Aviation Accident Summaries

Aviation Accident Summary CHI04FA257

Chesterfield, MO, USA

Aircraft #1

N843MC

Cessna 182T

Analysis

The airplane was destroyed on impact with trees and terrain during an attempted go-around. A post impact fire occurred. Night visual meteorological conditions prevailed at the time of the accident. The pilot representing the accident airplane informed the tower that he was 11 miles south of the airport and was inbound for landing on the north runway. The flight was cleared to land on runway 26R. The pilot informed the tower that he was going around. The flight was cleared to make right traffic for runway 26R. At approximately 2116, the pilot confirmed the clearance for right traffic. That was the last transmission received from the flight. The sheriff's report stated, "All of the witnesses stated they saw a low flying aircraft disappear behind the woods before hearing a loud crash and seeing an explosion, which lasted a brief period of time." The flaps were found extended to 25 degrees. An on-scene examination of the wreckage revealed no pre-impact anomalies. An excerpt from the airplane information manual stated, "BALKED LANDING 1. Power -- FULL THROTTLE and 2400 RPM. 2. Wing Flaps -- RETRACT TO 20". 3. Climb Speed -- 55 KIAS. 4. Wing Flaps -- RETRACT slowly after reaching a safe altitude and 70 KIAS. 5. Cowl Flaps -- OPEN." Plotted airplane radar track data showed that the airplane was climbing after its approach. The plot showed the airplane at 550 feet MSL at 2115:47, at about the end of runway 26R. The airplane's highest recorded altitude during that climb was 1050 feet MSL at 2116:33, about a mile west of runway 26R. The next plotted return showed the airplane at 950 feet MSL at 2116:38. The accident site was plotted and it was about a tenth of a mile north of the last return. The pilot's instructor informed management at the flight school that "I endorsed [the pilot ] because he did meet all of the standards for the practical test and he passed his Part 141 Graduation ride. I am writing you because even though [he] performed well on his Grad and will pass his practical test, I am worried about his complacent attitude toward flying and expressing my concern for his safety post check ride."

Factual Information

HISTORY OF FLIGHT On September 12, 2004, about 2116 central daylight time, a Cessna 182T, N843MC, piloted by a private pilot, was destroyed on impact with trees and terrain on Howell Island, near Chesterfield, Missouri, during a go-around from runway 26R (5,000 feet by 75 feet, dry asphalt) at the Spirit of St Louis Airport (SUS), near Chesterfield, Missouri. A post impact fire occurred. The personal flight was operating under 14 CFR Part 91. Night visual meteorological conditions prevailed at the time of the accident. No flight plan was on file. The pilot and three passengers were fatally injured. The flight originated from Sikeston Memorial Municipal Airport, near Sikeston, Missouri, at time unknown and was in the pattern at SUS performing a go-around maneuver at the time of the accident. The pilot representing N843MC informed the tower at SUS that he was 11 miles south of the airport and was inbound for landing on the north runway. The flight was cleared to land on runway 26R. The pilot informed the tower that he was going around. The flight was cleared to make right traffic for runway 26R. Approximately 2116, the pilot confirmed the clearance for right traffic and that was the last transmission received from the flight. The St. Charles County Sheriff's Department report said that seven witnesses were contacted. The report stated, "All of the witnesses stated they saw a low flying aircraft disappear behind the woods before hearing a loud crash and seeing an explosion, which lasted a brief period of time." PERSONNEL INFORMATION The pilot held a private pilot certificate with an airplane single-engine land rating. His pilot certificate was issued on August 21, 2004. The pilot took an initial check ride for his private pilot certificate on August 19, 2004. He did not pass that check ride and was given a notice of disapproval of application. The area failed on that check ride was on takeoffs, landings, and go-arounds. The particular failed task was the forward slip to a landing. On his application for his re-examination, he listed a total flight time of 72.2 hours. That application showed that he had 3.3 hours of night time and 13 night take-offs and landings. His Federal Aviation Administration (FAA) third-class medical certificate was issued on April 2, 2004, with a limitation that he "must wear corrective lenses for near and distant vision" and that the certificate was "not valid for any class after April 30, 2005." The pilot graduated from a 14 CFR Part 141 FAA approved flight school. The pilot's training course outline was reviewed. The pilot's final preparation for graduation ride lesson had an instructor's handwritten notes and comments annotated on it. Those notes and comments included "talking out loud, GUMPS check, patterns too wide, situational awareness, and checklists." That instructor wrote an e-mail to the management of the flight school. The e-mail stated: I am writing you concerning a current customer of mine. I began flying with [the accident pilot]on June 11. He was waiting for his current instructor to solo him when the instructor left for an airline, so he was assigned to me. He was very anxious to solo, a little too anxious in my opinion. I told him that I would solo him when I felt he was safe, and [he] seemed a bit frustrated that there may be a chance that I may delay his solo. This attitude worried me because I feel that a student pilot should trust his instructor's judgment. Throughout the rest of the training, [he] began showing complacency in the airplane. I would stress to him the importance of using checklists, yet he would not use them unless I made him. He seemed to think that I was only having him use the checklists to prepare him for the practical test, but I would explain that the checklist is there for his safety. [He] also felt that a GUMPS check or any before landing checklist was a waste of time if he was doing touch and go's and remaining in the pattern. An example of [his] attitude toward his training was during simulated engine failures. On two occasions I pulled the power back on the engine and expected [him] to follow emergency procedures. Both times he would argue with me that he did not want to simulate an emergency right then. He did not seem to respect the fact that an engine failure could happen at any time and he would never be expecting one. I endorsed [him] because he did meet all of the standards for the practical test and he passed his Part 141 Graduation ride. I am writing you because even though [he] performed well on his Grad and will pass his practical test, I am worried about his complacent attitude toward flying and expressing my concern for his safety post check ride. The flight school reported that after receiving this email from the flight instructor, that the flight school gave additional corrective counseling to the accident pilot. AIRCRAFT INFORMATION N843MC, a 2002 Cessna 182T, serial number 18281143, was a high wing, propeller-driven, fixed landing gear, semi-monocoque design, four-seat airplane. A 230 horsepower, six-cylinder, air cooled, horizontally opposed, fuel injected, Lycoming IO-540-AB1A5, serial number L 28421-48A, engine, powered the airplane. The propeller was a three-bladed, all-metal, constant speed, McCauley model. One propeller blade's serial number was confirmed as WB26223. The airplane's logbooks showed that an annual inspection was completed on March 24, 2004, and a 100-hour inspection was completed on August 4, 2004. The airplane had accumulated 419 hours of total time at the date of the 100-hour inspection. An excerpt from the airplane information manual stated: BALKED LANDING 1. Power -- FULL THROTTLE and 2400 RPM. 2. Wing Flaps -- RETRACT TO 20". 3. Climb Speed -- 55 KIAS. 4. Wing Flaps -- RETRACT slowly after reaching a safe altitude and 70 KIAS. 5. Cowl Flaps -- OPEN. METEOROLOGICAL INFORMATION The Aeronautical Information Manual stated that "Automatic Terminal Information Service (ATIS) is the continuous broadcast of recorded noncontrol information in selected high activity terminal areas. Its purpose is to improve controller effectiveness and to relieve frequency congestion by automating the repetitive transmission of essential but routine information. ... Pilots should notify controllers on initial contact that they have received the ATIS broadcast by repeating the alphabetical code word appended to the broadcast." ATIS information Kilo was current at the time of the accident. Information Kilo stated that recorded weather at 2054 indicated that the wind was calm, visibility was five miles with mist, few clouds at 7,500 feet, temperature 19 degrees C, dew point 17degrees C, and the altimeter was 30.06 inches of mercury. AIRPORT INFORMATION The North Central US Region Airport/Facility Directory (A/FD) indicated that the airport elevation at SUS was 463 feet above mean sea level (MSL). SUS was a towered airport with two runways, 08R/26L and 08L/26R. The A/FD stated that runway 08L/26R was 5,000 feet long and 75 feet wide. The runway surface was composed of asphalt. Runway 26R had a vertical approach slope indicator. WRECKAGE AND IMPACT INFORMATION An on-scene investigation was conducted. The airplane impacted a wooded area of Howell Island at latitude 38 degrees 39 minutes 44.713 seconds north and longitude 90 degrees 41 minutes 30.267 seconds west. A tree, about 34.5 feet from the shore exhibited a broken limb and impact marks. The airplane wreckage was scattered in a semicircular pattern around the tree. Ground vegetation in this area was found charred. The forward fuselage and engine were discolored and deformed by fire. The flight control cables were traced from their surfaces to the area under the flight controls in the forward part of the cockpit. All breaks in the cables were consistent with overload. The flap jackscrew was extended consistent with 25 degrees of flap extension. The even bank of cylinders was removed from the engine case. Crankshaft continuity was confirmed. The crankshaft rotated when a force was applied to a crankshaft cheek and crankshaft to camshaft continuity was established. The left magneto produced spark when rotated. The right magneto sustained heat damage. One propeller blade was not recovered. One propeller blade exhibited leading edge nicks and the other blade exhibited "S" shaped bending. No engine or airframe pre-impact anomalies were found. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot by the St. Charles County Medical Examiner's Office on September 13, 2004. The FAA Civil Aeromedical Institute prepared a Final Forensic Toxicology Accident Report. That report showed: 18 (mg/dL, mg/hg) ETHANOL detected in Muscle 5 (mg/dL, mg/hg) ACETALDEHYDE detected in Muscle TESTS AND RESEARCH Continuous Data Recording (CDR), which is airplane radar track data, was obtained from the FAA St Louis ASR-9 site. The rate of rotation for that site's antenna was about 4.5 seconds, and it recorded altitudes that represented the received airplane's pressure altitude reading. A correction factor was added to the pressure altitude to get an altitude referenced to MSL. The radar returns along with their respective MSL altitudes were plotted on a St Louis Visual Flight Rules Terminal Area Chart. The plotted data showed that the airplane was climbing after its approach to runway 26R. The plot showed the airplane at 550 feet MSL at 2115:47 at about the end of runway 26R. The airplane's highest recorded altitude during that climb was 1050 feet MSL at 2116:33, about a mile west of runway 26R. The next plotted return showed the airplane at 950 feet MSL at 2116:38. The accident site was plotted on that chart and it was about a tenth of a mile north of the last return. That plotted chart is appended to the docket material associated with this case. ADDITIONAL INFORMATION The parties to the investigation included the FAA, Textron Lycoming, and the Cessna Aircraft Company. The aircraft wreckage was released to a representative of the insurance company.

Probable Cause and Findings

The pilot not maintaining airspeed and the inadvertent stall he encountered during the go-around. A factor was the tree he impacted during his uncontrolled descent.

 

Source: NTSB Aviation Accident Database

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