Aviation Accident Summaries

Aviation Accident Summary ANC14FA002

Fairbanks, AK, USA

Aircraft #1

N1512Y

CESSNA 172C

Analysis

The pilot was departing on a short cross-country flight to deliver the airplane for some elective maintenance. He requested and received clearance for an intersection departure. After departure, an air traffic controller instructed the pilot to turn left and proceed on course, but the pilot did not respond. Controllers reported observing the airplane initiating a left turn before descending and impacting terrain on the south side of the airport property. Postaccident examinations of the airplane revealed no mechanical anomalies that would have precluded normal operation. However, the examinations did reveal propeller signatures consistent with the engine not producing power at the time of impact. About 2 gallons of what appeared to be 100LL aviation fuel was drained from the right fuel tank and about 0.5 gallon of fuel was drained from the left fuel tank at the accident site. The drained fuel was clean, and no water was present. The carburetor fuel bowl was removed, and it contained only a small amount of fuel. The accelerator pump was actuated by hand, and it did not discharge fuel. No fuel leakage was noted at the accident site. Given the amount of fuel removed from the airplane at the accident site and the propeller signatures consistent with a lack of power, it is likely that the loss of engine power resulted from fuel exhaustion. A Boeing 737 (737) airplane departed the parallel runway about 1 minute 45 seconds before the accident airplane departed. Although it is possible that wake turbulence existed in the 737's departure corridor, no evidence was found indicating that the accident airplane experienced wake turbulence. Toxicological testing revealed that the pilot had a significant amount of glucose in his urine and an elevated Hemoglobin A1C level, indicating that he had diabetes. Family members reported that the pilot was not actively being treated for the condition. The pilot's actual glucose level at the time of the accident could not be determined; however, based on the available evidence, it is unlikely that the pilot was acutely incapacitated by his diabetes at the time of the accident.

Factual Information

HISTORY OF FLIGHTOn October 17, 2013, about 1711 Alaska daylight time, a Cessna 172C airplane, N1512Y, sustained substantial damage when it collided with terrain shortly after departing runway 20L at the Fairbanks International Airport (FAI), Fairbanks, Alaska. The private pilot was fatally injured, and two passengers sustained serious injuries. The airplane was registered to, and operated by the pilot as a 14 Code of Federal Regulations Part 91 visual flight rules (VFR) cross-country flight when the accident occurred. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed for the flight destined to North Pole, Alaska. Air Traffic Controllers on duty at the time of the accident, reported that the airplane departed runway 20L at intersection Romeo. Shortly after departure, the pilot was cleared to turn left and proceed on course, but no verbal response was received from the pilot. The controllers observed the airplane initiate a left turn, before descending and impacting terrain on the south side of the airport property. In a telephone conversation with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC), the front seat passenger, the pilot's son, stated that the purpose of the flight was to take the airplane to a maintenance provider to install a new nose wheel assembly. He stated that he and the rear seat passenger had just decided to go along for the short flight. They pulled the airplane out of the hangar, and the pilot performed the preflight inspection. The passenger stated that they did not put fuel in the airplane, but he thought that the tanks were full. He stated that they taxied out to the runway, and commenced the takeoff. He did not remember anything after the airplane started the takeoff roll. Runway 2R/20L is about 6500 feet long. At taxiway Romeo there was about 3452 feet of runway available for takeoff. PERSONNEL INFORMATIONThe pilot, age 51, held a Private Pilot Certificate with a single engine land rating. His last FAA flight physical on 10/08/1997 reported he was 72 inches tall and weighed 229 pounds, when he was 35 years old. This pilot also reported at that time his flight experience included 400 total hours flight time and 50 hours within the last six months. No personal logbooks were located for the pilot. AIRCRAFT INFORMATIONThe four-seat, high-wing, fixed-gear airplane, serial number (S/N) 17249412, was manufactured in 1956. It was powered by a Continental O-300-C engine, serial number 22189-D-70-C R, rated at 145 horsepower. The airplane was equipped with a McCauley fixed pitch propeller. The engine was overhauled on October 24, 2007, and reinstalled at a tachometer time of 1,715.00. The last annual inspection was completed on August 15, 2013 at a tachometer time of 1904.3. METEOROLOGICAL INFORMATIONThe nearest official weather reporting station is located at the Fairbanks International Airport. At 1721 Alaska daylight time, an Aviation Routine Weather Report (METAR) was reporting, in part: Wind, 020 degrees (true) at 3 knots; visibility, 10 statute miles; clouds and sky condition, few clouds at 7,500 feet above ground level (AGL), broken clouds at 10,000 feet AGL, broken clouds at 13,500 feet AGL; temperature, 46 degrees F; dew point, 42 degrees F; altimeter, 29.70 inHg. AIRPORT INFORMATIONThe four-seat, high-wing, fixed-gear airplane, serial number (S/N) 17249412, was manufactured in 1956. It was powered by a Continental O-300-C engine, serial number 22189-D-70-C R, rated at 145 horsepower. The airplane was equipped with a McCauley fixed pitch propeller. The engine was overhauled on October 24, 2007, and reinstalled at a tachometer time of 1,715.00. The last annual inspection was completed on August 15, 2013 at a tachometer time of 1904.3. WRECKAGE AND IMPACT INFORMATIONExamination of the accident site by the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) revealed that the airplane came to rest in an upright, nose low position, adjacent to an airport perimeter fence, approximately 1,585 feet from the departure end of runway 20L. Wreckage debris remained within about 50 feet of the main wreckage, and all the major structural components of the airplane were located at the accident site. The airplane impacted the upsloped bank of a slough that runs around the south end of the FAI airport. The initial impact point was approximately 1,585 feet from the departure end of 20L. The first point of ground impact was noted to be the left wing tip. Portions of the left wingtip structure were found buried approximately 6 inches beneath the surface of the ground. Fragments of the left wing were found adjacent to the ground scar. There was an impact crater of size and shape consistent with the nose of the airplane located approximately 20 feet from the initial point of ground contact. The main wreckage came to rest approximately 25 feet from the nose impact crater. The airplane was resting at the base of an airport perimeter fence. The empennage was broken at a rivet line just aft of the fuselage, and was canted right approximately 120 degrees. The right elevator was resting against the right flap. The engine was separated from the firewall. The carburetor separated from the oil/induction pan, but remained connected to the engine control cables. The exhaust tubes showed no signs of ductile folding. Both propeller blades remained attached to the engine crankshaft. The propeller blades showed no rotational signatures. One blade was bent aft approximately 70 degrees at midspan. The other blade was undamaged. No chordwise scratches were noted on the propeller, and no rotational scoring was noted on the spinner. The left front seat was cut from the airplane by first responders in order to extract the pilot. The left seat belt sections remained connected to the airframe, and no stretching of the fabric or impact signatures were noted to the clasp. The spring was missing from the seatbelt clasp. The fuel selector linkage was broken. The accident airplane was equipped with two wing mounted, bladder style fuel tanks, one in each wing. The total fuel capacity of the airplane is 42 gallons, of which 37 are useable (2.5 gallons unusable in each wing). The fuel lines from each of the tanks are located near the rear of the bladder and wing. The vent tube is located on the outboard section of the bladder, near the front of the tank. Both of the airplane's fuel tanks were drained at the accident site. The right wing fuel tank held approximately 2 gallons of what appeared to be 100 Low Lead aviation gasoline. The left wing held approximately .5 gallons of 100 Low Lead. The drained fuel was clean, and no water was observed in the fuel. There were no visible signs of ruptured fuel tanks or fuel lines. No fuel odor was present during the on-scene examination, and first responders to the scene did not report any fuel odor or leakage. The carburetor fuel bowl was removed by an FAA inspector at the accident site. The inspector reported that the accelerator pump actuated by hand but did not discharge fuel, and the fuel bowl only contained a small amount of fuel. Flight control continuity was established from the ailerons to the control yokes. Elevator and rudder control continuity could only be established to the cockpit area due to damage to the airframe. On October 22, 2013, the NTSB IIC, two FAA inspectors, and representatives from Cessna and Continental motors examined the wreckage at the owner's hangar. During the wreckage examination, no preaccident airframe anomalies were noted. The fuel selector valve was determined to be in the "both on" position. The carburetor fuel screen was clean, and the floats appeared in good condition. The engine examination revealed no preaccident mechanical anomalies. Valve train and accessory continuity was established visually when the camshaft was turned. Thumb compression was noted on all cylinders. The engine was turned by hand, and the magnetos provided spark on top leads in the correct firing order. ADDITIONAL INFORMATIONApproximately 1 minute 45 seconds before the accident pilot received his takeoff clearance, a Boeing 737 was cleared for takeoff on the parallel runway (20R). The parallel runways are separated by 1,800-feet. The FAA Aeronautical Information Manual (AIM) (section 7-3-1) and the Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25A) provides information on wake vortices and avoidance techniques to pilots. In calm wind conditions, vortices created by large aircraft during takeoff and landing operations can remain for many minutes over the normal touchdown area. They can also slowly drift from one runway to a nearby parallel or crossing runway. The majority of wake vortices accidents occur when winds are between 3 and 10 knots. The speed and direction of the wind determines the horizontal motion of the wake vortices. If the wind is calm or is moving along the runway heading, a pair of vortices moves apart and away from the flight path of a landing or departing aircraft. With a crosswind of less than 5 knots, the lateral movement of the downwind vortex increases; as a result, the upwind vortex can remain near the flight path, and the downwind vortex can move more quickly towards another runway. With a crosswind of more than 5 knots, the vortices move quickly across the flight path. A tail wind can move the vortices of a leading aircraft forward into the touchdown zone. The AIM says that a light quartering tailwind requires "maximum caution". According to a recent Airbus Flight Operations Briefing Notes wake vortices typically last 30 seconds under normal conditions with winds above 5 knots, and up to 85 seconds when wind speeds are less than 5 knots. Vortices can last up to 100 seconds in still air. COMMUNICATIONSThe pilot was in contact with the Fairbanks Air Traffic Control Tower at the time of the accident. Air Traffic Controllers on duty at the time of the accident, reported that the airplane departed runway 20L at intersection Romeo. Shortly after departure, the pilot was cleared to turn left and proceed on course. The controllers observed the airplane initiate a left turn, before descending and impacting terrain on the south side of the airport property. MEDICAL AND PATHOLOGICAL INFORMATIONA postmortem examination of the pilot was done under the authority of the Alaska State Medical Examiner, Anchorage, Alaska, on October 21, 2013. The examination revealed that the cause of death for the pilot was attributed to multiple blunt force injuries. A toxicological examination by the FAA's Civil Aeromedical Institute (CAMI) on December 3, 2013 was negative for any carbon monoxide, alcohol, or drugs. Tests for glucose levels in the vitreous and urine revealed the following results: · 46 (mg/dl ) Glucose detected in Vitreous · 1668 (mg/dl ) Glucose detected in Urine · 10.3 (%) Hemoglobin A1C detected in Blood (Cavity) Conversations with the pilot's family members indicated that he was not actively being treated for diabetes.

Probable Cause and Findings

The pilot’s failure to ensure that adequate fuel was on board the airplane, which resulted in fuel exhaustion and a subsequent collision with terrain.

 

Source: NTSB Aviation Accident Database

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