Aviation Accident Summaries

Aviation Accident Summary WPR10LA006

Yankton, OR, USA

Aircraft #1

N61FS

Turpen RV-8

Analysis

The pilot reported that he was flying to an airport to obtain fuel. He recalled approaching the airport and noting low clouds in the area, but could not recall anything further regarding the circumstances near the end of the flight. Air traffic control information showed that the pilot requested an instrument flight rules (IFR) clearance and was cleared for the localizer approach. FAA radar data and the accident airplane’s onboard instrumentation data showed that although the airplane was on course, it had descended below the minimum descent altitudes and collided with terrain approximately 8 miles from the airport. There was no indication that the pilot had the appropriate instrument approach chart available while conducting the approach. Examination of the wreckage revealed no evidence of a pre-impact anomaly. Toxicology findings are consistent with the pilot using an over-the-counter antihistamine on the day of the accident that has been reported to cause sedation. It is conceivable that the pilot may have been impaired by use of the antihistamine or distracted by the symptoms for which he had been prescribed the medication, however, it could not be conclusively determined whether the pilot's medication contributed to the accident.

Factual Information

HISTORY OF FLIGHT On October 5, 2009, at 1000 Pacific daylight time, an experimental Turpen RV-8, N61FS, impacted terrain near Yankton, Oregon. The pilot was operating the airplane under the provisions of Title 14 Code of Federal Regulations Part 91. The airline transport pilot sustained serious injuries; the airplane was substantially damaged. Instrument meteorological conditions (IMC) prevailed at the pilot’s destination and the pilot had requested and received a pop-up instrument flight rules (IFR) clearance into Scappoose Industrial Airpark, Scappoose, Oregon. The airplane departed Bremerton National Airport, Bremerton, Washington, at 0922. According to air traffic control information, the pilot was flying under visual flight rules and had not filed a flight plan. As he approached his destination, IMC prevailed and he requested an IFR clearance. The pilot was cleared for the localizer approach to runway 15. Shortly thereafter, the airplane’s radar target no longer appeared on radar. The accident site was later located by Coast Guard personnel. Air Traffic Control Information According to Federal Aviation Administration air traffic control data, at 0952, the pilot requested vectors for the "localizer 14" approach due to poor weather conditions. The controller asked the pilot to verify requesting localizer runway 15 and that the airplane was IFR capable. The pilot confirmed and was then supplied a clearance. At 0954, the controller issued a heading for the pilot to intercept the localizer for runway 15, and verified with the pilot that the approach would terminate with a full stop landing. At 0955, the controller issued the latest aviation routine weather report (METAR) weather to the pilot. At 0957, the airplane was cleared for the Scappoose Localizer/DMS Runway 15 approach, and issued alternate missed approach instructions. At 0959, radar services were terminated with the pilot. Radar data was obtained from the Portland Approach facility, and then reviewed and plotted by a Safety Board air traffic investigator. The data showed that the airplane appeared on the localizer course for the approach; however, the airplane’s flight path was below the specified altitudes for the approach. The last radar return was approximately 8 miles north of runway 15. Pilot Statement In a phone interview following the accident, the pilot indicated that he was flying to Scappoose to obtain fuel. After departure from Bremerton, he climbed the airplane to 5,500 feet and requested flight following to Scappoose airport. The pilot recalled low clouds in the vicinity of Scappoose, but could not recall anything further. He indicated that he did not have instrument approach plates on board the airplane at the time of the accident. He did not recall obtaining an IFR clearance into Scappoose. PERSONNEL INFORMATION The pilot, age 43, held an airline transport pilot for airplane single-engine and multiengine land, and a first-class medical certificate issued on December 4, 2008, with no limitations. He also held a flight engineer certificate. The pilot reported approximately 11,300 hours total time, with 80 hours in the accident airplane. He had flown the accident airplane 12 hours in the last 30 days. AIRCRAFT INFORMATION The airplane was equipped with an Advanced Flight Systems (AFS) Panel Display AF-3500EE, an 8.4-inch cockpit display capable of displaying Electronic Flight Instrument System and engine performance information. The unit contained a crossbow attitude/heading reference system to provide the pilot with attitude and heading information. It also contained an internal air data system to provide the pilot with altitude and airspeed information, as well as an engine data interface, which provided various engine parameters. According to a representative from AFS, the unit was not equipped with approach plates. In addition to the AF-3500EE, the instrument panel was equipped with an airspeed indicator, an altimeter, a clock, a g-meter, a Garmin SL-30, and a panel mounted Garmin 496. METEOROLOGICAL INFORMATION At 0953, the following METAR was reported at Scappoose: winds calm, visibility 9 statute miles, clouds 400 feet overcast, temperature 8 degrees centigrade, dew point 7 degrees centigrade, altimeter 30.16 inches of Mercury. MEDICAL INFORMATION Toxicological samples were obtained from the pilot and submitted to the FAA Civil Aeromedical Institute in Oklahoma City, Oklahoma. The test results were positive for cetirizine and ibuprofen. The test results were negative for volatiles. In a phone conversation several weeks after the accident, the pilot indicated that he was not aware of any medication that he had been taking that would have resulted in the positive results. The Safety Board Medical Officer reviewed the airman medical file obtained from the Federal Aviation Administration Medical Certification Division. The pilot had not noted the use of any medications on his most recent application for airman medical certificate. Approximately two months following the accident, the pilot informed the FAA that his doctor suggested the use of cetirizine for chest congestion, but that he discontinued its use because it was ineffective. Cetirizine is not among antihistamines listed by the FAA as allowed by the Aerospace Medical Certification Division (Federal Air Surgeon’s Medical Bulletin, Vol. 41, No. 2, Summer 2003). TESTS AND RESEARCH Wreckage Examination Control continuity was obtained from the control stick to all control surfaces. The throttle, mixture, and propeller controls were all in the full-forward positions. The right wing had separated at the fuselage and the left wing had separated approximately mid-wing. The electric flap motor and actuator arm mechanism was examined and indicated that the arm was in the fully retracted position. The Textron Lycoming Aero Sport Power Ltd. IO-360-B1B engine was examined. The engine and propeller had sustained significant impact damage. One propeller blade was fractured at the hub and the other sustained impact damage. The top spark plugs and valve covers were removed. Thumb compression was obtained and all valves produced a similar amount of lift. The engine was electrically powered by one magneto (secured to the lower spark plugs) and an electronic ignition system (secured to the top spark plugs). The magneto was manually operated and produced spark at all leads. The engine was equipped with a Precision Fuel Injection Servo. Approximately 1/2-cup of fuel was drained from the servo and all lines leading to it contained fuel. The fuel manifold valve was examined. The gasket was soft and pliable and no contamination was evident. Fuel remained in the line to cylinder number 2. The engine driven fuel pump was removed from the engine and manually actuated. Cockpit Displays The onboard Advanced Flight Systems Panel Display AF-3500EE and a Garmin 496 were sent to the NTSB Recorders Laboratory. Both units retained data from the flight. The AF-3500EE data showed that the airplane departed at 09:22. At 09:26 the aircraft leveled off at 5,500 feet at a heading of 153 degrees magnetic. At 09:54 the airplane began a descent and reduced engine power. The airplane leveled off at approximately 3,000 ft, at a heading of 176 degrees magnetic, at 09:56. At 09:58 the airplane began a 900 feet per minute descent from 3,000 ft, engine RPM was reduced to 1,900 RPM. During the descent, a left turn to 148 degrees magnetic was performed. At 10:00:35, the airspeed was 103 knots, altitude was 820 ft, pitch was 10 degrees nose down and roll was 6 degrees left wing down. At 10:00:40, the airspeed was 75 knots, altitude was 750 ft, pitch was 5 degrees nose up and roll was 30 degrees left wing down. At 10:00:46, groundspeed was 69 knots, altitude was 710 ft, pitch was 41 degrees nose down and roll was 75 degrees right wing down. At 10:00:51, the airspeed was 11 knots, altitude was 620 ft, pitch was 77 degrees nose down and roll was 53 degrees left wing down. At 10:00:56, the recorded data ended.

Probable Cause and Findings

The pilot's inadequate planning during an instrument approach and failure to maintain the published minimum altitudes, which resulted in controlled flight into terrain.

 

Source: NTSB Aviation Accident Database

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