Aviation Accident Summaries

Aviation Accident Summary WPR11FA116

Adrian, OR, USA

Aircraft #1

N3083Q

CESSNA 182K

Analysis

The non-instrument-rated pilot was returning to his home airport about two hours after sunset on a dark night with low levels of ambient light. The pilot landed to refuel at an airport that was located about 40 miles northwest of his home airport. Around the time of his post-refueling departure, the weather in the valley between the refueling airport and his home airport varied from clear skies to a solid overcast cloud layer, with some areas being covered by patchy ground fog and mist. After takeoff, the pilot flew in a southerly direction along the western edge of the valley. As he continued to the south, he reached a location where the western edge of the valley is defined by a steeply rising line of hills. At that point the pilot turned about 10 degrees to the east and then proceeded along the eastern edge of the hilly area. After flying a little over five miles beyond the point where he turned to the east, the airplane impacted the steeply rising terrain on the eastern edge of the hills. The impact ground scars were consistent with the airplane being in a wings-level attitude, and an examination of the engine and propeller revealed evidence that was consistent with the engine being at cruise power or greater. The investigation did not reveal any evidence of anomalies or malfunctions associated with the airplane's airframe, engine, or systems. It is likely that the pilot failed to see the terrain and inadvertently flew into it while in cruise flight.

Factual Information

HISTORY OF FLIGHT On January 29, 2011, about 2030 mountain standard time (MST), a Cessna 182K, N3083Q, impacted hilly terrain about two miles south of Adrian, Oregon. The private pilot and his two passengers were killed in the accident sequence, and the airplane, which was registered to a friend of the pilot, but operated and maintained by the pilot, sustained substantial damage. The 14 Code of Federal Regulations Part 91 personal cross-country flight, which is estimated to have departed Ontario, Oregon, about 15 minutes prior to the accident, was being operated in an area where patchy ground fog and an occasional 2,300 foot overcast had been reported. No flight plan had been filed, and a search for the airplane was not initiated until the next morning when a family member reported the airplane missing. According to family members, the pilot and his two passengers, both of which were relatives of the pilot, departed Nampa Municipal Airport, Nampa, Idaho, sometime on the afternoon of January 28, en route to Portland, Oregon, where the airplane's occupants were going to attend a memorial service and a funeral. Later that day, about 1945 Pacific Standard Time (PST), the pilot landed at Madras City-County Airport, Madras, Oregon, which is located about 120 miles east of Portland. After landing at Madras, the pilot told the airport manager that he had already flown quite a ways west of Madras, and had attempted to get to Portland, but was unable to do so because of the weather conditions he encountered. He then stated that he wanted to refuel the airplane and try again to get through to Portland. According to the airport manager, he tried to talk the pilot out of a second try to make it to Portland, because it was already dark and the pilot was flying under visual flight rules (VFR). The manager said that at first the pilot was adamant about trying again to get through to Portland, but ultimately the manger was able to convince the pilot to drive his (the manager's) car to Portland free of charge, and to bring it back the next day with a full fuel tank. The pilot and his passengers therefore left the airplane at Madras, and continued on to Portland by private vehicle, where they reportedly arrived in time for the funeral, but not in time to attend the memorial service. At an undetermined time the next day (January 29) the pilot and his passengers departed Portland and drove the airport manager's vehicle back to Madras; a trip estimated by Microsoft's Streets and Trips to be about two hours and ten minutes long. After returning to Madras, around 1700 PST, the pilot had 10 gallons of 100LL aviation fuel put in the airplane's fuel system. According to the airport manager, soon thereafter, "…just as it was starting to get dark," the pilot departed for his return flight to Nampa. The manager also stated that a weather system with lowering ceilings was starting to move into the area about the time the pilot departed. The pilot did not make contact with any en route Federal Aviation Administration (FAA) facilities after departing Madras, and the next known location of the airplane and pilot was at Ontario Airport, Ontario, Oregon. According to refueling records, after landing at Ontario, the pilot took on 10 gallons of 100LL aviation fuel at 1957 MST. A few minutes after taking on fuel, one of the pilot's passengers sent a text-message to a family member saying that they were at Ontario getting fuel, and that they would be back in Nampa in about 20 minutes. When the pilot did not arrive home, family members became concerned, and after finding his vehicle still parked at the airport, they eventually reported the airplane as missing. Throughout the night of January 29, the local cell phone company pinged the phone of one of the occupants of the airplane, and by the next morning they felt that they had narrowed the location down to a 3,000 meter area, south of Adrian, Oregon. As a search airplane neared the area within which the phone was believed to be, its occupants began picking up the signal from an emergency locator transmitter (ELT). Although they were not able to locate the crashed airplane from the air, they were able to narrow the search area so that an all-terrain vehicle could be used to search on the ground. At 1152 on the morning of January 30, the wreckage was located on the east side of a steep hillside at 43 degrees, 40.425 minutes North by 117 degrees, 07.366 minutes West. PERSONNEL INFORMATION The pilot was a 38 year old male, whose private pilot certificate had been originally issued on October 12, 2010, which was about three and one-half months prior to the accident. His last airman's medical certificate, a third class, was issued on June 25, 2009. It was issued without waivers or limitations. The last documented flight times that were found were dated October 16, 2010. At that time the pilot had logged 133 hours total flying time, 3.6 hours at night, and 1.8 hours in a Cessna 182. Although the pilot's total night hours are unknown, based on the aircraft log book and the tachometer reading at the time of the accident, it is estimated that at the time of the accident the pilot had about 17.5 hours of total time as pilot-in-command of a Cessna 182. AIRCRAFT INFORMATION The airplane was a 1967 Cessna 182K, serial number 18258083. Its last recorded annual inspection was signed off on October 21, 2010. At the time of that inspection the tachometer read 664.8 hours, and the airframe total time was 5,849 hours. At the time of the accident the tachometer read 679.5 hours, making the total airframe time 5,863.7 hours. Although the airplane was registered to a friend of the pilot, since the time the pilot earned his private pilot license, the pilot and the registered owner reportedly had an agreement wherein the pilot would act as the operator of the airplane, having sole and exclusive use of it, and in return he was to maintain the airplane and have a non-owner insurance policy issued to cover his operation of the airplane. METEOROLOGICAL INFORMATION The 2053 aviation weather surface observation (METAR) for Ontario, Oregon, which is located about 25 miles north of the accident site, and about 40 miles northwest of the pilot's destination, recorded calm winds, eight statute miles visibility, an overcast ceiling at 2,300 feet, a temperature of one degree C, a dew point of minus one degree C, and an altimeter setting of 30.01 inches of mercury. The 2053 METAR for Caldwell, Idaho, which is located about 20 miles east of the accident site, and about seven miles northwest of the pilot's intended destination, recorded calm winds, eight statute miles visibility, clear, a temperature of one degree C, a dew point of minus five degrees C, and an altimeter setting of 30.00 inches of mercury. The 2053 METAR for Boise, Idaho, which is located about 43 miles east of the accident site, and about 15 miles east of the pilot's intended destination, recorded calm winds, five statute miles visibility, mist, few clouds at 12,000 feet, a temperature of one degree C, a dew point of minus one degree C, and an altimeter setting of 29.97 inches of mercury. According to a representative of the Malheur County Sheriff's Office who was involved in the aerial search for the aircraft, the localized weather conditions around the area of the Snake River at the time of the accident were variable. Some areas were under a solid cloud layer, some were under clear skies, and some areas were reported as having patchy ground fog and mist. A review of the astronomical data provided by the National Oceanic and Atmospheric Administration (NOAA) revealed that at the time of the accident it was a dark night due to low ambient light. According to the NOAA data, the sun had set more than two hours prior to the accident, at 1822, and the moon, which was only 11 percent illuminated, was not scheduled to come over the horizon until 0543 in the morning. According to Lockheed Martin Flight Services, the pilot did not contact any of their facilities for a pre-flight weather briefing covering the flight from Madras, Oregon, to Nampa, Idaho. According to the records of both Direct User Access Terminal Service (DUATS) providers, the pilot did not make use of their weather briefing programs either. WRECKAGE AND IMPACT INFORMATION The airplane impacted steeply rising terrain at the 3,000 foot level of the east facing 35 degree slope of the first line of hills that defines the west side of the valley in which Caldwell, Nampa, and Boise, Idaho are situated. At the point of initial impact, there was a crater about eight feet long, four feet wide, and two feet deep. The crater centerline was aligned on a heading of about 270 magnetic degrees. Just outboard of this crater, on both sides, were two smaller gouges in the terrain that were consistent with the impact of the two main landing gear. Both of the smaller craters contained small pieces of the fiberglass main gear wheel pants. Near the down-track end of the main crater was a scar line aligned on a heading of 350/170 degrees, which extended about 15 feet outboard of its center on both sides. At both ends of this scar line, which was consistent with the impact of the airplanes wings, were remains of the respective navigation and anti-collision strobe lights. The scar line itself was nearly in the horizontal plain, and was consistent with the airplane being near wings level at the moment of impact. Most of the airplane's structure, except for the right passenger door, which remained at the initial impact crater, came to rest about 45 feet diagonally up the hillside. The airplane had flipped over, and both the wings and the fuselage had come to rest upside-down. The leading edge of both wings, outboard of the lift strut attach fitting, were crushed directly aft to about the depth of the forward spar, with the severest damage being near the wing tips. Both flaps were found in the up position, and the flap actuator switch was in the neutral position. Both right and left aileron control continuity was established to where the cables entered the cabin. The engine, firewall, and instrument panel had been crushed nearly straight aft into the forward part of the cabin. The nose landing gear strut had been folded nearly straight aft, and was lying along the belly of the cabin area. Except for a few dents along its left side, from a point about three feet aft of the rear window, the fuselage structure primarily retained its pre-impact form. There was a small tear in the leading edge of the right horizontal stabilizer, but otherwise, the empennage was mostly undamaged. Elevator control continuity was able to be established from the elevator to the aft part of the cabin, and rudder control continuity was able to be established all the way to the rudder pedals. Elevator trim continuity was able to be established to the aft part of the cabin, and the trailing edge of the elevator trim tab itself was found three-eighths of an inch up (airplane nose down) from the trailing edge of the elevator. The throttle was found about one inch out from the panel, and there was control continuity to the carburetor. The propeller knob was found about one-half inch out from the panel, and the mixture knob was in the full in (rich) position. The carburetor heat was in the off position. The tachometer needle indicated 2,350 rpm, and the tachometer hours read 679.5. The engine had torn loose from its mounts, but remained attached to the fuselage through various lines and cables. Both magnetos had separated from their mounts. The right magneto remained attached to three ignition leads and had impact damage to its mounting flange. The left magneto was found approximately 20 feet upslope from the main wreckage. No spark was able to be generated from the left magneto when turned by hand. Spark was able to be generated at the three leads from the right magneto when turned by hand. The magnetos where disassembled, and no evidence of internal anomalies was found. The carburetor was undamaged, and light blue colored fuel was found in both the carburetor bowl, and in the gascolator. Both the carburetor finger screen and the screen were uncontaminated. Testing of the fuel in the carburetor with water detection paste indicated no water present. Both the float valve and the float valve seat were unremarkable, and the accelerator pump was found to function properly. The upper and lower spark plugs from cylinders 1, 3 and 5, and the lower spark plugs from cylinders 2, 4 and 6 were removed from the engine. In accordance with the Champion AV-27 chart, the spark plugs had normal wear signatures indicating a normal service life. The spark plug electrode areas had light gray deposits, with no indication of excessive lead deposits, contamination, or cracks in the insulators. The number 1, 2, 3, and 4 cylinders were boroscoped, and no evidence of valve, piston, or combustion chamber damage or abnormal thermal signatures was seen. The number five cylinder was boroscoped, but an oil residue in the combustion chamber restricted the visibility. The number 6 cylinder, which was the low point of the engine in the position it sat on the hillside, was filled with oil and could not be boroscoped. The crankshaft propeller flange had suffered significant impact damage, and the lower part of the front of the crankcase fractured open revealing the forward part of the camshaft and the propeller drive gear. The portion of the interior of the crankcase that could be seen through the fracture hole was lubricated with oil, and there were no signs of abnormal thermal stress. The propeller hub assembly had separated from the crankshaft flange, and fragments of the hub were found along the impact track. Both blades had separated from the propeller hub, and the one blade, designated A, was found near the main wreckage. The other blade, designated B, was found about 120 feet upslope from the main wreckage. Blade A had chord-wise scratches and burnishing of the paint across the outboard two-thirds of its cambered face. It also had leading edge impact scuffing along its outboard two-thirds, with a small amount of leading edge gouging along the most outboard three inches of its span. Blade B had both chord-wise and diagonal scratching and paint burnishing along the outboard one-half of its cambered face. It also had leading edge impact scuffing along its outboard one-half, with a significant degree of leading edge gouging along that same distance. Both blades displayed decreased pitch twist from their mid-section to their tip. MEDICAL AND PATHOLOGICAL INFORMATION At the direction of the Malheur County Medical Examiner an autopsy was performed on the pilot. That autopsy determined that the cause of death was massive blunt force trauma secondary to the pilot's involvement in an airplane crash accident. The FAA's Civil Aerospace Medical institute (CAMI) performed a forensic toxicology examination on specimens taken from the pilot. That examination was negative for carbon monoxide and cyanide in the blood, and negative for ethanol and tested drugs in the urine. ADDITIONAL INFORMATION The FAA's Air Traffic Organization Quality Assurance Office provided the NTSB Investigator-In-charge (IIC) a Google Digital Globe satellite photo of the area between Ontario Airport and the accident site. Overlaid on the photo was a radar ground track based on raw position data only (no altitude). The first radar hit (most northern) appeared at 2021 MST, about eight and one-half miles south of the Ontario Airport. That ground track continued in a southerly direction (about 200 degrees) for about 12 miles. At that point, which was just as the airplane was approaching the northern boundary of the hilly area that it eventfully impacted, the ground track turned left (east) about ten degrees, and proceeded along the eastern edge of the hilly area, and just west of the Snake River. From the point where the ten degree left turn was initiated, the ground track continued about three and one-half miles to the location of the last radar hit, which appeared at 2030 MST. Based on the photo overlay, the last radar hit was estimated to be located at 43 degrees, 4

Probable Cause and Findings

The non-instrument-rated pilot did not maintain sufficient altitude to clear mountainous terrain while in cruise flight in the dark.

 

Source: NTSB Aviation Accident Database

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