Aviation Accident Summaries

Aviation Accident Summary CEN09LA054

Mena, AR, USA

Aircraft #1

N2526V

CESSNA 177RG

Analysis

The pilot was en-route to a business engagement and was flying in an area of deteriorating weather conditions. The airplane impacted a mountain ridge in instrument meteorological conditions and was destroyed by impact forces and a postcrash fire. A witness, located approximately one mile north of the accident site, heard the sounds of impact and described “very foggy” conditions with a visibility of 50 feet. Another witness driving along the highway on the mountain ridge was in “dense fog” with visibility of 1/4 mile. The witness saw the wreckage on the side of the highway with the airplane fully involved in fire. The witness said the pilot was unbelted and almost completely outside the airplane. Because of the flames the witness said he was unable to get close enough to move the pilot. An examination of the airframe and engine showed no evidence of a preexisting anomaly that would have precluded normal operation. The report of the medical examiner noted the pilot’s cause of death as “Hypertensive Arteriosclerotic Cardiovascular Disease.” The pilot apparently died of a pre-existing natural disease during his attempt to extricate himself from the wreckage.

Factual Information

HISTORY OF FLIGHT On November 11, 2008, about 1400 central standard time(CST), a Cessna 177RG, N2526V, was destroyed when it impacted mountainous terrain near Mena, Arkansas. The commercial pilot, who was the only occupant, was fatally injured. The airplane was owned and operated by the pilot. Instrument meteorological conditions (IMC) prevailed at the time of the accident and a flight plan had not been filed for the Title 14 Code of Federal Regulations Part 91 flight. The airplane had departed the Willow Springs Memorial Airport (1H5) Willow Springs, Missouri, enroute to the San Antonio International Airport (SAT) San Antonio, Texas. A witness, located approximately one mile north of the accident site, heard a plane overhead in the fog going “really slow” when he heard the engine sputter three times and quit, then the sound of limbs breaking and seconds later the sound of a loud explosion. Another witness driving along the highway on the mountain ridge saw the wreckage on the side of the highway fully involved in flames. The witness said the victim was nearly completely outside the aircraft, unbelted, and positioned at 90 degrees from the fuselage, face down, with his feet trapped in the burning fuselage. Because of the flames the witness said he was unable to get close enough to move the victim. PERSONNEL INFORMATION The pilot, age 61, held a commercial pilot certificate with ratings in airplane single and multi-engine land, airplane single engine sea, and instrument airplane. The pilot was issued a second-class medical certificate on July 15, 2008, with no restrictions or limitations. The pilot also held a flight instructor certificate with ratings in airplane single and multi-engine, and instrument airplane and was actively involved as a flight instructor. According to calculations by the Federal Aviation Administration (FAA) inspector, the pilot had accumulated a total of 22,228 hours of pilot experience, with 2,525 hours of pilot experience in Cessna 177 airplanes, and a total of 96 hours in the previous 90 days. The pilot had been flying full time as a pilot since the 1960’s and had been employed for most of his career as a flight test pilot and sales pilot for several different avionics manufacturers. At the time of the accident, he was a flying regional sales manager for Garmin, Ltd. and was enroute to SAT where he was to be a presenter at an avionics seminar. According to family members, the pilot usually departed the 1H5 airport with “topped off” fuel tanks and usually flew visual flight rules (VFR) on his cross country flights. Further, they said if there were clouds down low, a lot of the time he would fly VFR on top and would try to stay down low just on the top of the clouds, but he would file instrument flight rules (IFR) if there were IMC conditions. AIRCRAFT INFORMATION The 1975 model Cessna 177RG, serial number 177RG0603, was a high-wing, single engine airplane with retractable landing gear. The airplane was powered by a Lycoming IO-360-A1B6D engine and was equipped with a two-blade McCauley constant speed, aluminum alloy propeller. It was configured to carry four occupants. Avionics equipment installed in the airplane included many of the latest Garmin avionics units, with multiple GPS receivers which displayed terrain, XM Weather, and traffic. In addition there was a JPI EDM930 installed which had the capability to monitor and record certain engine parameters. The airplane was issued a standard airworthiness certificate on November 5, 1974, and was certificated for normal category operations. The airplane was registered to the pilot on April 21, 1999. Aircraft maintenance logbooks were provided to the NTSB Investigator-in-charge (IIC) on April 29, 2009. A review of those documents showed the most recent annual inspection of the airplane was performed on March 1, 2008 at a “tach” time of 3,676.1 hours and a time since engine overhaul of 1,058.8 hours. The last entry in the aircraft maintenance logbooks was dated September 12, 2008 at a “tach” time of 3,794.5. The last entry in the engine maintenance logbook was dated October 9, 2008 at a “hobbs” time of 3,837.9 hours. METEOROLOGICAL INFORMATION A few weather observation locations are shown below in the order of the along the route of flight from the departure airport to the accident location. These indicated worsening weather conditions going from marginal or low visual flight rules(VFR) conditions to instrument flight rules (IFR) conditions. At 1308, the automated surface observing system (ASOS) at West Plains Municipal Airport (UNO), West Plains, Missouri, located approximately 7 miles southeast of the 1H5 departure airport, reported the wind from 160 degrees at 8 knots, visibility 10 statute miles, overcast ceiling at 2,800 feet, temperature 11 degrees Celsius, dew point 4 degrees Celsius, and an altimeter setting of 30.01 inches of Mercury. The elevation of the reporting station at UNO is 1,228 feet mean sea level (MSL). (This is a 1308 report, keep everything chronological) At 1253, the ASOS at Russellville Regional Airport (RUE), Russellville, Arkansas, located approximately 70 miles northeast of the accident site, reported the wind from 100 degrees at 5 knots, visibility 10 statute miles, overcast ceiling at 1,700 feet, temperature 12 degrees Celsius, dew point 8 degrees Celsius, and an altimeter setting of 29.99 inches of Mercury. The elevation of the reporting station at RUE is 404 feet MSL. At 1304, the ASOS at Fort Smith Regional Airport (FSM), Fort Smith, Arkansas, located approximately 43 miles north of the accident site, reported the wind from 080 degrees at 9 knots, visibility 10 statute miles, broken clouds at 1,300 feet, overcast clouds at 2,200 feet, temperature 13 degrees Celsius, dew point 9 degrees Celsius, and an altimeter setting of 29.95 inches of Mercury. The elevation of the reporting station at FSM is 469 feet MSL. At 1400, the ASOS at Mena Intermountain Municipal Airport (MEZ), Mena, Arkansas, located approximately 5 miles southeast of the accident site, reported the wind from 110 degrees at 6 knots, visibility 10 statute miles, overcast ceiling at 1,100 feet, temperature 16 degrees Celsius, dew point 13 degrees Celsius, and an altimeter setting of 29.94 inches of Mercury. The elevation of the reporting station at MEZ is 1,080 feet MSL. The elevation of the accident location was estimated at approximately 2,430 feet MSL. The first persons arriving at the accident location reported heavy fog or dense fog and a slow drizzle of mist and rain. They reported visibility ranging from 50 feet to ¼ mile. A witness who called 911 emergency was located approximately one mile north of the accident location. The elevation of the witness’s location was estimated at approximately 1,500 feet MSL. He reported fog with visibility of 50 feet. At 1353, the ASOS at airport name? Helms Sevier County Airport (DEQ), De Queen, Arkansas, located approximately 20 miles south of the accident site, reported the wind from 020 degrees at 3 knots, visibility 10 statute miles, overcast ceiling at 400 feet, temperature 14 degrees Celsius, dew point 12 degrees Celsius, and an altimeter setting of 29.93 inches of Mercury. The elevation of the reporting station at DEQ is 355 feet MSL. COMMUNICATIONS AND RADAR According to the FAA there was no record that the pilot had contacted an automated flight service station (AFSS) or that he had used either of the direct user access terminal (DUAT) facilities. Further, there was no record that the pilot had made contact with any air traffic control facility during the flight. There were several intermittent radar hits of an unidentified 1200 transponder beacon code beginning at 1924 1324 near Clarksville, Arkansas, and ending at 19471347 near Waldron, Arkansas. Those radar hits showed a reported altitude which varied from approximately 1,200 feet MSL to 1,400 feet MSL. The surface elevation along the flight path of those unidentified radar contacts ranges from approximately 400 feet MSL to approximately 700 feet MSL. WRECKAGE AND IMPACT INFORMATION The wreckage was examined at the accident site on the morning of November 12, 2008 by two FAA inspectors and an investigator from Cessna Aircraft. Evidence at the scene showed the airplane impacted trees and terrain on the rising north face of a mountainous ridge. Two of the trees at the initial tree strike location showed evidence of propeller cuts. The outboard section of the left stabilator was found near the base of those trees. The airplane came to rest upright at the edge of the wooded area approximately 40 feet from the initial tree strike on a measured heading of 190 degrees magnetic. The elevation was estimated at 2,430 feet MSL using a handheld GPS receiver. The final resting location of the airplane was approximately 20 feet north of the edge of State highway 88 and was approximately 10 feet below the crest of the ridge. State highway 88 is positioned on the top of the mountainous ridge and is oriented generally east to west. Both wings and the cabin area were present and were mostly consumed by fire. The rest of the main wreckage consisted of the propeller, which was still connected to the engine, which was still connected to the firewall. The rear empennage and tail section of the airplane were present and found upright and adjacent to the north end of the fire damaged cabin area. The wreckage was then moved to the facilities of Dawson Aircraft, Inc., Clinton, Arkansas, for further examination. PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on November 13, 2008, by the Arkansas State Crime Laboratory, Medical Examiner Division, Little Rock, Arkansas. The cause of death was noted as “Hypertensive Arteriosclerotic Cardiovascular Disease.” Under “Findings” was noted “Contusion of scalp; no other apparent blunt force injuries. Forensic toxicology was performed on specimens from the pilot by the Federal Aviation Administration (FAA), Aeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no Carbon Monoxide detected in blood, no Cyanide detected in blood, no Ethanol was detected in vitreous, and “no Drugs listed above detected in urine". SURVIVAL FACTORS The on-scene photos were reviewed along with statements and drawings from the first arriving witnesses. They showed that when the first witness arrived the airplane was fully involved in flames and “the upper portion of the cabin was gone”. The pilot was unbelted and almost completely outside and positioned at a 90 degree angle to left side of the airplane. The pilot was face down with both hands underneath his body in a pugilistic stance. His feet appeared to be pinned or trapped in the wreckage, and he was wearing a leather jacket. The witness attempted to move the pilot away from the burning airplane. Because of the flames he could not get close enough to move the pilot. TESTS AND RESEARCH On January 13, 2009, at the facilities of Dawson Aircraft, Inc., Clinton, Arkansas the airframe and engine were examined under the oversight of an FAA Inspector. The airframe had been exposed to fire damage and much of the airframe had been consumed. It was noted that both of the propeller blades sustained leading edge gouging, and cord wise scratching. Also noted was bending of both blades. The alternator was removed and examined, but was not tested. Nothing was observed that would have precluded the alternator from normal operation prior to impact. All of the spark plugs were removed, and most displayed a low service life and a color consistent with normal combustion when compared to the Champion Spark Plug Wear Guide P/N AV-27. The dual magneto was removed, it was observed heat damaged and the center shaft would not rotate by hand. The impulse coupling did not display any visible damage. The cap was removed and it was noted that the internal components were melted and sustained heat distortion. The engine driven diaphragm fuel pump was removed. It was noted that it sustained thermal exposure during the post impact fire; also the actuator arm was seized and would not move when hand pressure was applied. The oil filter sustained fire damage and was not cut open for inspection due to fire damage to the paper element. All of the fuel injector nozzles were removed and observed to be clear and free of contaminants. The fuel injection servo unit was removed with the induction air box connected, the inlet fuel screen was removed and an unmeasured amount of fuel was observed in the screen chamber. The induction air box sustained impact damage and it could not be determined what position the throttle plate was prior to initial impact. The fuel injection flow divider was removed and disassembled. Nothing was observed that would have precluded this unit from functioning as required prior to impact. The engine was rotated by hand from the crankshaft flange. Thumb suction and compression were obtained. Valve train continuity was observed through to the rocker arms and valves. Movement was observed at the accessory gears as required. All cylinders were inspected using a lighted bore scope. No defects were noted during the course of this engine examination that would have precluded this engine from making power prior to impact. Several damaged pieces of avionics equipment were removed from the airplane and sent to the NTSB Vehicle Recorder Laboratory. Upon arrival at the Vehicle Recorder Laboratory, an exterior examination revealed that the units had sustained catastrophic damage from smoke, heat, and fire. An internal inspection was performed. The majority of the units had suffered internal melting and carbonization of the electronic components. A surviving non-volatile memory integrated circuit ‘chip’ was identified within the attitude heading reference unit and removed for readout using a commercial EEPROM programmer. No accident related data was identified as being stored on this chip. No accident related data was recovered from any of the units.

Probable Cause and Findings

The pilot's failure to maintain clearance from rising terrain. Contributing to the accident was the pilot's continued flight into deteriorating weather conditions.

 

Source: NTSB Aviation Accident Database

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