Aviation Accident Summaries

Aviation Accident Summary CEN09LA355

Cordova, IL, USA

Aircraft #1

N1734S

AERO COMMANDER S2R

Analysis

The pilot was conducting an agricultural application pass at the time of the accident. A witness stated that the airplane pulled up over a house, located about mid-field, during a spray run. The witness commented that the airplane pulled up higher than others he had observed, adding that most airplanes “just skim[ed] the trees” when they flew over the house. He reported that the accident airplane dropped back down after it cleared the house, apparently to resume spraying; however, it impacted the ground. The airplane bounced once before settling back down and sliding to a stop. A postaccident examination of the airplane did not reveal any failures or malfunctions consistent with a preimpact failure. The pilot had about 200 hours of agricultural application experience the previous season. However, he had recently started flying the accident airplane, which was about 15 knots faster in spray runs than the airplane the pilot had flown the previous season. The pilot had accumulated about 28 hours in the accident airplane. Postmortem toxicology testing on the pilot’s blood was consistent with use of marijuana and propoxyphene, a prescription narcotic painkiller. However, the source of the blood was not specified. Accordingly, a reliable estimate could not be made of the time of last use or the probability of impairment due to either substance. The pilot had not indicated the use of any medication or illegal drugs or the presence of any medical condition at the time of his most recent medical certificate application.

Factual Information

HISTORY OF FLIGHT On June 12, 2009, at 1623 central daylight time, an Aero Commander S2R, N1734S, piloted by a commercial pilot, was destroyed during an in-flight collision with terrain and post impact fire near Cordova, Illinois. The agricultural application flight was being conducted under 14 Code of Federal Regulations Part 137 without a flight plan. Visual meteorological conditions prevailed. The pilot sustained fatal injuries. The local flight departed Frank’s Flying Service Airport (4IL5), Morrison, Illinois, about 1545. A witness located about one-eighth mile east of the accident site stated that the airplane made an agricultural application pass over the north end of the field. The airplane then reversed course and began a pass from west to east along the south end of the field. He observed the airplane pull up over a house located about mid-field along the south edge of the property. He commented that it did not turn when it went over the house and pulled up higher than he had observed other agricultural airplanes fly when they sprayed that field. He added that most airplanes “just skim the trees” when they fly over the house during spray runs. He reported that the accident airplane dropped back down, apparently to resume spraying; however, it impacted the ground. The airplane bounced once before settling back down and sliding to a stop. It came to rest east of the initial impact point, but with the airplane oriented on a south heading. A post impact fire ensued. PERSONNEL INFORMATION The pilot, age 46, held a commercial pilot certificate, issued June 2, 2008, with airplane single-engine land and instrument airplane ratings. He had completed a basic agricultural aircraft operations course in April 2008. The pilot was issued a second class airman medical certificate on June 6, 2008. On his application for that medical certificate, the pilot reported 330 hours total flight time, with 70 hours during the past 6 months. The last entry in the pilot’s logbook was dated July 11, 2008. His logged flight time totaled 361.8 hours, with 155.3 hours of that total logged as dual instruction received. The airplane operator stated that the accident pilot had approached him in early 2008 about becoming an agricultural pilot. He informed the pilot that he would need a commercial pilot certificate and to attend an agricultural operations course before he could hire him. The pilot subsequently earned a commercial certificate and attended an agricultural spray course. The operator noted that the pilot flew agricultural flights in a DW-1 Eagle during the 2008 season, accumulating approximately 200 hours. He moved into the Aero Commander for the 2009 spray season. He noted that the accident pilot picked up the accident airplane from Michigan when he bought it shortly before the accident. He estimated that the pilot flew the airplane about 28 hours in order to get familiar with it. The accident airplane was about 10 – 15 knots faster in spray runs than the DW-1 Eagle. AIRCRAFT INFORMATION The accident airplane was a 1970 Aero Commander S2R airplane. It was powered by a Pratt & Whitney R-1340 AN2 S3H1-G radial engine, serial number 14669. The most recent annual inspection was completed on June 30, 2008, at 8,715 hours total airframe time. The maintenance logs contained no entries subsequent to the annual inspection. Maintenance records indicated that the engine was removed from the airframe in November 2007 due to metal contamination. The engine was disassembled and several components were replaced. The engine was re-assembled and tested in January 2008. Records indicate that the applicable airworthiness directives and manufacturer service bulletins were complied with at that time. The engine was subsequently re-installed on the accident airplane in April 2008. At the time of that partial overhaul, the engine had accumulated about 10,060 hours total time and about 736 hours since major overhaul. METEOROLOGICAL INFORMATION The Whiteside County Airport (SQI) Automated Weather Observing System (AWOS), located about 15 miles east of the accident site, at 1615, recorded conditions as: Wind from 160 degrees at 3 knots; 10 miles visibility; scattered clouds at 6,500 feet above ground level (agl); temperature 25 degrees Celsius (C); dew point 12 degrees C; and altimeter 29.94 inches of mercury. At 1635, the SQI AWOS recorded conditions as: Wind calm; 10 miles visibility; few clouds at 7,500 feet agl; temperature 26 degrees Celsius (C); dew point 11 degrees C; and altimeter 29.93 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane came to rest upright oriented on a south heading about 500 feet east of a single family residence. The impact path was about 200 feet long and oriented in an easterly direction. The main landing gear, spray booms and engine separated from the airframe and were located in the debris path. The fuselage, inboard sections of both wings, and the forward section of the empennage were consumed by the post impact fire. The flight control surfaces remained attached to the airframe and control continuity was established from each control surface to the cockpit area. A post accident examination of the engine did not reveal any indication of a pre-impact anomaly. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was performed at the Winnebago County Coroner’s office, Rockford, Illinois, on June 15, 2009. The cause of death was due to injuries received as a result of the accident. The Federal Aviation Administration (FAA) Civil Aero Medical Institute toxicology report stated: 10 percent Carbon Monoxide detected in Blood; 0.55 (ug/ml) Cyanide detected in Blood; 8.506 (ug/mL, ug/g) Norpropoxyphene detected in Urine; 0.704 (ug/mL, ug/g) Norpropoxyphene detected in Blood; 0.118 (ug/ml, ug/g) Propoxyphene detected in Urine; 0.046 (ug/ml, ug/g) Propoxyphene detected in Blood; 0.2322 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Lung; 0.0066 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Blood; 0.0703 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Kidney; 0.069 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Urine; 0.0134 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Blood; 0.0108 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Lung. The specific source of the blood utilized for FAA toxicology testing was not specified in the autopsy report or on documentation accompanying the specimens. The pilot’s most recent application for FAA airman medical certificate, dated June 6, 2008, indicated “No” for “Do you currently use any medication” and for all items under “Medical History,” including specifically “Substance dependence or failed a drug test ever; or substance abuse or use of illegal substance in the last 2 years.”

Probable Cause and Findings

The pilot’s failure to maintain clearance with terrain after clearing an obstacle during an agricultural application pass.

 

Source: NTSB Aviation Accident Database

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