Aviation Accident Summaries

Aviation Accident Summary LAX04FA241

Carson City, NV, USA

Aircraft #1

N63BB

Cessna 337

Analysis

During a left climbing turn on a go-around the aircraft stalled and entered a spin to ground impact. According to witnesses, the airplane entered a left traffic pattern at the uncontrolled airport for runway 9, although the airport facility directory published pattern is for right traffic. The witnesses saw the airplane line up on final approach for a parallel taxiway south of runway 9, then it started a go-around. The airplane performed a continuous left climbing turn to about 1,000 feet above ground level. While in the turn the airplane appeared to stall, followed by the nose dropping as the airplane entered a 1 1/2 turn spin that continued to ground impact about 5,000 feet northeast of the center of the airport. The density altitude was calculated at 7,200 feet mean sea level. A post crash fire thermally destroyed the airplane. An examination of the ashen remains of the aircraft found no evidence of a preimpact mechanical malfunction or failure. Toxicological analysis detected diphenhydramine, amphetamine, and methamphetamine in tissue samples from the pilot. Diphenhydramine is an over-the-counter antihistamine, commonly known by the trade name Benadryl, that has sedative effects commonly resulting in drowsiness and measurable negative effects on complex cognitive and motor tasks. In legal prescription form, amphetamine may be used for Attention Deficit Hyperactivity Disorder (ADHD), narcolepsy, and weight control; methamphetamine may be used for ADHD or severe obesity. Methamphetamine may also be detected as a result of recent use of a Vick's inhaler, which contains a form of the medication. There was no blood available for analysis, so it was not possible to determine when the substances might have been taken or whether the pilot was likely to have been impaired by them. The pilot did not indicate the use of any medications on his most recent application for airman medical certificate, approximately 6 weeks prior to the accident. The flight originated in New York a few day prior, and made stops in Pennsylvania, Ohio, Kentucky, South Carolina, Kansas, and Utah.

Factual Information

HISTORY OF FLIGHT On June 16, 2004, about 1242 Pacific daylight time, a Cessna 337, N63BB, collided with terrain while on approach to the Carson City Airport, Carson City, Nevada. The airplane was operated by the pilot under the provisions of 14 CFR Part 91. The airline transport licensed pilot, the sole occupant, was fatally injured. The airplane was destroyed by impact and post crash fire. Visual meteorological conditions prevailed and a flight plan had not been filed. The flight departured Provo, Utah, with Carson City as the destination. Limited information recovered from the pilot's logbook revealed that the flight originated from Brookhaven Airport, Shirley, New York. There were stops made en route at Allentown, Pennsylvania; Murray, Kentucky; Mansfield, Ohio; Darlington, South Carolina; Dodge City, Kansas; and the last stop prior to Carson City was Provo, Utah, where the airplane had been topped off with the addition of 75.4 gallons of 100LL aviation fuel on the morning of June 16th. According to witnesses, the airplane entered a left traffic pattern at the uncontrolled airport for runway 9, although the airport facility directory published pattern if for right traffic. The witnesses saw the airplane line up on final approach for a parallel taxiway south of runway 9, then it started a go-around. The airplane performed a continuous left climbing turn to about 1,000 feet above ground level (agl). While in the turn the airplane appeared to stall, followed by the nose dropping as the airplane entered a 1 1/2 turn spin that continued to ground impact about 5,000 feet northeast of the center of the airport. The primary wreckage was at 39 degrees 11.491 minutes north latitude by 119 degrees 43.022 west longitude. The airport elevation is 4,697 feet mean sea level, and the density altitude was 7,200 feet. PERSONNEL INFORMATION The pilot held an airline transport pilot certificate and was rated for airplane single and multiengine land centerline thrust airplanes. According to information obtained from insurance company records, he had about 600 hours in a Cessna 337 and about 1,000 hours in a Piper PA-28-140 airplanes. The pilot first obtained a student pilot's certificate on July 10, 2002. The pilot's most recent and second flight physical occurred on May 11, 2004, at which time he reported 1,700 total hours with 500 in the past 6 months. AIRCRAFT INFORMATION According to logbook information, the most recent annual inspection occurred on October 3, 2003, at a recording tachometer reading of 452.2 hours. The airplane total time is about 4,250 hours. WRECKAGE AND IMPACT INFORMATION The accident site was located about 1/4 mile south and east of the approach end to runway 27, in an area of open brush covered desert terrain. A post crash fire had consumed most of the airplane structure. The wreckage was examined at the accident site by the National Transportation Safety Board Investigator. The recovered airplane's available components revealed that the landing gear was in the down position with 10 degrees of flaps (jackscrew extension was 3.8 inches) and 5 degrees of down elevator tab (jackscrew extension was 2.7 inches). Control continuity was confirmed through the right tail boom and right wing to the cabin area. The left wing and the left tail boom control cable continuity was confirmed to the wing root and the base of the left wing strut from the cockpit area. Flap cable continuity was confirmed for both flaps. The entire fuel system, including the fuel selector panel was thermally destroyed. Mechanical continuity was established in both engines. The accessory sections were thermally destroyed. MEDICAL AND PATHOLOGICAL INFORMATION On June 17, 2004, the Washoe County Medical Examiner performed an autopsy on the pilot. During the course of the procedure samples were obtained for toxicological analysis by the Federal Aviation Administration Civil Aeromedical Examiner, Oklahoma City, Oklahoma. Due to the extent of the post crash fire, limited samples were available. The results of the limited samples were carbon monoxide was not performed and cyanide was not performed. No ethanol was detected from the samples available. A limited drug analysis detected Diphenhydramine in liver and heart samples. Amphetamine was detected in a liver sample, also 0.071 (ug/ml,ug.g) Methamphetamine was detected in liver and in heart samples. The pilot did not indicate the use of any medications on his most recent application for airman medical certificate, approximately 6 weeks prior to the accident. There was no blood available for analysis. ADDITIONAL INFORMATION The wreckage was released to the insurance company representative on August 5, 2004.

Probable Cause and Findings

the pilot's failure to maintain an adequate airspeed while maneuvering during a go-around that led to an inadvertent stall spin.

 

Source: NTSB Aviation Accident Database

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