Aviation Accident Summaries

Aviation Accident Summary DEN01FA111

Meeker, CO, USA

Aircraft #1

N5999V

Piper PA-28-161

Analysis

The pilot joined a flying club and got a checkout in a PA-28-161, an airplane which he had never flown before. He was told not to fly the airplane cross-country but to fly locally for an additional 5 hours. Although the airplane had been upgraded from a 160 to a 180 horsepower engine, he was told not to fly it with three adult passengers aboard. The pilot scheduled the airplane for 2 days. He obtained a "standard" weather briefing for a VFR flight from Reno, NV, to Hawthorne, NV, and an "outlook" weather briefing for Denver, CO. He filed a VFR flight plan to Hawthorne, but there is no record that he flew to Hawthorne. The airplane, with the pilot and 3 adult passengers on board, was reported missing. Six days later, fishermen found airplane debris floating in Upper Marvine Lake, located about 30 miles east of Meeker, CO. The debris was identified as having come from the missing airplane. The airplane had stopped in Meeker for fuel, and was en route to the Denver area. The wreckage was recovered, and examination disclosed no discrepancies with the airframe, engine, and propeller. The airplane was estimated to have been 111 pounds overweight when it departed Meeker, elevation 6,421 feet msl. Toxicological tests revealed the pilot had amphetamine and methamphetamine in blood and urine. The levels found in the blood were high, suggestive of regular use and probable addiction. The effects of methamphetamine include increased alertness, euphoria, insomnia, and increased self-confidence. Long-term use could lead to paranoia, loss of physical coordination, and weight loss. If use were to be discontinued, within hours a regular user might experience severe withdrawal symptoms, including depression, fatigue, abdominal cramps, and headache. Overdoses may result in loss of consciousness or seizures. Regular users can tolerate high doses. The levels found in the blood indicate the pilot had recently used methamphetamine and was impaired by its effect. This could have led him to attempt maneuvers beyond his abilities. Although possible but not likely, the pilot could have had an acute event resulting in incapacitation, such as fainting or seizure.

Factual Information

HISTORY OF FLIGHT On May 29, 2001, approximately 1525 mountain daylight time, a Piper PA-28-161, N5999V, was destroyed when it impacted water and sank to the bottom of Upper Marvine Lake, approximately 32 nautical miles east of Meeker, Colorado. The private pilot and three passengers were fatally injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the personal flight being conducted under Title 14 CFR Part 91.The flight originated at Meeker, Colorado, approximately 1500, and was en route to Jefferson County Airport, Broomfield, Colorado. According to Nevada-Cal Aero Flying Service documents, the pilot joined the Reno-based flying club on May 27, 2001. A flight instructor was assigned to administer a "club checkout" to "access (sic) the pilot proficiency for insurance purposes." The pilot told the instructor that most of his flight time had been accrued in Cessna 152s and 172s, and that he had never flown the PA-28-161. The instructor told him that the PA-28-161 was normally powered by a 160 horsepower engine, "but because of density altitude considerations," the airplane had been upgraded to a 180 horsepower engine. He was also told that the PA-28-161 "was not a 4 place airplane and under no circumstances [was he] to place 4 adults into this plane." The pilot was also told that in addition to the club checkout, he would need to log an additional 5 hours of "local flying time" before he could fly the airplane cross-country. The pilot said that he had scheduled the airplane on May 29 for that purpose. The checkout was satisfactory and the instructor gave the pilot the combination to the "lock box" containing the keys to the various airplanes. According to the club's flight schedule, the pilot had scheduled the airplane from 0830 to 1730 on May 29 and all of May 30. According to a club memo, the accident pilot took the airplane on May 29 before his scheduled time, "bumping" a club member from the 0600 to 0830 time slot, and "bumping" another club member from the 1730 to 2030 time slot. "He made no mention at any time that he intended to leave the area, and absolutely no mention of taking the airplane to Colorado," the instructor wrote. According to a club spokesperson, the accident flight was an "unauthorized flight." According to family sources, the pilot and his passengers were en route to Denver to attend the second game of the Stanley Cup Finals between the Colorado Avalanche and New Jersey Devils professional hockey teams. FAA documents indicate that on May 29 at 0429, the pilot telephoned the Reno Automated Flight Service Station (AFSS) and requested an "outlook" weather briefing from Reno, Nevada, to Denver, Colorado, and a "standard" weather briefing from Reno to Hawthorne, Nevada. He was told that the only AIRMET (Aeronautical Meteorology) in effect was for IFR conditions throughout the eastern third of Colorado. Ceilings and visibilities were forecast to be below 1,000 feet and 3 miles, respectively, and VFR flight was not recommended. At the time of the briefing, Broomfield-Jefferson County Airport (Jeffco, BJC) was reporting VFR conditions with thunderstorms to the south and moving south. The pilot then requested and was given the winds aloft for Reno, Salt Lake City, Utah, Grand Junction, Colorado, and Denver. The briefing was terminated at 0434. At 0642, the pilot telephoned Reno AFSS again and filed a VFR flight plan from Reno to Hawthorne. The pilot indicated he would depart Reno at 0600 and cruise at 7,500 feet and 120 knots. He estimated the time en route would be 1 hour, 30 minutes, and said he had 4 hours, 30 minutes of fuel on board. The call was terminated at 0646. FAA documents indicate N5999V departed Reno at 0726, but do not indicate whether the VFR flight plan was activated or when the airplane arrived in Hawthorne. There was no record of the airplane arriving in Hawthorne. FAA records did not contain any other flight plan filed by the pilot. It was later determined that the pilot stopped in Meeker for fuel. According to a fuel receipt from Coulter Aviation, the airplane was serviced with 19.8 gallons of 100-LL avgas. The transaction was recorded at 1458. A local pilot said he watched the pilot make a downwind takeoff. He said the airplane "struggled" for altitude. When the occupants failed to contact family members that evening, FAA was notified that the airplane was overdue and an alert notice (ALNOT) was issued at 2324. The Civil Air Patrol initiated an aerial search on May 30. On June 4, 2001, fishermen found debris floating in Upper Marvine Lake in the Flat Tops Primitive Area of the White River National Forest. The debris was taken to the Rio Blanco Sheriff's Office and, on June 6th, it was positively identified as having come from N5999V. The accident occurred during the hours of daylight at a location of 39 degrees, 56.50' north latitude, and 107 degrees, 22.18' west longitude. PERSONNEL INFORMATION The 38-year-old pilot held a private pilot certificate with an airplane single-engine land rating, dated May 28, 1996. He also held a first class airman medical certificate, dated on May 22, 1999. According to his application for membership with Nevada-Cal Aero Flying Service, dated May 27, 2001, his total flight time was 282.7 hours, of which 2.8 hours were accrued in the previous 90 days. The last entry in a logbook recovered from the wreckage, dated October 27, 1999, indicated the pilot had accumulated 258 total flight hours, of which 144.7 hours were as pilot-in-command. A more recent logbook was not located. AIRCRAFT INFORMATION N5999V (s/n 28-7716223), a model PA-28-161, was manufactured by the Piper Aircraft Corporation in 1977. The original engine (160 horsepower) had been removed and replaced with a Textron Lycoming O-360-A4M engine (s/n L-21495-36A), rated at 180 horsepower, and a Sensenich 2-blade, all-metal, fixed-pitch propeller (m/n 76EM8-0-60) in accordance with a supplemental type certificate. Despite the O-320-A1A engine weighing 230 pounds and the O-360-A4M engine weighing 250 pounds, the removal and installation instructions contained the statement: "No change to maximum gross weight or center of gravity limits will be made." The following entries were made in the airplane maintenance records: INSPECTION 100-HOUR ANNUAL Date May 3, 2001 January 25, 2001 Total time, airframe 8,731.58 hours 8,623.57 hours Total time, engine 6,734.57 hours 6,626.56 hours Time since major overhaul 1,977.57 hours 1,869.56 hours Tachometer 3,244.41 hours 3,136.40 hours Hobbs meter Not reported 828.2 hours At the accident site, the tachometer and Hobbs meter registered 3,289.76 and 1,002.8 hours, respectively. The ELT (emergency locator transmitter) battery was replaced on June 8, 2000, and was due to expire in March 2004. The airplane was last certified for IFR flight on March 31, 1999. METEOROLOGICAL INFORMATION The following weather observation was recorded at Meeker (EEO) at 1517: Wind, 290 degrees at 11 knots, gusts to 21 knots; visibility, (greater than) 10 statute miles; sky condition, clear; temperature, 23 degrees C. (73.4 degrees F.); dew point, -2 degrees C. (28.4 degrees F.); altimeter setting, 30.02; remarks, wind shifted at 1457. WRECKAGE AND IMPACT INFORMATION Upper Marvine Lake is situated approximately 9,300 feet msl, and is approximately a 3-1/2 hour horseback ride from the nearest road. Because motorized equipment is prohibited in a wilderness area, permission had to be obtained from the U.S. Forest Service to ferry in retrieval equipment and personnel by helicopter. On June 6, 2001, a remote underwater camera located the airplane in approximately 43 feet of water. The camera showed the airplane lying on its left side. The left and right wings, cowling, and empennage were separated from the airframe. Salvage operations commenced on June 9, 2001, and the wreckage was lifted by helicopter from the lake. The occupants, who were still in the airplane, were recovered. The wreckage was examined on the shore, and reexamined on June 23, 2001, at Beegles Aircraft Services in Greeley. Colorado. The flaps were retracted and the fuel selector was positioned on the right tank. There was compression damage to both fuel tanks. Leading edge compression damage was noted on the outboard portion of the right wing, and both wings displayed impact separation signatures. Control cable continuity was established from all control surfaces to their respective cockpit controls. Three threads were exposed on the upper shaft of the horizontal stabilator pitch trim drum and, according to the New Piper Aircraft Corporation, this was consistent with a setting of 1 degree nose down/tab up. One propeller blade was straight, and the other was bent aft approximately 15 degrees at a point 12 inches from the tip. Some scratching was noted on the cambered surface. There were no leading edge gouges. The front fuselage bore compression damage on both sides, the greatest being in the right front cabin area, to wit: the control column was dislodged, the lower front instrument panel was bent, and the right front seat lower frame was bent aft. The flap handle, located on the floor between the front seats, was bent to the left. According to rescuers, all four occupants were wearing their seatbelts, and the front seat occupants were wearing their shoulder harnesses. Cockpit examination revealed that the throttle, mixture, and carburetor heat controls were in the mid-range positions. The clock had stopped at 2:25. The airspeed indicator read 150 mph, the vertical speed indicator read 2,000 feet per minute down, and the altimeter, set to 30.04, indicated 8,600 feet. The directional gyro read 350 degrees, and the artificial horizon displayed a left wing, nose-down attitude. The tachometer indicated 2,000 rpm. The master switch was off, but the magneto switch was on both. The fuel pump was on, pitot heat was off, and the anticollision and landing lights were on. The navigation and communication radios were digital and no frequency information could be obtained. However, the primary and secondary omni bearing selectors were set to 115 degrees and 025 degrees, respectively. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy (01-115) was performed on the pilot by at the Community Hospital, Grand Junction, Colorado. Death was due to traumatic injuries. The Rio Blanco Coroner's Office performed gross examinations of the three passengers. The death of the front seat passenger was attributed to traumatic injuries, and the deaths of the rear seat passengers were attributed to asphyxiation due to drowning. FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma performed a toxicological screen on specimens from the pilot. According to CAMI's report (200100161001), no carbon monoxide, cyanide, and ethanol were detected in specimens. There was, however, 0.196 (ug/ml, ug/g) amphetamine in blood, 0.773 (ug/ml, ug/g) methamphetamine in blood, 11.925 (ug/ml, ug/g) amphetamine in urine, and 77.1 (ug/ml, ug/g) methamphetamine in urine. According to the book, "The Pharmacological Basis of Therapeutics," by Joel E. Hardman, Lee E. Limbird, Perry B. Molinoff, Raymond W. Ruddon, and Alfred Goodman Gilman (c. 1996), methamphetamine, commonly referred to as "speed" or "crystal meth," is a highly addictive and illegal stimulant. Amphetamine, a metabolite of methamphetamine, is also a stimulant. TESTS AND RESEARCH On June 26, 2001, the engine was examined at Beegles Aircraft Services. Thumb suction and compression was obtained from all cylinders. Valve continuity was established. Both magnetos were water damaged and could not be tested. The carburetor contained no fuel and was unremarkable. The engine-driven fuel pump was functionally tested and contained some residual fuel. The spark plugs were full of rust and mud, and would not spark. The ignition harness was water-soaked and could not be tested. There was impact scoring on the starter housing. The alternator was unremarkable. The vacuum pump produced suction when turned by hand. The oil system was intact and unremarkable. When the airplane departed Meeker, its estimated weight and center of gravity were 2,436.5 pounds and 91.88 inches aft of datum, respectively. Maximum certificated gross weight for the PA-28-161 is 2,325.0 pounds, and the center of gravity limits are between +87.0 and +93.0 inches aft of datum. Meeker Airport is situated at an elevation of 6,421 feet above mean sea level (msl). Upper Marvine Lake is approximately 9,300 feet msl and 32 nautical miles east of the Meeker Airport. The 2,879 foot difference would a require climb rate of approximately 90 feet per mile. Using the altimeter setting of 30.02, obtained from the Meeker 1517 weather observation, a pressure altitude of 6,321 feet was computed. Using the temperature of 23 degrees C., and consulting the PA-28-181's Climb Performance Chart (N5999V was equipped with a 180 hp engine), it was calculated that the airplane could climb approximately 340 feet per minute. At a best rate of climb (Vx) airspeed of 76 knots, the airplane would cover the 32 nautical miles in 25.25 minutes, and could conceivably climb 8,585 feet. There was considerably higher terrain surrounding the lake. The computed density altitude at the accident site was approximately 11,515 feet msl. According to the New Piper Aircraft Corporation spokesman, the service ceiling of the PA-28-161 is 11,000 feet when operated in the normal category, and 14,000 feet when operated in the utility category. ADDITIONAL INFORMATION In addition to the Federal Aviation Administration, parties to the investigation included Textron-Lycoming and the New Piper Aircraft Corporation. The wreckage was released to Beegles Aircraft Service on June 26, 2001.

Probable Cause and Findings

the pilot's failure to maintain terrain clearance as a result of his drug induced impairment. A factor was his exceeding the airplane's gross weight limits.

 

Source: NTSB Aviation Accident Database

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