pilot showed positive results for amphetamine, methamphetamine, and trimethoprim, an antibiotic used to treat infections. However, it could not be determined from available samples when the amphetamine and methamphetamine had been ingested, and, therefore, whether they would have impaired the pilot’s performance. Review of the pilot's medical records indicated that he had diabetes, and, one day prior to the accident, he had been treated for a skin infection. It is possible that the pilot was distracted by his medical condition and that this may have impaired his performance and contributed to his decision to continue the VFR flight into deteriorating weather conditions.
HISTORY OF FLIGHT On May 28, 2011, approximately 1800 Pacific daylight time (PDT), N9831V, a Cessna R172K, collided with terrain about 4 miles north-northwest of Cold Springs, Nevada. The owner was operating the privately owned airplane under the provisions of Title 14 Code of Federal Regulations Part 91. The airplane was substantially damaged. The instrument-rated private pilot, the airplane owner, who held a private pilot certificate, and a passenger, sustained fatal injuries. A combination of visual and instrument meteorological conditions existed along the route of flight. At the time of the accident, the pilot was not operating under a flight plan or visual flight rules flight following. The airplane departed Roseburg, Oregon, operating under an instrument flight rules clearance at 1507. According to personnel at the Roseburg fixed-base-operator (FBO), the airplane owner had likely flown to Roseburg on Friday, May 27. On Saturday, the airplane owner contacted the FBO to query whether or not there was an instrument-rated pilot that could fly the airplane from Roseburg to Albuquerque, New Mexico, and be reimbursed for expenses. The pilot was contacted, and arrived at the airport to check out the airplane prior to the flight. He also filled the fuel tanks to capacity. According to the personnel at the FBO, the pilot intended to fly the owner and passenger to Reno International Airport, Reno, Nevada, and then return to Roseburg, as weather conditions improved along the route of flight after Reno. According to the owner of Ocean Air, a flight school at Roseburg, the airplane owner needed a pilot with an instrument rating to fly the airplane out of Roseburg. He indicated that the aircraft owner likely arrived on Friday because when the owner arrived to work on Saturday morning, the airplane was parked on the ramp. The airplane owner contacted the owner of Ocean Air by telephone and asked if he knew of someone with an instrument rating that could fly the airplane to Albuquerque, New Mexico. The owner of Ocean Air put him in touch with the pilot. Prior to their departure, the pilot and aircraft owner flew around the pattern so that the pilot could become familiar with the airplane. The airplane was topped off with fuel prior to departure. According to the owner of Ocean Air, the pilot was not being paid for the flight, but being reimbursed for his expenses. He was building time for his commercial rating. The airplane was reported missing on May 31 by the pilot's family, and an Alert Notice (ALNOT) was issued. The wreckage was located at 1915 PDT on May 31. PERSONNEL INFORMATION Pilot The pilot, age 47, held a private pilot certificate for single-engine land and instrument. He held a second-class medical certificate issued on June 22, 2009, with the restriction that he must wear corrective lenses. The pilot was located in the left seat. According to a friend of the pilot, he was trying to accrue flight hours as he was working on his commercial certificate. A review of the pilot's logbook showed that he had 342 hours, with 12 hours flown in the last 30 days. The logbook showed 59.4 hours simulated instrument flight time, and 16.1 hours operating in actual instrument conditions. Owner The owner, age 41, held a private pilot certificate for airplane single-engine land. He also held a mechanic certificate for airframe and powerplant. The owner held a third-class medical certificate issued July 8, 2008, with no limitations. The owner was located in the right seat. AIRCRAFT INFORMATION The four-seat, high-wing, fixed-gear airplane, serial number (SN) R1722351 was manufactured in 1977. It was powered by a Continental Motors IO-360-K engine, and equipped with a McCauley 2A34C203/90DCA-14 propeller. The airplane was fueled to capacity on May 28, at the Roseburg airport. The maintenance records for the airplane were not located. A receipt from Crown Aviation, Everett, Washington, was located in the wreckage. It showed that the transponder, altimeter, and static systems were checked in December 2010. According to personnel at Crown Aviation, they did not perform annual inspections on the airplane. The tachometer time recorded during the December 2010 tests was 3,016.61 hours. WRECKAGE AND IMPACT INFORMATION The airplane impacted steep, rocky, mountainous terrain, at an elevation of approximately 6,400 feet mean sea level. The wreckage was confined to the impact area. The accident site was located at the following global positioning coordinates: N 39 degrees 44.037 minutes, W 119 degrees 59.57 minutes. The aircraft was on a heading of east-northeast. The nose of the airplane was on a heading of 080 degrees magnetic, and the empennage section to the aft cockpit was on a heading of 020 degrees magnetic. Airplane The wreckage was confined to the impact area. The cockpit area was compressed downward and the empennage remained intact. All control surfaces remained secured to their attach points. The right wing leading-edge was crushed aft and perpendicular to the longitudinal axis of the airplane from the wingtip inboard to the strut attach point. Tapering compression was evident and the crushing was more pronounced on the outboard section, and lessened as it moved inboard. The left wing sustained crush damage on the underside. The aileron and flap control surfaces remained attached to both wings, and the control cables remained connected at their attach points. The flap actuator measured 1.8 inches, which according to the Cessna representative, equates to a flap extension between 5-10 degrees. The empennage section was examined. The elevator and rudder control surfaces remained attached. The outboard right horizontal stabilizer and elevator were bent upward at the tips. All control cables remained attached at their respective connection points in the empennage. The elevator trim was extended 2.0 inches, which according to the Cessna representative, is beyond the maximum up limit of 25 degrees tab up (1.88 inches). All of the seats were separated from the floor assembly and the seat rails were fragmented. The front seats had compression damage. The rear seat also sustained compression damage. All occupants were wearing their respective restraint systems; 3-point restraint systems in the front seats and 2-point in the rear seat. The airplane was equipped with an ACK Technologies Inc. electronic locator transmitter (ELT), model E-01, SN 008831. The unit was found in the "off" position in the wreckage and did not activate. Tests of the unit following its removal were unsuccessful. Removal of the batteries showed corrosion. The housing of the ELT showed that the batteries were due for replacement in March 2011. Examination of the recovered airframe and flight control system components revealed no evidence of pre impact mechanical malfunction. The ELT was not armed for the flight, and the batteries were corroded and unable to supply power. Instruments The following instruments, or portions of them, were identified: • Tachometer (3059.38 hours) • Clock • Vertical speed indicator (face) • Altimeter (face), Kollsman window setting 29.73 • Airspeed indicator • Altitude indicator • Directional gyro • Automatic direction finder • Turn coordinator • Marker beacons • 1Apollo IImorrow FlyBuddy (Global Positioning System) The housing from a Honeywell Bendix King RoHS unit, PN 066-01207-0099, SN AA012011, was discovered loose within the wreckage. The housing was sent to the NTSB Recorder Laboratory, but due to the damage, no information was obtained. Two gyros were found loose within the wreckage and were disassembled. One was electric (turn coordinator), and the other was not (directional gyro). Rotational scoring was evident on each gyro. The attitude indicator gyro was also examined. Rotational scoring was identified. Examination of the recovered instruments revealed no evidence of pre impact mechanical malfunction. Engine Investigators examined the engine and its components. The six- cylinder, normally-aspirated, direct-drive, air-cooled, fuel-injected, horizontally opposed, engine produces 195 horsepower at 2,600 rpm. The engine sustained extensive impact damage and the propeller was separated. The forward crankshaft was exposed and cylinder number 6 had separated. The number 6 piston remained attached to the crankshaft. The cylinders were borescoped and showed normal coloration and deposits. There was no evidence of damage or abnormal thermal discoloration. The pushrods and valves for each cylinder were intact for cylinders 1-5. The pushrods for cylinder 6 were found near the engine. The spark plugs were removed and examined. The spark plugs for the number 6 cylinder were coated with dirt and debris. The spark plugs for cylinders 1 and 5 were oil coated. The number 1 cylinder electrode was off-center. The coloration on the remainder of the spark plugs was light gray. According to the Champion Aviation Check-A-Plug AV-27 chart the remaining spark plugs had normal to worn out signatures. The magnetos were removed and rotated manually using a drill. Spark was obtained at all posts. The fuel control was disassembled and no anomalies were noted. The fuel pump drive shaft and swirl chamber and mixture side of the fuel pump was found impact damaged throughout. The coupling attachment to the driveshaft was fractured in four corners. The fuel manifold was examined. The manifold screen contained minimal fibrous material. The diaphragm was intact and the retaining screw was tight. The air throttle assembly was intact and the throttle linkage was bent. The vacuum pump was examined. The rotor was cracked and the blades remained intact. A small piece of material, consistent in material and color with the fractured fitting on the exterior of the vacuum pump was found within the housing. There was no evidence of rotational scoring from the debris. The coupling was not sheared. Propeller Investigators examined the propeller and its components. The propeller assembly sustained extensive impact damage and was in multiple pieces. The hub and spinner were separated and in multiple pieces. Propeller blade A was separated from the hub. It was fractured mid-span, as well as about 8 inches from the tip. Leading edge gouging and chordwise striations were evident. Propeller blade B was separated from the hub and remained intact. Chordwise striations were evident. Examination of the recovered engine and propeller components revealed no evidence of pre impact mechanical malfunction. COMMUNICATIONS A Safety Board air traffic control specialist reviewed services provided to the aircraft. According to Federal Aviation Administration air traffic control personnel, the pilot had departed on an instrument flight rules flight plan to Reno. During the flight, the pilot canceled his instrument flight rules(IFR) clearance, was receiving flight following services, and changed the destination to Susanville Municipal Airport, Susanville, California. Due to poor radar coverage, radar services were terminated. The pilot read back the termination of services. Susanville is located approximately 58 miles northwest of the accident site. According to the Safety Board specialist, all services provided were consistent with air traffic control requirements. The last recorded radar return was 98 miles northwest of the initial destination airport, Reno, and 76 miles northwest of the accident site. METEOROLOGICAL INFORMATION A Safety Board meteorologist completed a weather study. The NWS Surface Analysis Chart for 1700 PDT depicted a low pressure center in far eastern Utah, with a stationary front extending southwestward from the low pressure center into southern California. Isobars were relatively closely spaced over southern Nevada and southeastern California. Some station models in the accident region were indicating a wind from varying directions with magnitudes near 15 and 20 knots; however station models in northwestern Nevada indicated the wind was generally from the northwest. These station models indicated partly cloudy skies near the accident location, with nearby station models in California indicated overcast skies. Temperatures across the region were generally between 4-10 Centigrade. Dew point temperatures in the accident region were close to -1 Centigrade. Unofficial weather observations were retrieved from the Citizen Weather Observer Program (APRSWXNET) weather station AT998, which was located about 3 miles to the southeast of the accident site at an elevation of approximately 5,150 feet. At 1731, the following conditions were reported: temperature, 2.8 degrees Centigrade, dew point, 0 degrees Centigrade, relative humidity, 82 percent, wind speed, 10.5 knots, wind gusts, 15.6 knots, wind direction, 246 degrees, and altimeter, 29.68 inches of mercury. At 1801, the following conditions were reported: temperature, 2.2 degrees Centigrade, dew point, -0.4 degrees Centigrade, relative humidity, 83 percent, wind speed, 11.3 knots, wind gusts, 15.6 knots, wind direction, 246 degrees, and altimeter, and 29.65 inches of mercury. The closest official aviation weather report was Reno International Airport (RNO), Reno, Nevada. At 1655, the following conditions were reported: wind, 320 degrees magnetic at 18 knots, gusting to 25 knots, visibility, 10 statute miles, temperature, 08 degrees Centigrade, dew point, 0 degrees Centigrade, altimeter, 29.70 inches of mercury, cloud conditions, scattered 5,000 feet, broken 12,000 feet. Remarks: showers and rain in the vicinity, with mountain top obscuration. A special aviation weather surface observation (METAR) at Reno was issued at 1727. The following conditions were reported: wind, 290 degrees magnetic at 10 knots, visibility, 10 miles, temperature, 07 degrees Celsius, dew point, 1 degree Celsius, altimeter, 29.75 inches of mercury, ceiling, broken, 2,800 feet; light rain and mountain top obscuration in the vicinity. At 1755, the following conditions were reported: wind 300 degrees magnetic at 12 knots, gusting to 19 knots, visibility 8 statute miles, temperature, 5 degrees Centigrade, dew point, 2 degrees Centigrade, altimeter, 29.74 inches of mercury, cloud conditions, broken 1,900 feet, overcast 2,400 feet. Remarks: station with a precipitation discriminator, rain began at 1715 PDT, sea-level pressure 1006.2 hPa, breaks in the overcast ceiling more than 10 miles to the south, hourly precipitation one-hundredth of an inch, hourly temperature 5.0°C and hourly dew point temperature 2.2°C. At the time of the accident, three AIRMETs were active for the accident location: An AIRMET ZULU for ice was issued at 1345 PDT, advising of moderate icing between the freezing level and FL220. An AIRMET TANGO for turbulence was issued at 1345 PDT, advising of moderate turbulence below FL180. An AIRMET SIERRA for mountain obscuration was issued at 1345 PDT, advising of mountains obscured by clouds, precipitation and mist. An Area Forecast for the northern portions of the Sierra Nevada mountain range in California, issued at 1245 PDT, forecasted for the time of the accident: broken ceiling at 8,000 feet msl, visibility 3 to 5 miles, light snow/mist. An Area Forecast for northern Nevada, issued at 1245 PDT, forecasted for the time of the accident: broken ceiling at 8,000 feet msl, widely scattered light rain showers/isolated thunderstorms and light rain. At 1549 PDT, an urgent Winter Weather Message was issued by the National Weather Service Office in Reno, indicating a Winter Weather Advisory for snow was in effect at the time of the accident for areas near the accident site. Current Icing Potential (CIP) products are produced by the NWS Aviation Weather Center and are intended to be supplemental to other icing advisories (e.g. AIRMETs and SIGMETs). CIP analyses indicated there was a moderate to high probability of icing at 7,000, 9,000, and 11,000 feet. In addition, CIP icing severity and super cooled large droplet (SLD) icing analyses indicated an SLD threat in the accident area at 9,000 and 11,000 feet, with icing severities generally in the “light” category. MEDICAL AND PATHOLOGICAL INFORMATION The Washoe County Medic
The pilot's continued visual flight rules flight into instrument meteorological conditions, which resulted in a controlled collision with terrain.
Source: NTSB Aviation Accident Database
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