Aviation Accident Summaries

Aviation Accident Summary MIA02FA104

Lutz, FL, USA

Aircraft #1

N942SP

Cessna 172S

Analysis

The pilot had been involved in a helicopter accident that occurred 10 hours 52 minutes before the airplane accident which the helicopter he was flying solo crashed onto the roof of a house. He sustained minor injuries and there were no injuries to the three occupants of the house. The pilot was transported to a hospital where a testing of a blood specimen taken 1 hour 40 minutes after the accident indicates 136 g/dL ethanol detected. Testing of a sample from the same specimen by the FAA Toxicology and Accident Research Laboratory (CAMI) indicated 105 mg/dL ethanol in blood, or .105 percent by weight in blood. CAMI also detected acetone (1 mg/dL, mg/hg), acetaldehyde (8 mg/dL, mg/hg), citalopram (0.017 ug/ml,ug/g), and zolpidem (0.433 ug/ml,ug/g) in the blood specimen. The medical records from the hospital indicate a physician note at 2300 hours (approximately 1.5 hours after the accident), indicating slurred speech. A nursing note without a time stamp indicates the pilot admitted to ingesting ethanol "earlier today." The primary diagnosis on the emergency department physician note is, "ethanol intoxication, concussion." The pilot was released from the hospital to his parents at 0235 hours on the 4th of June, and he was transported to his apartment which he shared with a roommate. The roommate reported to the pilot's mother that on the day of the airplane accident, the pilot was watching television at 0630 hours. On the morning of the airplane accident sometime before 0710 hours, the pilot was observed taxiing the airplane to runway 36. Several witnesses reported hearing the pilot abruptly apply power to the engine several times before departing about 0709 hours. After takeoff the flight proceeded in a northwesterly direction and without establishing contact with the Tampa Approach Control or Tampa Air Traffic Control Tower, orbited for approximately 62 minutes while flying at approximately 2,200 feet. During this time an airplane that was inbound to KTPA was vectored by a controller to where the airplane was orbiting in an attempt to identify the airplane to controllers; the pilot reported seeing the pilot in the left side of the airplane. The pilot assisting air traffic control also reported that he believed the orbiting pilot was aware of the close proximity of the two airplane because it appeared to him that the orbiting pilot was maneuvering to avoid him. Attempts to communicate with the pilot on the departure airport CTAF were negative. Additionally, attempts by a flight crew member of a law enforcement helicopter to communicate with the pilot on guard (121.5 MHz) were also unsuccessful. After orbiting for 62 minutes, the airplane departed the orbits flying in a northwesterly direction for 1.6 minutes, then completed a 180 degree turn to the right. The airplane then flew in a southeasterly direction for 36 seconds, turned to the left flying in a northwesterly direction, then completed a right 360 degree descending turn. The airplane continued in a northwesterly direction, where the last primary radar target was noted in close proximity to the accident site. A witness located near the accident site area reported hearing the airplane flying at what she thought was a low altitude then heard the engine "revving" up followed by hearing the impact. Several other witnesses across the street from the crash site reported hearing the engine sound that was steady with no sputtering. The engine sound remained the same from the time they heard it until the impact. Another witness reported that he first observed the airplane when it was approximately 30-40 feet above the tops of trees. The airplane at that time was in a 80-degree nose low attitude on a southeast heading. He observed the airplane collide with the trees then heard the impact. Examination of the accident site revealed damage to trees at decreasing heights. All components necessary to sustain flight were either attached or partially attached to the airplane or were found in close proximity to the main wreckage. Examination of the flight controls for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. The flaps were retracted. Examination of the engine revealed no evidence of preimpact failure or malfunction. The No. 1 communication/navigation transceiver was in the on position with maximum volume and the active communication frequency was set to 119.9 MHz, which is the frequency for the East Satellite sector of the Tampa Air Traffic Control Tower. The autopsy report indicates the cause of death as blunt trauma, while the manner of death was listed as "undetermined." A toxicology analysis by CAMI of postmortem specimens was positive in the blood for ethanol (69 mg/dL), acetaldehyde (82 mg/dL), citalopram (0.205 ug/ml, and zolpidem (1.54 ug/ml). The kidney tested positive for ethanol (84 mg/dL), citalopram, di-n-desmethylcitalopram, n-desmethylcitalopram, and zolpidem. The muscle tested positive for ethanol (105 mg/dL). The liver tested positive for citalopram, di-n-desmethylcitalopram, n-desmethylcitalopram, and zolpidem. The gastric contents tested positive for citalopram, di-n-desmethylcitalopram, n-desmethylcitalopram, and zolpidem. Carbon monoxide and cyanide testing was not performed. A note on the CAMI toxicology report indicates, "The ethanol found in this case may potentially be from postmortem ethanol formation and not from the ingestion of ethanol." The levels of citalopram and zolpidem detected in the post mortem blood specimen are more than 12 times and more than 3 times, respectively, greater than the levels of each detected in a hospital blood specimen taken 1 hour 40 minutes following the first accident. Additionally, the CAMI toxicology report indicates citalopram and zolpidem were detected in the submitted postmortem gastric specimen. The pilot had been charged with DUI in May 2001, and reported such on his FAA medical application dated June 1, 2001. The pilot plead nolo contendere to the DUI charge on October 4, 2001. The pilot's medical records from his private physician indicate on May 23, 2002, he complained of insomnia, and depression. The doctor provided samples of 20 mg Celexa (citalopram), one-half tablet daily, and prescribed 10 mg Ambien, 1/2 to 1 tablet to be taken at bedtime. His physician did not request a psychiatric consultation or an inquiry regarding suicidal intent or alcohol/drug use.

Factual Information

HISTORY OF FLIGHT On June 4, 2002, about 0823 eastern daylight time, a Cessna 172S, N942SP, registered to Helicopters & Airplanes, Inc., collided with trees then the ground near Lutz, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 personal, local flight. The airplane was destroyed by impact and the private-rated pilot, the sole occupant, was fatally injured. The flight originated about 0709 from Vandenberg Airport, Tampa, Florida. The pilot was observed taxiing the airplane to runway 36 at the Vandenberg Airport, and one witness located on the airport reported the pilot did not perform an engine run-up before takeoff but he "gunned the throttle two times and took off at 0710 am." Another witness on the airport reported hearing the pilot run up the engine abruptly several times before observing the pilot taxi onto runway 36. An individual who was working at a fixed-base operator (FBO) at the Vandenberg airport reported that on the day of the accident sometime after 0730 hours, Tampa Approach Control contacted the FBO and asked for someone there to attempt to contact the pilot on the airport's common traffic advisory frequency (CTAF). She reported making repeated broadcasts on the CTAF for the accident pilot, but he did not respond. According to a chronological sequence of events prepared by the air traffic manager of the Tampa International Airport Air Traffic Control Tower, at approximately 0716, a radar target associated with the accident airplane was noted orbiting at 2,000 feet north-northeast of the Tampa International Airport (KTPA). At approximately 0718, the departure controller questioned the tower controller about the orbiting airplane; the tower controller advised he was not aware of the airplane and it must be a class B airspace violator. At approximately 0726, the pilot of Flight Express 820 which was inbound to KTPA was vectored by a controller in the area of the orbiting airplane to help identify the airplane; he provided the registration of the airplane to the controller at approximately 0730. At approximately 0734, the Flight Express 820 pilot advised the controller that he thought the airplane was based at the Vandenberg Airport. At 0738, the operations supervisor contacted the FBO at Vandenberg who provided the name of the owner of the airplane. The FBO was also asked to attempt to communicate with the pilot on the airport UNICOM frequency. At 0742, the operations supervisor advised the tower controller that a police helicopter would become airborne to track the orbiting airplane. At approximately 0753, the operations supervisor contacted the U.S. Coast Guard requesting their assistance. At approximately 0758, the operations supervisor contacted the St. Petersburg Automated Flight Service Station and requested personnel attempt to communicate with the pilot of the orbiting airplane on the appropriate PIE VORTAC frequency. At approximately 0803, a flightcrew member of a police department helicopter reported on the frequency and the flight was vectored to the area of the orbiting airplane. A flightcrew member of the police department helicopter broadcast on 121.5 for the orbiting airplane, but there was no response from the pilot. At approximately 0812, a flightcrew member of the police department helicopter advised they would return to get a Cessna which had a camera. At approximately 0821:24, the radar target was lost momentarily, a target was reacquired at 0821:35, and the radar target was finally lost at 0823:10, with the last recorded altitude of 700 feet mean sea level. The pilot of Flight Express 820 later reported in writing to the National Transportation Safety Board (NTSB) that while flying in close proximity to the accident airplane, he observed the pilot of the orbiting airplane sitting upright in the "left side of the aircraft." He also reported he thought the pilot of the orbiting airplane was aware of the close proximity of both airplanes because, "...it appeared that he was maneuvering to avoid me, although I was unable to see the pilot moving at any time nor was I close enough to see any facial expressions or physical gestures of any kind." The pilot of the Tampa Police Department helicopter which was dispatched to the orbiting airplane reported observing the airplane from 3/4 mile away. He later reported the airplane was flying left orbits. A witness near the accident site reported hearing the airplane flying at what she thought was a low altitude then heard the engine "revving" up followed by hearing the impact. Several other witnesses across the street from the crash site reported hearing the engine sound that was steady with no sputtering. The engine sound remained the same from the time they heard it until the impact. Another witness reported that he first observed the airplane when it was approximately 30-40 feet above the tops of trees. The airplane at that time was in a 80-degree nose low attitude on a southeast heading. He observed the airplane collide with the trees then heard the impact. Several law enforcement aircraft and a U.S. Coast Guard helicopter were dispatched to the area of the last known position of the orbiting airplane. Additionally, a ground search for the airplane was initiated by local law enforcement personnel. National Transportation Safety Board (NTSB) review of recorded radar data for beacon code 1200 radar returns revealed a target was first observed at 0709:07, at 400 feet mean sea level (msl) just north of runway 36 at the Vandenberg Airport. The flight proceeded in a northwest then westerly direction where from approximately 0715 to 0817, the flight orbited at approximately 2,200 feet over the intersection of Ehrlich Road and Dale Mabry Highway. At approximately 0817, the flight departed from the orbiting area and proceeded in a northwesterly direction for approximately 1.6 minutes, then turned to the right completing a 180-degree turn. The airplane then proceeded in a southeasterly direction for approximately 36 seconds and at approximately 0819:55, the airplane turned to the left and proceeded in a northerly direction flying at 2,100 feet until 0820:31. The airplane then turned to the left, climbed 100 feet over the next 12 seconds, then the airplane turned to the right and performed a right descending 360-degree turn. The airplane then proceeded in a northwesterly direction where at 0822:31, the last radar return with altitude was reported. The last radar target at 0822:43, was a primary only radar return. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot was issued a private pilot certificate with airplane single engine land rating on July 2, 2000. He was issued a third class medical certificate with no limitations on June 1, 2001. A review of FAA records indicated the pilot did not have any previous accident or incidents, or previous enforcement actions. A review of the medical application for the June 2001 medical revealed he listed his total flight time as 292 hours. Further review of the application revealed the pilot checked the "yes" block in response to the question, "History of ...any conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug...." Review of the pilot's driver license records revealed he was charged with driving under the influence (DUI) on May 9, 2001; he pleaded nolo contendere to the charge on October 4, 2001. AIRCRAFT INFORMATION The airplane was manufactured by Cessna Aircraft Company in 1999, as model 172S, and was designated serial number 172S8137. It was certificated in the normal and utility categories, and was equipped with a 180-horsepower Lycoming IO-360-L2A engine, and a fixed pitch McCauley propeller. A review of the maintenance records revealed the airplane was last inspected on June 3, 2002, in accordance with an annual inspection. The airplane had accumulated 1.2 hours since the inspection at the time of the accident. METEOROLOGICAL INFORMATION A METAR weather observation taken from the Tampa International Airport (KTPA) on the day of the accident at 0753 (approximately 29 minutes before the accident), indicates the wind was calm, the visibility was 10 statute miles, scattered and overcast clouds existed at 13,000 and 25,000 feet, respectively, the temperature and dew point were 27 and 21 degrees Celsius, respectively, and the altimeter setting was 29.97 inHg. The accident site was located approximately 007 degrees and 9 nautical miles from KTPA. COMMUNICATIONS The pilot did not establish two way communications with any air traffic control facility. The common traffic advisory frequency (CTAF) at the Vandenberg Airport is not recorded. WRECKAGE AND IMPACT INFORMATION The airplane crashed in a wooded area located near a residential area. The accident site was located at 28 degrees 07.630 minutes North latitude and 082 degrees 31.522 minutes West longitude, or approximately 12 nautical miles and 310 degrees from the departure airport (Vandenberg Airport). Examination of the accident site revealed damage to trees at decreasing heights. The main wreckage consisting of the upright fuselage, partially attached vertical stabilizer, and engine assembly was located approximately 68 feet from the first tree contact location. The descent angle between the first trees contacted and the location where the main wreckage came to rest was calculated to be approximately 40 degrees. Aircraft debris was located along the energy path which was oriented on a magnetic heading of 146 degrees. The first two identified trees contacted by the airplane were located 14 feet apart and left and right of a centerline when viewed from the center point of the trees to the main wreckage location. The first two trees contacted were at differing heights, with the tree to the left of the centerline damaged approximately 75 feet above ground level (agl), while the tree to the right of the centerline was damaged approximately 85 feet agl. The propeller, which was separated from the engine was located partially buried in the ground at the base of a tree located near the location where the fuselage came to rest. A root from the tree adjacent to where the propeller came to rest exhibited 45-degree cuts at both ends, while a 7-inch diameter tree trunk with a 45-degree cut surface was found along the energy path. Examination of the airplane revealed all components necessary to sustain flight were located attached or partially attached to the airplane or were in close proximity to the main wreckage. Both wings were fragmented, and the vertical stabilizer remained partially secured to the fuselage. Flight control cable continuity was confirmed for elevator and rudder. Examination of the left aileron flight control cable revealed tension overload at the wing root area, while the right aileron flight control cable exhibited tension overload midspan of the wing. The aileron balance cable also exhibited tension overload. The elevator trim tab was found positioned 5 degrees trailing edge tab up, which equates to nose down trim. The flaps were found retracted as determined by the flap actuator. Examination of the cockpit revealed the throttle and mixture controls were positioned to full open and full rich, respectively, while the magneto switch was in the "both" position. The fuel selector was found near the "both" detent; the fuel selector valve actuating rod was bent. The horns of the pilot's control yoke were not damaged; the yoke separated at the joint behind the instrument panel associated with impact damage. The horns of the copilot's yoke were also not damaged, but the shaft of the control yoke was fractured at the location where the shaft secures to the control yoke. The pilot's (left front seat) lapbelt /shoulder harness was not buckled and the lapbelt webbing on the male and female sides was not failed, but the shoulder harness webbing was cut across the webbing. The co-pilot's (right front seat) lapbelt/shoulder harness was also not buckled, but one of the side flanges of the female side of the buckle was bent approximately 30 degrees, and the male side of the buckle exhibited a mark on top of the buckle. A pin that secures the lapbelt to the female side of the buckle was out of position approximately .80 inch; a gouge was noted on the pin. The webbing of the shoulder harness was cut across the webbing, and a tear near the edge was noted; the tear paralleled the edge of the webbing. Examination of the flight and engine instruments revealed the vertical speed indicator was indicating a descent rate of 1,400 feet-per-minute, the left and right fuel quantity gauges indicated zero and five gallons, respectively, the oil temperature indicated 200 degrees Fahrenheit, and the oil pressure indicated 100 psi. A headset was plugged into the left sidewall interior fittings; the microphone cord was broken. The No. 1 communication and navigation transceiver was in the "on" position and the volume was found positioned to the maximum setting. The No. 2 communication and navigation transceiver was in the "off" position. The audio mode control panel was examined and impact damage precluded determining the position of the communication selector switch. The transponder was set to "altitude." Examination of the engine revealed the crankshaft was fractured at the opening of both crankcase halves, which was aft of the propeller flange. Rotation of the engine by hand from one of the accessory drive pads revealed crankshaft, camshaft, and valve train continuity. Thumb compression was noted in all cylinders during hand rotation of the crankshaft. The left magneto was in position though impact damage was noted, while the right magneto was separated from the accessory case but remained attached to the engine by the ignition leads. Both magnetos produced spark at all towers when rotated by hand. Examination of the spark plugs revealed all exhibited medium gray coloration with slight to moderate wear of the electrode. The servo fuel injector was separated from the engine; the inlet screen was clean. The engine-driven fuel pump was also separated from the engine. Residual 100 low lead fuel was noted in the engine-driven fuel pump and fuel manifold valve. All two-piece fuel injector nozzles were free of obstructions. Examination of the two-bladed fixed pitch propeller revealed one blade was bent aft approximately 90-degrees with a sloping forward bend near the blade tip. The other blade was missing an approximate 10-inch section from the length, the leading edge was twisted towards low pitch, and a slight forward bend was noted at the tip of the remaining section of blade. No alcoholic beverages were found in the wreckage; a bottle of "Advil" was found in the wreckage. Papers located in the wreckage containing hand written information were reviewed; one of the pages was found to contain the frequency 119.9 MHz, which was later determined to be the Tampa Air Traffic Control Tower East Satellite Sector frequency. MEDICAL AND PATHOLOGICAL INFORMATION The pilot was involved in a helicopter accident the day before at approximately 2130 hours, in which the helicopter he was flying solo descended onto the roof of a house in a residential area located in Tampa, Florida. There were no injuries to the three occupants of the house, and the pilot sustained minor injuries as a result of the helicopter accident which occurred approximately 10 hours 53 minutes before the airplane accident. Following the helicopter accident, the pilot was transported to a local hospital for examination. NTSB report MIA02FA106 discusses the facts, conditions, and circumstances of the helicopter accident. The NTSB medical officer prepared a factual report based on his review of: 1) the pilot's medical records from the hospital that treated him immediately following the helicopter accident, 2) medical records from the pilot's private physician, 3) the toxicology report from CAMI from specimens taken while the pilot was hospitalized following the helicopter accident, 4) the toxicology report from CAMI from postmortem specimens, and 5) the autopsy report. The factual report indicates that with r

Probable Cause and Findings

The suicidal act by the pilot resulting in the in-flight collision with trees then the ground. A contributing factor in the accident was the pilot's depression. Findings in the investigation were the pilot's overdose of zolpidem and citalopram before the accident flight departed, and his intentional operation of the airplane while impaired by alcohol.

 

Source: NTSB Aviation Accident Database

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