Aviation Accident Summaries

Aviation Accident Summary CHI99FA264

DETROIT LAKES, MN, USA

Aircraft #1

N6996R

Beech C23

Analysis

A witness reported that the airplane lifted-off runway 13 (4,500 feet by 75 feet, dry/asphalt) approximately 600 feet from the end of the runway. The witness reported that that airplane climbed to an altitude of 150-200 feet above the ground before it began an increasing left banking turn. The witness stated that the airplane was climbing in a nose high pitch attitude and that the airplane's bank angle was approximately 50-60 degrees with the airplane's nose began to pitch down. The witness reported that the airplane's maximum nose-down pitch angle was 70-80 degrees at the time of the impact with terrain. No anomalies were found with the airframe structure or its systems that could be associated with a preexisting condition. No anomalies were found with the aircraft engine or its systems that could be associated with a preexisting condition. The active ingredient of marijuana (Tetrahydrocannabinol) and its metabolite substance (Tetrahydrocannabinol Carboxylic Acid) was found during a Federal Aviation Administration (FAA) Toxicology examination. The levels of Tetrahydrocannabinol and Tetrahydrocannabinol Carboxylic Acid found in the pilot's tissues and fluids would be consistent with the direct inhalation of marijuana less than one-hour before the time of the accident. According to the book entitled, 'Fit To Fly A Pilot's Guide to Health & Safety', author Richard O. Reingart MD, the active ingredient in marijuana is, '...THC (delta 9 tetra hydrocannibinal)....' The book continues, 'THC causes temporary euphoria and relaxation. However, more than alcohol, it distorts perception, weakens critical judgment, and interferes with the ability to concentrate. THC also increases heart rate and the incidence of cardiac arrhythmias. Short term memory is impaired, IQ is thought to be diminished, and there is a decrease in reaction time and tracking (similar to alcohol).'

Factual Information

HISTORY OF FLIGHT On July 29, 1999, at 1420 central daylight time, a Beechcraft C23, N6996R, piloted by a commercial pilot, was destroyed during an in-flight collision with terrain and subsequent postimpact fire shortly after a takeoff from runway 13 (4,500 feet by 75 feet, dry/asphalt) at the Detroit Lakes Airport, Detroit Lakes, Minnesota. Visual meteorological conditions prevailed at the time of the accident. The positioning flight was operating under the provisions of 14 CFR Part 91 and was not operating on a flight plan. The pilot, who was the sole occupant, was fatally injured. The flight was originating at the time of the accident with exact destination unknown. A witness stated that the takeoff run was uneventful, with the airplane lifting-off the runway approximately 600 feet from the end of the runway. The witness reported that the airplane climbed to an altitude of 150-200 feet above ground level (agl) before it began an increasing left banking turn toward the north. The witness reported that the airplane was climbing in a nose high pitch attitude and that the airplane's bank angle was approximately 50-60 degrees when the airplane's nose began to pitch down. The witness stated that the airplane's maximum nose-down pitch angle was 70-80 degrees at the time of the impact and that the airplane wings were level at the time of impact. The witness reported that the fire started approximately 1-2 seconds after the impact with the terrain. PERSONAL INFORMATION The pilot, born May 14, 1974, was the holder of a commercial pilot certificate with privileges for single and multiengine land airplanes. The pilot was instrument rated and was certified as an advanced ground instructor. Federal Aviation Administration (FAA) records indicate that the pilot's last aviation medical examination was preformed on January 21, 1999. The FAA records indicate that the pilot was issued a second-class medical with no limitations or restrictions. The pilot was involved in another airplane accident, dated July 23, 1999, and had provided a National Transportation Safety Board Pilot/Operator Aircraft Accident Report, in which his current flight hours were recorded. According this report, the pilot had accumulated a total of 1,359 hours of flight time. The report stated that he had completed a Biennial Flight Review on "08/03/99" in a Beechcraft Skipper. The pilot's personal logbook was recovered at the accident site, but was unreadable due to fire and water damage. AIRCRAFT INFORMATION The aircraft was a Beechcraft C23, Sundowner, serial number M-1744. The Beechcraft C23 is a single-engine, low-wing monoplane of all metal construction, equipped with a fixed landing gear, and can accommodate a pilot and three passengers. The airplane was issued a Standard Airworthiness Certificate on December 3, 1975. The airplane had logged a total-time of 3,191 hours at the time of the accident. The last annual inspection was completed on May 25, 1999 and the airplane was determined to be in an unairworthy condition due to an Airworthiness Directive (AD) on the engine oil pump not being in compliance. According to AD 96-09-10 Textron Lycoming, the purpose of the AD was, "To prevent oil pump failure due to impeller failure, which could result in an engine failure." A copy of AD 96-09-10 and the referenced Textron Lycoming Service Bulletin No. 524 are appended to this report. During the post-accident inspection of the engine and its components the engine oil pump was disassembled. Examination of the oil pump revealed no anomalies that would preclude the normal operation of the pump and both of the oil pump's impeller gears were intact. The engine was an Avco Lycoming O-360-A4K, serial number L-20523-36A, and at the time of accident had accumulated 1,571 hours since major overhaul. METEOROLOGICAL INFORMATION A weather observation located at the departure airport, reported the weather at the time of the accident as: Observation Time: 1355 cdt Wind: 160-degrees at 5 knots Visibility: 10 statute miles Sky Condition: Sky clear Temperature: 31-degrees centigrade Dew Point Temperature: 17-degrees centigrade Altimeter Pressure: 29.69 inches of mercury WRECKAGE AND IMPACT INFORMATION An examination of the wreckage was conducted on July 30, 1999. The aircraft impacted a cornfield that was approximately 1/4 mile east of the departure end of runway. The aircraft came to rest on a 240-degree magnetic heading and a global positioning system (GPS) unit identified the accident location as: 46-degrees 49.205-minutes North Latitude 95-degrees 52.340-minutes West Longitude All of the wreckage was located within a 35-foot radius of the initial impact location. The aircraft was consumed by a post impact fire from the firewall to a point approximately 16-inches forward of the empennage. Aileron, stabilator, and rudder continuity were established from the remaining control surfaces to the forward-cockpit area. The flaps were found in the fully retracted position. The cockpit and the instrument panel were consumed by fire. No anomalies, relative to the airframe or its systems, were found that could be associated with a preexisting condition. The engine was recovered from the accident location to a maintenance facility for examination. The engine was found with a black soot-like substance over the entire crankcase with evidence of sustained exposure to heat and fire. The ignition system, including the magnetos and harness, was compromised by fire. Engine continuity was established throughout the engine and its accessories by rotating the engine by means of the propeller. Quantitative compression readings for each of the cylinders could not be accurately determined due to impact damage. Cylinders number one and three were removed for examination of the cylinders and their pistons. No rust or contamination was found in the cylinders and pistons, and no abnormal wear signatures were noted on the components. The upper spark plugs were removed and exhibited a light gray color. The engine accessory section and the engine-driven oil pump were removed for inspection. Examination of the oil pump revealed no anomalies that would preclude the normal operation of the pump and both of the oil pump's impeller gears were intact. No anomalies, relative to the engine or its systems, were found that could be associated with a preexisting condition. The propeller was found attached to the engine with visible evidence of impact damage. One propeller blade was bent aft approximately 30-degress, just outboard of the propeller flange. The propeller blade faces had evidence of chordwise scratching and burnishing. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot at the Ramsey County Medical Examiners Office, St. Paul, Minnesota, on July 30, 1999. A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma. The toxicology report indicated the following results: * No Ethanol detected in Heart Fluid * No Ethanol detected in Kidney Fluid * 0.043 (ug/ml, ug/g) Tetrahydrocannabinol (Marijuana) detected in Heart Fluid * 0.012 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marijuana) detected in Heart Fluid * 0.057 (ug/ml, ug/g) Tetrahydrocannabinol (Marijuana) detected in Kidney Fluid * 0.18 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marijuana) detected in Kidney Fluid * 0.352 (ug/ml, ug/g) Tetrahydrocannabinol (Marijuana) detected in Liver * 2.969 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marijuana) detected in Liver TESTS AND RESEARCH The manager of the FAA Toxicology and Research Laboratory stated in a memo that, "The 99 ng/ml of THC and the 56 ng/ml of THC-COOH in blood would indicate a recent exposure to marihuana [marijuana] of less than 1.0 hour." The time duration since direct inhalation was calculated from an equation reported in the Journal of Analytical Toxicology, Volume 16 September/October 1992, on page 285. According to the book entitled, "Fit To Fly A Pilot's Guide to Health & Safety", author Richard O. Reingart MD, the active ingredient in marijuana is, "...THC (delta 9 tetra hydrocannibinal)...." The book continues, "THC causes temporary euphoria and relaxation. However, more than alcohol, it distorts perception, weakens critical judgment, and interferes with the ability to concentrate. THC also increases heart rate and the incidence of cardiac arrhythmias. Short term memory is impaired, IQ is thought to be diminished, and there is a decrease in reaction time and tracking (similar to alcohol)." ADDITIONAL INFORMATION Parties to the investigation were: Federal Aviation Administration Flight Standards District Office, Minneapolis, Minnesota. Raytheon Aircraft Company, Wichita, Kansas. The wreckage was released to a representative of the Detroit Lakes Police on July 30, 1999.

Probable Cause and Findings

Aircraft control not obtained/maintained by the pilot. A factor to the accident was the pilot's impairment due to drugs.

 

Source: NTSB Aviation Accident Database

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