Aviation Accident Summaries

Aviation Accident Summary FTW03FA048

Salem, UT, USA

Aircraft #1

N367T

Beech A36

Analysis

The 450-hour non-instrument rated private pilot collided with a mountain during a cross country flight in instrument meteorological conditions. Prior to departure, the pilot received a weather briefing from a flight service station and was advised that visual flight was not recommended. The pilot elected to depart and received another weather briefing while en route. The pilot was again advised that visual flight was not recommended due to mountain obscuration and icing. Approximately 1 hour and 10 minutes into the flight, several witnesses heard the airplane (with the engine running) flying low toward a mountain followed by the sound of an explosion. One witness reported that it was snowing and the visibility was approximately 150 feet. Another witness reported the weather as a mixture of rain, sleet, and snow falling at the time of the accident. The airplane collided with mountainous terrain approximately 10 miles southwest of the destination airport at an elevation of 5,273 feet. Examination of the airplane revealed the landing gear was extended and the flaps were retracted. No mechanical deficiencies were noted with the airplane or the engine. The pilot, who was reported to be a physician, tested positive for several prescription narcotic painkillers, an over-the-counter pain releiver/fever reducer, and two over-the-counter antihistamines.

Factual Information

HISTORY OF FLIGHT On November 24, 2002, at 1820 mountain standard time, a single-engine Beech A36 airplane, N367T, was destroyed when it impacted terrain near Salem, Utah. The airplane was registered to and operated by the pilot. The non-instrument rated private pilot and the passenger sustained fatal injuries. Instrument meteorological conditions prevailed and a visual flight rules (VFR) flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The approximately 204 nautical mile cross-country flight originated from the St. George Municipal Airport (SGU), near St. George, Utah, at 1709, and was destined for the Spanish Fork Springville Airport (U77), near Spanish Fork, Utah. At 1654, the pilot contacted a Flight Service Station and received a pre-flight weather briefing and filed a flight plan. At that time, a briefer informed the pilot that VFR was not recommended. Approximately 15 minutes later, after take off, the pilot received an in-flight weather briefing from Flight Watch and was once again informed that VFR was not recommended due to mountain obscuration and icing. A witness, who lived approximately one-mile from the accident site, said that he and his wife were looking outside the window of their home toward the north when they heard an airplane flying overhead in a northerly direction toward the mountain. He said it was snowing at the time and the forward visibility was approximately 150-feet. The witness said the airplane was close to the ground based on the sound of the engine, which was "steady and normal without any strain." Shortly after, he heard the sound and felt the vibration of an explosion. The witness then told his wife to call 911and he immediately responded to the accident site. A second witness said that he heard the airplane as it approached from the southwest toward the foothills of the mountain. He was unable to see the airplane but said that the engine sounded "fine." Shortly after, he observed and heard an explosion. A third witness also observed the airplane as it flew "very low" from west to east toward the mountain. He said the lights on the airplane's wings were flashing and the engine was running smoothly. PERSONNEL INFORMATION The 60-year old pilot was issued a private pilot certificate for airplane single-engine land on August 7, 1999. His last Federal Aviation Administration (FAA) third class medical certificate was issued on September 18, 2002. At that time, the pilot reported a total of 450 flight hours. AIRCRAFT INFORMATION The airplane was registered to the owner on April 20, 2000. The engine's oil and filter was changed, at a tach time of 1,036.0 on November 1, 2002. On November 22, 2002, the airplane was serviced with 17.82 gallons of 100LL, aviation grade fuel by the Spanish Fork Flying Service located in Spanish Fork, Utah. The airplane was equipped with a Micro Aerodynamics, Inc. Vortex Generator kit , a Turbo-Flite turbo normalizing system, and an Apollo MX 20. METEOROLOGICAL INFORMATION At 1835, the weather observation facility at the Provo Municipal Airport, (PVU) near Provo, Utah, approximately 20 miles nort-north west of the accident site, was reported as wind from 310 degrees at 25 knots gusting to 30 knots, visibility 10 miles, broken cloud layers at 2,700 feet, 3,600 feet and 4,600 feet, temperature 36 degrees Fahrenheit, dew point 31 degrees Fahrenheit, and an altimeter setting of 30.08 inches of Mercury. A witness, who was driving a vehicle approximately 1.5 miles from the accident , reported that a mixture of rain, sleet and snow began to fall at 1815 and lasted for approximately 30 minutes. WRECKAGE AND IMPACT INFORMATION According to a Global Positioning System Unit (GPS), the accident site was situated at Latitude 040 degrees 02.997 minutes North and Longitude 111 degrees 37.482 minutes West. The airplane initially impacted the side of a mountain at 5,273 feet mean sea level (msl) approximately 10 miles south of the Spanish Fork Springville Airport. The initial impact crater measured 36 feet by 21 feet. The nose landing gear strut, nose landing gear doors, and one outboard main landing gear door were found within the initial impact crater. The main wreckage, which included the propeller, engine, outboard sections of both wings, empennage and tail were located 82 feet north of the initial impact crater at 5,295 feet msl. The fuselage, inboard sections of both wings and the cockpit were consumed by fire. The flap actuators were extended 1.75 inches, which indicated the flaps were retracted. The damage to the nose landing gear strut, nose landing gear doors and main landing gear doors was consistent with the landing gear being extended at the time of impact. A section of the cockpit instruments were recovered. The instrument panel contained the air speed indicator which indicated 165 knots, fuel flow/manifold pressure gauge and heading indicator, which indicated 358 degrees, and the heading bug was selected on 297 degrees. The attitude indicator, turn coordinator, vertical speed indicator, and altimeter were not located. Examination of the engine revealed that crankshaft continuity could not be established due to impact damage. The fuel pump sustained impact and fire damage; however, its coupler was intact. The fuel injector sustained fire and impact damage; however, its fuel screen was clear and free and contaminants. The fuel manifold sustain fire damage and its diaphragm was melted; however, its screen was clear and free of contaminants. The vacuum pump sustained heat damage and its coupler was melted. The internal rotor and vanes sustained damage consistent with impact. The vacuum pump rotor was separated in three pieces and the six vanes were intact. The top spark plugs were removed and observed to be of the correct type and displayed signatures consistent with light wear. The piston heads were viewed through the top spark plug holes and the piston heads were all intact with light deposits. The engine's turbocharger displayed impact and heat damage. The impeller displayed nicks and the impeller blades were bent opposite the direction of rotation. Dirt was observed throughout the turbocharger. MEDICAL AND PATHOLOGICAL INFORMATION Toxicological testing was performed by the FAA's Civil Aeromedical Institute of Oklahoma City, Oklahoma. The pilot (a physician) tested positive for Cetirizine (a prescription antihistamine), Dihydrocodeine (a prescription narcotic painkiller) , Diphenhydramine (an over- the-counter antihistamine), Hydrocodone (a prescription narcotic), Hydromorphone (a prescription narcotic), Acetminophen (an over- the-counter/pain reliever), and Normeperidine (a prescription narcotic). The results were: Cetirizine detected in Blood Dihydrocodeine detected in Blood Dihydrocodeine detected in Urine Diphenhydramine present in Urine. .238 (ug/ml, ug/g) Diphengydramine detected in Blood .074 (ug/ml, ug/g) Hydrocodone detected in Urine .197 (ug/ml, ug/g) Hydromorphone detected in Urine 24.55 (ug/ml, ug/g) Acetaminophen detected in Urine. Normeperidine detected in Blood, Liver and Urine. A review of the pilot's last application for an Airman Medical Certificate in September 2002 revealed that he reported the use of a thyroid medication, but did not report the use of the medications found in the toxicology report. An autopsy was conducted on the pilot on November 26, 2002, by the State of Utah Medical Examiner, Salt Lake City, Utah. The cause of death was declared as "...the consequence of massive deceleration injuries." ADDITIONAL INFORMATION The airplane was released to a representative of the owner's insurance company on November 27, 2002.

Probable Cause and Findings

The pilot's inadequate inflight planning/decision to continue flight from visual to instrument meteorological conditions, which resulted in his failure to maintain clearance from terrain while in cruise flight. A low ceiling, obscuration, mountainous terrain and impairing drugs in the pilot's system were factors.

 

Source: NTSB Aviation Accident Database

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