Aviation Accident Summaries

Aviation Accident Summary WPR22FA255

Lake McMurray, WA, USA

Aircraft #1

N2588C

AERONCA 7BCM

Analysis

The pilot was enroute conducting a visual flight rules (VFR) flight at a low altitude. It is likely given the weather conditions and PIREPs that low ceilings obscured the trees and high terrain from the pilot and resulted in a controlled flight into terrain. While the closet METAR reported cloud ceilings above 1,000 ft above ground level (agl), the PIREPs and a sounding analysis program indicated that the ceiling of the clouds was about 300 ft agl near the high terrain. The accident flight likely encountered instrument meteorological conditions and mountain obscuration conditions as the flight approached higher terrain. The pilot’s autopsy revealed significant multivessel atherosclerotic coronary disease with 80-90% narrowing of the left main and left anterior descending coronary arteries, a significant restenosis of a left anterior descending coronary artery stent, and more than 95% narrowing of the right coronary artery. The heart muscle had an area of scarring in the posterior left ventricle and interventricular septum consistent with an old injury from insufficient blood flow. Microscopic examination of the coronary system did not identify any acute clot or plaque rupture. In the autopsy report, the pathologist noted that the pilot’s family had indicated that the pilot had no new health complaints in the weeks before the accident. Due to his heart disease, the pilot was at significantly increased risk of a sudden distracting, impairing, or incapacitating cardiac event, including angina, arrhythmia, or heart attack. There is no forensic evidence that such an event occurred. However, such an event cannot be excluded by forensic evidence alone. Given the available information about the circumstances of the crash, distracting or otherwise impairing symptoms such as chest pain or palpitations cannot be excluded. This pilot may have experienced a physiologic stress response to the poor weather conditions under which he was flying. A normal stress response would have included increased heart rate, an increase in blood flow demand from his heart, and increased respiratory rate. Physiological stress has been associated with an increased risk of cardiac symptoms such as chest pain or palpitations, most notable in patients with pre-existing cardiac disease. Thus, whether the pilot's heart disease contributed to the crash could not be determined.

Factual Information

HISTORY OF FLIGHTOn July 16, 2022, about 0730 Pacific daylight time, an Aeronca 7BCM, N2588C, airplane was destroyed when it was involved in an accident near Lake McMurray, Washington. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A concerned family member reported the airplane overdue to authorities and the Federal Aviation Administration (FAA) issued an Alert Notice shortly afterwards; it indicated that the airplane departed from the vicinity of the Arlington Municipal Airport (AWO), Arlington, Washington, on a cross-country flight to Mears Field Airport (3W5) Concrete, Washington. A search for the airplane was initiated; the airplane wreckage was subsequently located about 27 miles southwest of 3W5 in heavily forested terrain about 950 ft mean sea level (msl) elevation. PERSONNEL INFORMATIONThe private pilot held ratings for airplane single-engine land and instrument airplane. The pilot was issued an FAA third-class airman medical certificate on December 29, 2016, with the following limitation: “Must wear corrective lenses for near and distant vision. Not valid for any class after December, 31, 2017.” The pilot reported on his most recent application that he had accumulated 2,280 total hours of flight experience with 20 hours in the 6 months before the examination. The pilot’s Medical Certificate expired for all classes in 2017. Subsequently, the pilot had applied for BasicMed. His BasicMed Course Date was April 21, 2018, and the Comprehensive Medical Examination Checklist date was December 11, 2017. The BasicMed had expired at the time of the accident. AIRCRAFT INFORMATIONThe airframe and engine maintenance logbooks revealed that the airplane had an annual inspection on August 2, 2021, at an aircraft total time of 5,484.15 hours and an engine tach time of 1329.55 hours. METEOROLOGICAL INFORMATIONThe NWS Surface Analysis Chart indicated a low-pressure system in eastern Washington with a cold front stretched from eastern Washington south-westward across Oregon and California. The nearest weather station to the accident site depicted overcast clouds. The area surrounding the accident site was documented by Aviation Routine Weather Reports (METARS) and special reports (SPECs). The airport in the vicinity of the departure was the closest official weather station to the accident site. AWO had an Automated Weather Observing System (AWOS). The AWO AWOS was located about 10 miles southeast of the accident site and was reporting an overcast ceiling at 1,300 ft msl and a visibility of 10 statute miles, which indicated marginal VFR conditions due to the ceiling. A sounding analysis program for the area of the accident site indicated cloud cover from about 1,000 ft msl through 5,500 ft msl with a base of about 300 ft above ground level (agl).. Further, an AIRMET was active for IMC/mountain obscuration in the area. Additionally, several PIREPS in the area had low cloud ceilings as low as 600 ft agl. A search of archived information indicated that the pilot did not request weather information from Leidos Flight Service or ForeFlight. It is unknown what, if any, weather information the accident pilot viewed before or during the accident flight. AIRPORT INFORMATIONThe airframe and engine maintenance logbooks revealed that the airplane had an annual inspection on August 2, 2021, at an aircraft total time of 5,484.15 hours and an engine tach time of 1329.55 hours. WRECKAGE AND IMPACT INFORMATIONExamination of the wreckage site revealed a couple of treetops were cut off near where the airplane came to rest. The debris path of about 120 ft in length was oriented on northerly heading, consistent with his intended destination. All major structural components were observed with the main wreckage. The airplane came to rest upright on a southwest heading and a postimpact fire consumed most of the airplane wreckage. The site was located near the top of a hill on a slope of about 15° and populated with tall trees over 100 ft in height. The terrain elevation to the south of the site was noted to be lower. A postaccident examination of the airframe and engine revealed extensive thermal damage to the airplane wreckage. Flight control continuity was established and no preimpact anomalies were noted on the engine. The examination revealed no evidence of preimpact mechanical failures or malfunctions that would have precluded normal operation. ADDITIONAL INFORMATIONThe FAA Advisory Circular 61-134, General Aviation Controlled Flight Into Terrain Awareness, states the following about flying in IMC conditions: “Operating in marginal VFR/IMC conditions is more commonly known as scud running. According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC.” As defined in 14 CFR part 91, ceiling, cloud, or visibility conditions less than that specified for VFR or Special VFR is IMC and IFR applies. However, some pilots, including some with instrument ratings, continue to fly VFR in conditions less than that specified for VFR. The result is often a CFIT accident when the pilot tries to continue flying or maneuvering beneath a lowering ceiling and hits an obstacle or terrain or impacts water…The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot’s skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough.” Recommendations include: “(1) Know and fly above minimum published safe altitudes. VFR: Fly a minimum of 1,000 feet above the highest terrain in your immediate operating area in non-mountainous areas. Fly a minimum of 2,000 feet in mountainous areas,” and (2) Maintain situational awareness both vertically and horizontally.” Additionally, the NTSB has identified CFIT and Unintended flight into IMC as a high-risk occurrence category. MEDICAL AND PATHOLOGICAL INFORMATIONThe pilot had received a special issuance of medical certification for angina and coronary artery disease requiring coronary artery angioplasty and stent placement with medication use. The first issuance of this authorization was in 2002 and the last was in 2017. The pilot’s autopsy report revealed the cause of death was thermal injury and inhalation of products of combustion. The heart findings revealed significant multivessel atherosclerotic coronary disease with 80-90% narrowing of the left main and left anterior descending coronary arteries, a significant restenosis of a left anterior descending coronary artery stent, and more than 95% narrowing of the right coronary artery. Additionally, the heart muscle had an area of scarring in the posterior left ventricle and interventricular septum consistent with an old injury from insufficient blood flow. Microscopic examination of the coronary system did not identify any acute clot or plaque rupture. In the autopsy report, the pathologist noted that the pilot’s family had indicated that the pilot had no new health complaints in the weeks before the accident. Toxicology testing performed by the FAA’s Forensic Services Laboratory on the pilot’s blood, urine, liver tissue, muscle tissue, etc., identified no evidence of impairing drugs. Rosuvastatin was detected. Rosuvastatin (Crestor) is a prescription cholesterol medication and is acceptable for FAA medical certification.

Probable Cause and Findings

The pilot’s decision to continue visual flight into an area of instrument meteorological conditions, which resulted in a loss of visual reference and subsequent controlled flight into terrain.

 

Source: NTSB Aviation Accident Database

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