Aviation Accident Summaries

Aviation Accident Summary CEN22FA376

Centennial, CO, USA

Aircraft #1

N727PC

CESSNA 182Q

Analysis

A witness reported that he saw the accident airplane climbing after takeoff. He stated that the airplane was “going really slow” and that the engine was “sputtering.” The airplane appeared to be “floating in the air” before it “dipped” and came back up. The left wing dropped and the airplane rolled to the right and descended into the ground. The airplane sustained damage consistent with a nose-low impact with terrain. Examination of the airplane and engine did not reveal any mechanical anomalies that would have precluded normal operation. The amount of fuel on board at the time of the accident could not be determined. Recorded engine data showed a reduction in fuel flow prior to a reduction in engine speed toward the end of the recording. Changes in fuel flow during this period correlated to engine speed. Postaccident examination of the airplane fuel system revealed little residual fuel aboard and in enclosed components. The reduction of fuel flow prior to a decrease in engine speed and the lack of residual fuel in the airplane fuel system were consistent with fuel exhaustion but contradicted the recorded fuel available for undetermined reasons. The pilot had cardiovascular disease including severe coronary artery disease. This conveyed increased risk of a sudden impairing or incapacitating cardiac event such as abnormal heartbeat or heart attack. Such an event can cause chest pain, shortness of breath, palpitations, nausea, sweating, unconsciousness, and death. There is no autopsy evidence that such an event occurred, although such an event does not reliably leave autopsy evidence if it occurs just before death. Despite the risk it conveys, even severe coronary artery disease is often asymptomatic. This is partly because, as coronary artery narrowing by plaque progresses over time, diminishing blood flow to downstream heart muscle may be supplemented by increasing blood flow through collateral vessels. It is unlikely that the pilot’s cardiovascular disease contributed to the accident.

Factual Information

HISTORY OF FLIGHTOn August 9, 2022, at 1250 mountain daylight time, a Cessna 182Q, N727PC, was destroyed when it was in involved in an accident near Centennial, Colorado. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A witness, who was in his car at a stoplight near the airport, stated that he saw the accident airplane “going really slow” after takeoff. He was able to hear the engine “sputtering” and stated that the airplane appeared to be “floating in the air” before it “dipped” and came back up. He then stated that the left wing dropped, and the airplane rolled to the right and descended into the ground. PERSONNEL INFORMATIONThe last entry in the pilot’s logbook was dated July 15, 2022, for a flight in the accident airplane that was 1.2 hours in duration; this was the only logbook entry listing the accident airplane. The flight instructor who had flown with the accident pilot during that flight stated that, as part of the airplane checkout, he wanted to perform stalls with the wing flaps extended, landings with 20° and 40° flap extension, and takeoffs with 20° flap extension; however, during their flight, the airplane’s flaps would not extend. They returned to the airport and he believed that the owner was going to have maintenance performed on the flap system. A couple of weeks later, the instructor received a text message from the accident pilot asking if he was ok to fly the accident airplane; the instructor responded that it was between him and the airplane owner. He did not have any further communication with the accident pilot. AIRCRAFT INFORMATIONReview of the airplane’s maintenance logbooks revealed an entry for an annual inspection completed at a tachometer time of 1,554.5 hours, total time of 435 hours, and prop time of 435 hours. The date of the entry appeared to have been corrected to read, “2-3-22.” The aircraft time sheet recovered from the wreckage had its last complete entry dated August 6, 2022, at an hour meter (Hobbs) In of 1,174.5, Hobbs Out of 1,175.7, Total Hobbs of 1.2, Tach Out of 1,561.0, Tach In of 1,561.5, Tach Total of 0.4, Fuel Added of 38 gallons. The tachometer indicated 1,561.6 hours and the hour meter indicated 1,176.2 hours at the time of the accident. AIRPORT INFORMATIONReview of the airplane’s maintenance logbooks revealed an entry for an annual inspection completed at a tachometer time of 1,554.5 hours, total time of 435 hours, and prop time of 435 hours. The date of the entry appeared to have been corrected to read, “2-3-22.” The aircraft time sheet recovered from the wreckage had its last complete entry dated August 6, 2022, at an hour meter (Hobbs) In of 1,174.5, Hobbs Out of 1,175.7, Total Hobbs of 1.2, Tach Out of 1,561.0, Tach In of 1,561.5, Tach Total of 0.4, Fuel Added of 38 gallons. The tachometer indicated 1,561.6 hours and the hour meter indicated 1,176.2 hours at the time of the accident. WRECKAGE AND IMPACT INFORMATIONThe airplane came to rest in an open field. All the major airframe components, the engine, and the propeller were located at the accident site. The left wing separated from the fuselage. The wing leading edges and fuselage exhibited impact damage consistent with a nose-low, low-speed impact with terrain. There was no evidence of soot or fire. There was no smell of fuel at the accident site. Flight control continuity from all the flight control surfaces to the cockpit controls was confirmed. The elevator trim actuator was in the approximately neutral position. The cockpit wing flap selector sustained accident impact damage and was positioned between UP and 10°; the wing flap motor/actuator was in the fully retracted/UP position. The right wing was attached to the fuselage and bent upward about midspan. The left and right wing fuel caps were attached and secured to their respective wing filler ports. The areas around the wing fuel filler ports did not exhibit staining consistent with fuel leakage. No fuel was present when the wings were raised by their wing tips to drain residual fuel toward their wing roots. The left and right wing fuel tank pickup screens did not contain debris. Both wing fuel cap diaphragms were intact and pliable. The underlying vent holes of both caps were not obstructed. Throttle, mixture, and propeller control continuity from the cockpit controls to their respective engine accessories was confirmed. The throttle and propeller control knobs were fully forward. The mixture control knob was about one inch from its fully forward position. The cockpit fuel selector handle was positioned to the BOTH position on the fuel selector placard plate. The fuel selector handle was separated from the fuel selector assembly valve stem due to impact damage. The fuel lines leading to the fuel selector were attached and secure and without evidence of fuel leakage. The fuel selector valve was between its detents. The fuel selector valve assembly did not contain debris. The fuel system was modified with a header tank as part of a supplemental type certificate. The fuel lines leading to the header tank were intact and secure with no evidence of fuel leakage. The header tank was intact and contained 1 pint of liquid consistent in color and odor with 100 low-lead aviation fuel. The fuel lines leading to the gascolator were intact and secure with no evidence of leakage. Disassembly of the gascolator revealed that it contained a liquid that was about 1/16 of the volume of the gascolator bowl, and the liquid was consistent with 100 low lead aviation fuel. The gascolator bowl and gascolator screen did not contain debris. The electric fuel pump contained about 1/8 of its volume of a liquid consistent with 100 low-lead aviation fuel. The electric fuel pump operated when connected to an electrical source. There was no fuel of downstream of the gascolator. Examination of the engine and engine accessories revealed no mechanical anomalies that would have precluded normal operation. FLIGHT RECORDERSA data plot of recorded data from the airplane’s engine diagnostic module showed a reduction in fuel flow prior to a reduction in engine rpm toward the end of the recorded data. Changes in fuel flow during this period correlated to changes in engine speed. MEDICAL AND PATHOLOGICAL INFORMATIONThe pilot’s most recent third-class Federal Aviation Administration medical certificate was issued on June 14, 2022, with a limitation for corrective lenses for near and distant vision. According to the pilot’s autopsy report, his cause of death was multiple injuries, and his manner of death was accident. His autopsy identified severe coronary artery disease with greater than 95% narrowing of the right coronary artery and up to 60% narrowing of the left anterior descending coronary artery by plaque. No coronary artery thrombus or heart muscle scarring from an old heart attack was identified. The autopsy report described the heart as mildly-to-moderately dilated; heart weight and right ventricular wall thickness were normal, while the thicknesses of the left ventricular wall and interventricular septum were low-normal. The autopsy examination did not identify other significant natural disease. Postmortem toxicological testing did not identify any substances likely to have impairing effects.

Probable Cause and Findings

The loss of engine power during a departure climb for undetermined reasons and the aerodynamic stall, which resulted in an uncontrolled descent and impact with terrain.

 

Source: NTSB Aviation Accident Database

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