Aviation Accident Summaries

Aviation Accident Summary ATL06LA058

Double Springs, AL, USA

Aircraft #1

N2157V

Cessna 182T

Analysis

The pilot departed Pine Bluff, Arkansas on a local flight and landed in Clarksdale, Mississippi. The pilot informed a lineman after landing that he had been flying for 60 years and that he was lost, almost out of gas, did not have any maps, and he did not know how to get home. An attempt was made by the lineman to fly with the pilot back to Pine Bluff or drive him home in a car. The pilot declined the offer. The pilot departed Clarksdale enroute to Pine Bluff. A witness located in the vicinity of Double Springs, Alabama, observed the airplane approaching his location at a very low altitude above the trees. The airplane turned to the left, flew over a day care center, made another turn, and flew towards the south. A short time later the witness heard an impact noise. The witness informed his mother he thought an airplane had crashed. They both departed to a friends house located in the vicinity of the crash site, went to the edge of a wood line and observed a flashing red light. They called out to see if any one would answer, the pilot responded and walked out of the wood line. The pilot informed them he had been involved in a vehicle accident. Examination of the airplane revealed the right wing was accelerated forward. The left wing was separated from the airframe and the leading edge of the wing was compressed inward. The left and right flaps were fully extended. No anomalies were noted with the airframe, flight controls, engine assembly and accessories. The pilot stated in an interview with the NTSB investigator-in-charge that he had no idea how he ended up in Double Springs, Alabama. The pilot had been diagnosed by his private physician with dementia since 2003, but had concealed that diagnosis from the FAA.

Factual Information

HISTORY OF FLIGHT On March 31, 2006, at 2015 central standard time, a Cessna 182T, N2157V, registered to Wings South Inc., and operated by a private owner as a 14 CFR Part 91 personal flight, collided with trees while maneuvering in the vicinity of Double Springs, Alabama. Visual meteorological conditions prevailed and no flight plan was filed. The airplane received substantial damage. The airline transport rated pilot received serious injuries. The flight originated at Fletcher Field, Clarksdale, Mississippi, on March 31, 2006, at 1800. The destination airport was Grinder Field, Pine Bluff, Arkansas. According to a lineman at Pine Bluff Aviation Commission, Pine Bluff, Arkansas, the pilot departed Pine Bluff at 04:50 PM on March 31, 2006. An employee at Fletcher Field, Clarksdale, Mississippi, stated he noticed the airplane landing at the airport at 05:45 PM. The pilot was having trouble deciding which exit to take to the ramp. The airplane stopped at each exit until the airplane came to the end of the runway. The airplane was subsequently taxied to the ramp. The pilot shut down the airplane and exited with out turning off the master switch. Upon exiting the airplane the pilot stated, "You know I've been flying for 60 years, and don't tell anybody, but I'm lost. I know I'm in Clarksdale, but I don't know how to get home." The employee having worked at Grinder Field asked the pilot the names of 3 or 4 people. The pilot had a blank look on his face. The pilot informed him that he was almost out of gas and he did not have any maps. The employee informed the pilot to go inside and he could obtain a map. The pilot paid for his fuel and returned to the airplane. The employee stated to the fixed base operator owner (FBO) that, "this guy (the pilot) has something wrong with him, almost like dementia or Alzheimer's." The employee watched the pilot return to the airplane. The pilot got in and out of the pilot's door 4 times. The employee went out to the airplane and asked the pilot if he had a problem. The pilot stated his door would not close. The employee asked the pilot if he would like them to drive him home and the pilot said no. The pilot entered the airplane through the passenger door, secured the door, slid over to the pilot seat, opened the pilot door, closed it, and secured it with out any problems. The employee returned to the FBO and called Grinder Field and informed them of the situation and asked them to be look out for the pilot. The employee watched the airplane take off and head towards the northeast for a couple of minutes before the airplane turned back towards the northwest. The heading to Pine Bluff is 264-degrees. The heading to Double Springs is 92-degrees. A witness located at a restaurant in the vicinity of Double Springs, Alabama, stated he heard and observed an airplane approaching his location heading north-northwest. The airplane was at a very low altitude, turned to the left, and flew over a day care center located behind the restaurant. The airplane made another turn and flew south towards highway 278. The witness stated he watched the airplane until he could not see it or its lights. A short time later he heard an impact noise. He went inside the restaurant and informed his mother what he saw and heard. They both went outside and drove their van to a friend's house located near the airplanes last observed location. They contacted the friend at his home and he informed them that he did not hear anything. The friend got his four-wheeler and they all went towards a wood line and observed a flashing red light in the woods. They called out to see if anyone would answer. The pilot responded and walked out of the woods and came to their location. The pilot informed them that he had been in a vehicle accident. The 911 emergency operators were called, and emergency responders arrived on scene. The pilot stated in an interview with the NTSB on April 11, 2006, that he did not know how he ended up in Double Springs, Alabama. He stated he remembered being at a low altitude above the trees looking for an airport or a place to land off site. He stated he did not remember lowering the flaps or the airplane colliding with the trees. He further stated the airplane did not have any mechanical problems before the accident. PERSONNEL INFORMATION Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the pilot was issued an airline transport pilot certificate on December 12, 2002, with ratings for airplane multiengine land and instrument, commercial pilot, airplane single engine land, and glider. The pilot held a third class medical issued on January 4, 2005, with the restriction, "must wear corrective lenses." The pilot stated to the NTSB on April 11, 2006, that he had been diagnosed by his private physician with mild cognitive memory impairment (dementia) about 6 to 8 years ago. The pilot stated this information had not been provided to the Aviation Medical Examiner when he renewed his third-class medical certificate. The pilot reported on his application for the medical certificate that he had accumulated 4,250 total flight hours. The pilot voluntarily surrendered his airman certificate to the FAA on April 12, 2006. Review of the pilot's logbook revealed he has 4,106 total flight hours. There are no flights recorded in the Cessna 182T. The last entry in the pilot's logbook is March 5, 2003. There is no entry in the logbook for a current flight review. AIRCRAFT INFORMATION Review of the airplane logbooks revealed the last annual inspection was conducted on January 14, 2005. The tachometer time was 19 hours and the total time since new was 19 hours. The tachometer time at the crash site was 43.1 hours. The Hobbs meter at the crash site was 51.0 and the airframe total time was 51 hours. The altimeter encoding system and static system check was performed on December 28, 2005. The airplane was refueled last at Clarksdale, Mississippi, on March 31, 2006, and 31 gallons of 100 low lead aviation fuel was added to the left main fuel tank. METEOROLOGICAL INFORMATION The 2053 surface weather observation at Northwest Alabama Regional Airport, Muscle Shoals, Alabama, located 39 nautical miles northwest of the crash site was: wind 200-degrees at 9 knots, visibility 9 miles, clear, temperature 66 degrees Fahrenheit, dew point temperature 63 degrees Fahrenheit, and altimeter 30.07. WRECKAGE AND IMPACT INFORMATION The wreckage was located 1 mile west of Double Springs, Alabama, and one-quarter mile south of Highway 278 in a wooded area behind the American Legion. The FAA conducted the on scene examination of the wreckage. Examination of the wreckage revealed the airplane collided with trees in a descending 45-degree nose down level attitude and it came to rest in a nose down attitude on a heading between 205 to 210 degrees magnetic. The NTSB conducted a follow up examination after the airplane was recovered to Griffin, Georgia, on April 14, 2006. The propeller remained attached to the propeller flange and the spinner-received damage. No evidence of rotation was present on the spinner. One propeller blade was turned 180-degrees in the propeller hub and bent aft. Another propeller blade was turned 90-degrees with the leading edge forward, and bent towards the cambered side. The remaining propeller blade received leading edge bending at the propeller tip. The engine assembly was displaced to the right, and the engine cowling was buckled on both sides. The lower firewall was buckled up and aft into the cabin area. The right side of the firewall was pushed aft. The nose landing gear was bent backwards, and separated from the airframe. The fuselage forward of the forward doorpost was pushed up and aft. The right cabin door was jammed closed. The left door upper hinge was separated. All seats remained attached to the fuselage. The throttle was in the forward position. The propeller control was in the full forward position. The mixture control lever was full rich. The fuel selector handle was between the 11:00 to 11:30 clock position and bent to the left. Shop air was applied to the left forward fuel line and fuel was expelled from the main engine fuel supply line and wing root fuel lines. The airplane was equipped with seatbelts and shoulder harness. The left seatbelt and shoulder harness was in use, and had not been cut by emergency responders. The left main landing gear remained attached to the airframe. The right main landing gear was separated from the airframe. Control cable continuity for the rudder pedals were confirmed from the area of the fuel selector aft to the baggage compartment. Continuity of the rudder cables forward of the fuel selector could not be confirmed due to airframe damage. Continuity of the left and right aileron cables was confirmed from the control yokes extending aft to the left and right wing roots. Continuity of the left and right elevator cables was confirmed from the control yokes aft to the baggage compartment. A Mississippi Aeronautical chart dated April 1, 2004, was located in the forward cabin area. No other aeronautical charts were located in the airplane. The right wing was accelerated forward and remained attached to the airframe. The leading edge of the right wing was damaged at 2-feet and 6-feet outboard of the wing root. The remaining wing was pushed aft and down outboard of the right wing strut attachment point extending outboard to the wing tip fairing. The forward wing attachment bolt was intact and the rear wing attachment bolt separated. The right main fuel tank was not ruptured and the fuel cap had a tight seal. The right wing was leaning downward and fuel was draining out of the fuel tank vent. The aileron was attached to its attachment points. Right aileron continuity was confirmed from the aileron bell crank extending inboard to the wing root. The flap was attached to its attachment points and was extended to the full down position. The right main wing strut was attached to the wing and fuselage attachment points. The empennage was not damage and vertical fin was not damaged. The rudder remained attached to the airframe and was not damaged. The left and right horizontal stabilizers were damaged. The left and right elevators remained attached to the airframe. The left elevator exhibited diagonal bending at mid span. The right elevator was torn and bent downward at the counterweight. The elevator trim tab was intact. The elevator trim tab was set to a 0 degree position. Continuity was confirmed to the rudder from the aft end of the baggage compartment extending aft to the rudder horn where the rudder cables had been cut by recovery personnel. Continuity was confirmed to the left and right elevators from aft of the baggage compartment to the aft elevator bell crank. The left wing was separated from the airframe. The leading edge of the wing was compressed inward at the wing root extending outboard 6-feet 6-inches. The aft wing attachment point was pushed inboard and penetrated the left main fuel tank. The remaining leading edge of the left wing was pushed inward 9-feet outboard of the wing root and extended outboard to the left wing tip fairing. The left main fuel tank was ruptured and the left main fuel tank cap had a tight seal. The aileron was attached to its attachment points. Left aileron continuity was confirmed from the aileron bell crank extending inboard to the wing root. The flap was attached to its attachment points and was extended to the full down position. The left wing strut separated from the wing and the fuselage attachment points. Examination of the engine assembly revealed the upper right engine mount leg was separated. The remaining engine mount legs were intact. The lower right engine tubular mount was bent aft, and the cross tube in-between the lower engine mounts was bent. The remaining engine mount tubes were intact. Examination of the engine assembly revealed no damage to the left engine exhaust tubes and muffler. The right engine exhaust tubes and muffler was not damaged. The right exhaust tail pipe was crushed aft of the muffler. The left and right induction tubes were not damaged. The intake air box was crushed, and the induction air filter was not contaminated. Examination of the engine assembly revealed the throttle was full forward at the fuel servo. The mixture control arm was bent and was in the full rich position. The fuel servo and fuel pump remained attached to the engine and were not damaged. The left and right magnetos and engine harness remained attached to the engine and no damage was noted. The starter and alternator remained attached to the engine and no damage was noted. The starter ring gear was intact. The starter drive pinion was extended and bent. The upper and lower vacuum pumps remained attached to the engine and were not damaged. The oil cooler remained attached to the engine and was not damage. The oil filter remained attached to the engine and was not damaged. The engine oil dipstick indicated 6 quarts of oil. The propeller governor remained attached to the engine and no damage was noted. The propeller governor control arm was in the full forward position. The engine was partially disassembled. The crankshaft and crankshaft flange were intact and not bent. The top and bottom spark plugs were removed and were gray in color and "normal" when compared to the Champion Check A Plug chart. The No.2 bottom spark plug was oily. The engine was rotated by turning the propeller. Compression and suction was obtained at all cylinders. Continuity was established from the crankshaft to the rear gears. The rocker arms and valves moved when the crankshaft was rotated. The oil filter and oil suction screen were removed, opened, and were free of contaminants. The aircraft fuel strainer was disassembled, fuel was present, and the filter screen was free of contaminants. The engine driven fuel pump produced fuel at the outlet port when the engine was rotated by the propeller. The fuel servo was removed and fuel was present in the servo and in the fuel line between the fuel servo and the fuel pump. The servo inlet screen was removed and free of contaminants. The fuel manifold was removed and disassembled. No damage was noted to the diaphragm. The fuel injector nozzles were removed and were not obstructed. Spark was produced at all 12 magneto ignition leads when the engine was rotated by the propeller. The upper vacuum pump was removed and produced air pressure at the outlet port when the drive coupling was turned by hand. The lower vacuum pump was not removed due to firewall damage. The lower vacuum pump drive coupling was observed to rotate as the propeller was turned by hand. The propeller governor was removed and the oil screen was free of contaminants. MEDICAL AND PATHOLOGICAL INFORMATION The pilot was transported to the University of Alabama Medical Center, Birmingham, Alabama with serious injuries. The Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma performed toxicology of specimens from the pilot. The results were negative for ethanol and drugs. Carbon monoxide and cyanide testing was not performed. Review of the pilot's post-accident hospitalization medical records notes a history from the pilot's family stating the pilot "has memory problems, can't make quick decisions, and gets lost." In addition review of medical records from the pilot's personal physician and gerontologist revealed that the pilot had a history of memory problems for at least 10 years, and a diagnosis of dementia since 2003. He had been on two different medications for his dementia since 2004, with progression of symptoms and increasing difficulty with memory. He had been advised by physicians not to fly alone more than two years prior to the accident and had been noted on at least two occasions to have stopped taking prescribed medication. The pilot's most recent application for 3rd Class Airman Medical Certificate on 1/4/05 did not note the pilot's history of dementia or use of medications to treat dementia. ADDITIONAL INFORMATION Review of the Cessna Information Manual for the Skylane Model 182T revealed the stall speeds with full flaps at 30-de

Probable Cause and Findings

The pilot's failure to maintain airspeed resulting in a stall. A factor in the accident was the pilot's physical impairment due to dementia and his failure to report the medical condition to the aviation medical examiner..

 

Source: NTSB Aviation Accident Database

Get all the details on your iPhone or iPad with:

Aviation Accidents App

In-Depth Access to Aviation Accident Reports