14 CFR Part 91: General Aviation
Accident occurred Saturday, May 26, 2012 in St. George, UT
Probable Cause Approval Date: 02/03/2014
Aircraft: CESSNA 172S, registration: N953SP
Injuries: 4 Fatal.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
Prior to the flight, the pilot and passengers were at a party, during which time the pilot and all but one passenger (the designated driver) consumed multiple alcoholic beverages. They left to go to another party and while en route, the vehicle was pulled over by a police officer. During the diversion, the group agreed to instead go to a nearby city to gamble.
The flight subsequently departed around 0120 with the airplane about 160 lbs. over its maximum gross weight. An airport video recording that captured the takeoff revealed that the airplane remained either on the ground or in ground effect for over two-thirds of the length of the runway, consistent with the pilot attempting to gain airspeed in the overweight airplane. The airplane then aggressively pitched nose up and climbed out of view of the camera. Seconds later, the airplane reappeared in a near-vertical descent into the dirt area at the end of the runway, most likely due to an aerodynamic stall during the steep climb.
A review of the pilot's toxicological tests found that the post-mortem blood ethanol level was 0.105 percent, which is more than twice the Federal Aviation Administration limit for civil aviators (0.04 percent). The evidence points to ingestion as the primary source of the ethanol in the pilot and implies that his pre-mortem ethanol level was high enough to significantly impair his judgment and psychomotor skills. It is likely that the pilot's consumption of alcohol preflight contributed to this accident. Postaccident examinations of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain adequate airspeed during an aggressive pitch-up maneuver, which resulted in a low-altitude aerodynamic stall shortly after takeoff. Contributing to the accident was the pilot's impairment from alcohol consumption and an over-gross-weight airplane.
HISTORY OF FLIGHT
On May 26, 2012, about 0120 mountain daylight time, a Cessna 172S, N953SP, collided with terrain shortly after departing from St. George Municipal Airport, St. George, Utah. Diamond Flying LLC was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot and three passengers were fatally injured; the airplane sustained substantial damage. The local personal flight was departing from St. George with a planned destination of Mesquite, Nevada. Visual meteorological conditions prevailed, and no flight plan had been filed.
A friend of the pilot stated that he arrived at a party on the evening of May 25 and the pilot was already there. He recalled both himself and the pilot having several alcoholic beverages (two shots of Southern Comfort liqueur) between 2030 and 2200, but was not aware of his alcohol consumption before or after that time frame; there was also Bud Light and Smirnoff Vodka at the party. He recalled two of the passengers were also drinking alcohol at the party and the third passenger did not consume any alcohol because he was the designated driver for the group. Shortly thereafter, himself, the pilot, and three passengers all left the party and decided to drive to another party.
The friend further stated that while en route to the other party, the vehicle was pulled over by a police officer. While they were all waiting in the car for the officer to complete the traffic stop, one of the passengers suggested that the group should go to Mesquite, since he frequently drove there on the weekends to gamble. The group agreed to go, with the exception of the friend, who decided that he would stay in town instead and he called someone to pick him up from the car's location. Some of the passengers called him a little later to again try to encourage him to go, but he refused and made a last call to them at 0110 when he let them know he was going back to the party. Nobody ever mentioned or gave him any indication that they were going to take an airplane to Mesquite.
The airport was equipped with a video recording system that consisted of a fixed based security camera system. A review of the video files revealed that the airplane could be seen in the night time conditions by the blinking left-wing strobe light and the navigation light mounted on the tail. The airplane appeared to depart from runway 19 and maneuver at a low altitude for the length of the runway while increasing its airspeed. Near the end of the runway (about 2/3 of the way down the 9,300 ft runway), the airplane began a rapid ascent and continued out of the view of the camera. After about 7 seconds, the airplane reappears further down the frame in a rapid descent.
The pilot, age 23, held a commercial pilot certificate, with ratings for single and multiengine land, and instrument flight. His first-class medical certificate was issued on April 16, 2012, and contained no limitations. The pilot was employed by GoJet Airlines, LLC., as a first officer in the Bombardier CL-600 series airplanes.
The pilot's personal flight records were not recovered. On his last application for a medical certificate the pilot reported a total flight time of 3,000 hours.
The pilot's resume submitted to GoJet indicated that he had previously been employed at Comair Airlines; he additionally was employed as a line technician at St. George Jet Center from 2003 to 2006. The computerized flight logs at GoJet reported his last recorded total time as about 2,230 hours, with his last proficiency training occurring about 1.5 months prior to the accident.
The pilot's family stated that the airplane belonged to a friend of the family and the pilot would borrow the airplane occasionally. The owner was not aware that the pilot had intended to fly the airplane the morning of the accident, however, that was not unusual, and the pilot and his father had permission to use the airplane when they desired. The pilot acquired a significant portion of his flight time from the St. George Municipal Airport and would commonly take friends flying without much notice.
The pilot's friend indicated that he did not consume alcohol very often and he had only seen him drink on three occasions in the last 2 years. The pilot's family indicated that he did not consume alcohol.
The Cessna 172S airplane, serial number 172S8153, was manufactured in 1999. The last annual inspection record was not contained in the airplane's logbook, but was provided as a separate entry after the accident. It indicated that the last inspection was completed on August 10, 2011, at a total airframe and engine tachometer time of 1,091.4 hours.
The airplane's Hobbs sheet located within the wreckage indicated that the last recorded flights were performed by the accident pilot on October 17 and 20, where he wrote that he had amassed 18.6 and 4.4 hours, respectively.
The last known date that the airplane was refueled at St. George was recorded from Above View Aviation on May 18, 2012. The airplane was fueled with 18.5 gallons, which the fuel technician reported was a top-off to full fuel tanks. The last known fueling occurred at Chandler Air Service, Chandler, Arizona, where the airplane received 20.54 gallons of fuel, which based on the distance calculation from the two airports, equates to additionally being topped-off to full fuel tanks on that occasion.
Using average fuel consumption rates in the airplane flight manual climb and cruise performance charts, investigators conservatively estimated that the airplane had about 28 gallons of fuel onboard at the time of the accident. The disposition of the fuel load between the two standard capacity wing tanks could not be determined. The calculations used are contained in the public docket for this accident.
Weight and Balance
Weight and balance computations were made for the accident takeoff at based on the airplane's empty weight, total moment, and center of gravity that were obtained from the operator's maintenance records. The takeoff condition used the previously estimated 28 gallons of fuel. The occupant weights and seating positions were obtained from the Utah Department Office of the Medical Examiner. The detailed computations are appended to this report.
For the takeoff condition, the gross weight was about 2,710 pounds and the center of gravity was 44.92-inches. The maximum authorized gross takeoff weight was 2,550 pounds with the center of gravity range at that weight between 41.0 and 47.3 inches forward and aft, respectively. Review of the Cessna Pilot's Operating Handbook (POH) for the Cessna 172S disclosed that with the flaps in the retracted position, at the maximum gross weight, the stall speed at zero degrees of bank is 48 knots indicated airspeed (KIAS) and altitude loss during recovery "may be as much as 230 feet." Normal initial climb segment airspeed is 73 KIAS at 3,000 feet msl, with a 620-foot-per-minute climb rate.
Cessna does not provide or supply stall speeds outside the maximum gross weight envelope. The applicable POH states that the airplane's "stall characteristics are conventional and aural warning is provided by a stall warning horn which sounds between 5 and 10 kts above the stall in all configurations."
The recorded video files were captured from security cameras located at the southwest corner of the St. George's Airport Rescue and Fire Fighting Facility and at the upper southwest corner of the South Terminal Building.
One video file disclosed that at 04 seconds and 21 frames into the recording the first indication of the accident airplane appears in the right-hand portion of the frame. The only visible indication of the airplane was the port wingtip strobe, port wingtip position light and white tail navigation light. The airplane continued to cross the image plane toward the departure end of runway 19 until 16 seconds and 22 frames in the recording when the airplane began a rapid ascent in an upward facing arc. The airplane continued ascending upward until 19 seconds and 03 frames when it disappeared out of the upper region of the recorded frame. At 25 seconds and 28 frames, the airplane reappears in the upper region of the frame in a rapid descent. At 27 seconds and 24 frames, the airplane's position lights disappeared behind a bright light bloom from the South Terminal Building's ramp area. No other salient information pertaining to the accident was captured during the 51-second recording.
The other video file reveals that at 04 seconds and 01 frame into the recording the first indication of the accident airplane appears in the right-hand portion of the frame. The only visible indication of the airplane is the port wingtip strobe, port wingtip position light and white tail navigation light. The airplane continues to cross the image plane towards the departure end of runway 19 until 14 seconds and 05 frames into the recording when the last indication of the accident airplane's taillight disappears out of the image frame. No other salient information pertaining to the accident was captured during the 23-second recording.
In an effort to determine an approximate ground speed during the takeoff, geometric reference points were utilized and the time was analyzed as the airplane moved between each of the points. To accomplish this, lines of perspective were created from the center of the camera's lens through each known taxiway light position and beyond the runway centerline. Using the airplane's tail position light, a frame reference was taken at each of the perspective lines as the airplane moved through the image. As the airplane's taillight passed each perspective line, the time in whole seconds and number of carryover frames were recorded. Using mapping software, the distance between each line of perspective along the runway centerline was measured and the resulting average groundspeed of about 107 kts was calculated for the 637 feet of captured video. The last two segments of video showed a decrease of groundspeed from about 107 to 91 kts. The pitch and bank angle of the airplane could not be determined from the video.
A routine aviation weather report (METAR) generated by an Automated Surface Observation System (ASOS) at the airport, indicated that about 5 minutes prior the accident the conditions were as follows: wind was from 260 degrees at 9 knots; temperature 66 degrees Fahrenheit; dew point 28 degrees Fahrenheit; and altimeter 29.60 inHg.
According to the U.S. Naval Observatory, on the morning of the accident, the time of sunrise was 0618. At the time of the accident, the moon was below the horizon and the sky was dark.
WRECKAGE AND IMPACT INFORMATION
The accident site was located in the hard dirt area (the southerly primary surface) adjacent to the departure end of runway 19. Situated on the level terrain, the airplane came to rest in an inverted attitude and was oriented on a 315-degree magnetic bearing. The main wreckage, which consisted of a majority of the airframe and engine, was located about 525 feet from the edge of the runway.
The first identified point of impact was a ground scar impression about 40 feet from the main wreckage that dimensionally and geometrically resembled the wings with a crater-like impression in the center. The span of the ground disturbance was about 36.5 feet, with red lens fragments located near the east side and green fragments on the westerly side; the airplane's wingspan was 36 feet. Imbedded in the center crater was a portion of a propeller blade and the nose wheel. In the debris field from the ground scar to the main wreckage was oil sump, the propeller and engine accessories.
Contained within the wreckage were bottle caps from Bud light and Blue Moon beer bottles.
The destination airport in Mesquite (elevation 2,000 ft msl), was about 28 nm from St. George Municipal Airport (elevation 2,900 ft msl) on a bearing of about 245 degrees. A mountain range extended longitudinally between the two airports with peaks reaching up to 6,000 ft msl. The surrounding area was unpopulated desert and few lights were in the immediate vicinity. Driving an automobile between the two airports is about 37 nm and would take about 45 minutes.
MEDICAL AND PATHOLOGICAL INFORMATION
The Utah Department of Health, Office of the Medical Examiner, completed an autopsy on the pilot. The examiner's pathological diagnosis as cause of death was noted as, "Multiple blunt force injuries."
The FAA Civil Aeromedical Institute (CAMI) performed toxicological screenings on the pilot. According to CAMI's report (#201200100001) the toxicological findings were positive for ethanol (alcohol). Specifically, the following was detected in the pilot's specimens: 0.105 gm/dL ethanol in blood, 0.121 gm/dL ethanol in brain, 0.098 gm/dL ethanol in heart; methanol and n-propanol was also detected in the blood as well. The toxicology report additionally noted no evidence of putrefaction in the specimens received.
None of the passengers were FAA certificated pilots. CAMI additionally performed toxicological screenings on the passengers, of which two were positive for ethanol. One passenger's blood contained 0.088 gm/dL ethanol and the other passenger had 0.160 gm/dL of ethanol detected in his blood.
TESTS AND RESEARCH
Following recovery, the wreckage was examined at a hangar at the St. George Municipal Airport.
Investigators established continuity for the elevators and rudders from the aft bulk head area to the control surfaces. The ailerons cables separated in the cabin overhead area location, with the cable ends exhibiting a broom straw appearance consistent with overload. Continuity was established in the wings (from cabin to their respective bellcranks), but the cockpit area's extensive damage prohibited investigators from tracing the cable paths. The wing flap actuator jackscrew was flush with the body, which, according to the Cessna representative, corresponded to a flaps being in the retracted position. The elevator trim was measured to be 1.3 inches, which the Cessna representative stated was a neutral position.
The Lycoming IO-360-L2A, serial number L-28167-51A, sustained impact damage. Despite several attempts, investigators could not rotate the crankshaft and proceeded to remove cylinders No. 1 and 3 cylinders. The No. 2 and 4 cylinders were examined through the spark plug holes utilizing a lighted borescope. The combustion chambers were mechanically undamaged, and there was no evidence of foreign object ingestion or detonation. The valves were intact and undamaged. There was no evidence of valve to piston face contact observed. The gas path and combustion signatures observed at the spark plugs, combustion chambers and exhaust system components displayed coloration that the Lycoming representative said was consistent with normal to lean operation.
There was no oil residue observed in the exhaust system gas path. Ductile bending and crushing of the exhaust system components was observed.
Removal of the fuel manifold (spider) revealed that it contained slight traces of liquid that was consistent in odor with that of Avgas. The diaphragm was pliable and the spring was intact.
The left magneto was broken as a result of impact and could not be functionally tested. The right magneto, which was located away from the engine in the debris field, was rotated by hand. Spark was obtained at each post during rotation.
The vacuum pump was disassembled and the drive gear was found intact; there was no visible evidence of damage. The rotor/vane assembly was also intact and undamaged. Light rotational scoring was observed on both the rotor and housing.
The propeller and its respective flange were broken free of the crankshaft. One blade was twisted and bent aft with leading edge gouges and chordwise polishing/scratches; about 8 to 10 inches of the tip was broken away. The other blade was found relatively straight with some evidence of twisting and chordwise scratching.
There was no evidence of mechanical malfunction or failure with the airframe or engine that would have precluded normal operation. A detailed examination report with accompanying pictures is contained in the public docket for this accident.
FAA regulation 14 CFR 91.17, alcohol or drugs, in part, stated:
(a) No person may act or attempt to act as a crewmember of a civil airplane -- (1) Within 8 hours after the consumption of any alcoholic beverage; (2) While under the influence of alcohol; (3) While using any drug that affects the person's faculties in any way contrary to safety; or (4) While having 0.04 percent by weight or more alcohol in the blood. (b) Except in an emergency, no pilot of a civil airplane may allow a person who appears to be intoxicated or who demonstrates by manner or physical indications that the individual is under the influence of drugs (except a medical patient under proper care) to be carried in that airplane.
The National Institute on Alcohol Abuse and Alcoholism addressed alcohol dependent individuals and their automobile driving abilities in publication No. 28, April 1995. It stated that "The tolerance acquired for a specific task or in a specific environment is not readily transferable to new conditions," and that "a driver encountering a new environment or an unexpected situation could instantly lose any previously acquired tolerance to alcohol's impairing effects on driving performance."
Within the wreckage, four cellular phones were recovered, all of which sustained too much damage for any data recovery.
The pilot was not communicating with any FAA air traffic control facility during the time period encompassing the accident sequence. The airport and casinos in Mesquite had not received a call from the pilot, a common practice for arriving aircraft that need a shuttle from the airport to the casinos.
NTSB Identification: WPR12FA230
14 CFR Part 91: General Aviation
Accident occurred Saturday, May 26, 2012 in St. George, UT
Aircraft: CESSNA 172S, registration: N953SP
Injuries: 4 Fatal.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
On May 26, 2012, about 0120 mountain daylight time, a Cessna 172S, N953SP, collided with terrain shortly after departing from St. George Municipal Airport, St. George, Utah. Diamond Flying LLC was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot and three passenger sustained fatal injuries; the airplane sustained substantial damage. The local personal flight was departing from St. George with a planned destination of Mesquite, Nevada. Visual meteorological conditions prevailed, and no flight plan had been filed.
A review of the recorded security camera footage at the airport revealed that the airplane could be seen in the nighttime conditions by the blinking left-wing strobe light and the navigation light mounted on the tail. The airplane appeared to depart from runway 19 and maneuver at a low altitude for the length of the runway while increasing its airspeed. Near the end of the runway, the airplane began a rapid ascent and continued out of the view of the camera. After about 7 seconds, the airplane reappears further down the frame in a rapid descent.
The accident site was located in the hard dirt area (the southerly primary surface) adjacent to the departure end of runway 19. Situated on the level terrain, the airplane came to rest in an inverted attitude and was oriented on a 315-degree magnetic bearing. The main wreckage, which consisted of a majority of the airframe and engine, was located about 525 feet from the edge of the runway's center point.
The first identified point of impact was a ground scar impression about 40 feet from the main wreckage that dimensionally and geometrically resembled the wings with a crater-like impression in between. The span of the ground disturbance was about 36.5 feet, with red lens fragments located near the east side and green fragments on the westerly side; the airplane's wingspan was 36.1 feet. Imbedded in the center crater was a portion of a propeller blade and the nose wheel. In the debris field from the ground scar to the main wreckage was the oil sump, the propeller, and engine accessories.
A routine aviation weather report (METAR) generated by an Automated Surface Observation System (ASOS) at the airport, indicated that about 5 minutes prior to the accident the conditions were as follows: wind was from 260 degrees at 9 knots; temperature 66 degrees Fahrenheit; dew point 28 degrees Fahrenheit; and altimeter 29.60 inHg.
Zoë Keliher, an air safety investigator with the National Transportation Safety Board, explains the process behind her investigation into the crash of the single engine plane in which four people were killed early Saturday as she combs through the wreckage inside a hangar at the St. George Airport Monday, May 28, 2012.
ST. GEORGE – The Federal Aviation Administration investigation into the recent plane crash of May 26, 2012, at St. George Municipal Airport seeks public input.
FAA Inspector Lewis Olsen, out of Salt Lake City, is the investigator in charge of the FAA investigation. He said that he has confirmed that Tanner Holt flew the plane that was involved in the crash of May 26 to Phoenix, Ariz., and back to St. George the week before the crash, returning on May 20. He has not been able to identify the airport in Phoenix that Holt flew into and out of.
“I need to calculate the weight and balance,” said Olsen. In order to do so, he said he needs to determine “how much fuel could he possibly have on board.”
Olsen asked that anyone who knows the passengers that accompanied Holt to Phoenix, and those passengers themselves, contact him directly. He said the questions he will ask are: ”Who went to Phoenix? Where did you park? Did you see him get fuel? And, if so, how much?”
Olsen said that the bodies of the victims of the crash have been transported to the coroner in Salt Lake City.
“Amongst the four there is the smell of alcohol,” Olsen said. “We are doing toxicology.”
He said toxicology is being run on more than just one of them.
The FAA Investigation is a separate investigation from that being performed by the National Transportation Safety Board.
Authorities on Monday allowed the news media to photograph the wreckage of the single-engine plane that crashed near the St. George Municipal Airport Saturday, killing four Washington County men.
The photographs show the wreckage after it was relocated to the interior of a hangar at the airport.
The National Transportation Safety Board and Federal Aviation Administration are investigating the cause of the crash.