Tuesday, August 9, 2016

Cessna 172K Skyhawk, N251JM: Fatal accident occurred December 26, 2013 in Fresno, California

Deadly Fresno plane crash may change federal policy 




FRESNO, Calif. (KFSN) -- A deadly Fresno plane crash could change national policies for pilots. Tim Farmer crashed his Cessna 172K Skyhawk in December 2013. He and his 9-year-old nephew, Finn Thompson, both died.

Farmer tried to land at Chandler Airport on a pretty clear and calm night, but on his third pass, he clipped a tree. Investigators now believe the 72-year-old had a health issue that's common as people get older, but one that gets no mention in FAA safety brochures.

As the NTSB took Tim Farmer's Cessna away from Chandler in pieces, the plane's wreckage gave away little as to why it went down the day after Christmas. But as they dug into Farmer's medical history, they found the clue they needed.

"At night, he would've had difficulty seeing the runway and making out the runway and he had demonstrated that three weeks prior," said Dr. Nicholas Webster of the NTSB.

Earlier that month, investigators say Farmer couldn't see well enough to taxi off the runway at his home airport until someone lit it up with his truck's headlights. Farmer's corrected vision was still 20/20, but his optometrist documented a four-year progression of cataracts.

"It's a clouding of the natural lens in the eye, so instead of looking through a clear glass of water, think about a glass of milk," said Dr. Richard Moors, an ophthalmologist at Eye-Q in Fresno who's also a pilot.

The condition affects more than 20-percent of Americans older than 65, and half of everyone over 75. That means about 12,000 active pilots may have cataracts making flight riskier, especially at night.

It's a big enough concern for the National Highway Traffic Safety Administration to put out a brochure about driving with cataracts. But FAA safety brochures never bring it up. Because of Farmer's crash, the NTSB now says they should because flying with a cataract is even more dangerous than driving with one.

"There's a minimum speed they have to maintain while flying and slowing down may not be an option," said Dr. Webster. "Pulling off to the side of the road may not be an option."

A representative from the FAA tells us they take these recommendations seriously and they'll have a response within the next two months. He said pilots have periodic medical exams and should be aware of any conditions that could make flying riskier, including cataracts.

Story and video:  http://abc30.com


http://registry.faa.gov/N251JM

NTSB Identification: WPR14FA078
14 CFR Part 91: General Aviation
Accident occurred Thursday, December 26, 2013 in Fresno, CA
Probable Cause Approval Date: 12/09/2015
Aircraft: CESSNA 172K, registration: N251JM
Injuries: 2 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.

The non-instrument rated pilot was on a cross-country flight in dark night, hazy, visual flight rules conditions. As the pilot approached his intended destination airport, witnesses observed the pilot attempt to land the airplane three times. During the third attempt to land, the airplane struck a 62-ft-tall tree with the left wingtip; the tree was located about 1,400 ft from the approach end of the runway. The airplane then continued to fly over the runway and entered a left turn. Subsequently, the airplane descended rapidly into the ground. Wreckage and impact signatures were consistent with a near-vertical impact with the ground. Examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures. Review of the pilot’s Federal Aviation Administration medical records revealed that the pilot had not reported any medical conditions. However, according to the pilot’s personal medical records, the pilot had elevated cholesterol, gout, high blood pressure, and chronic depression that was in remission; all were adequately controlled and the medications being used were unlikely to impair the pilot’s performance.

Although the pilot’s corrected visual acuity remained 20/20 bilaterally, he had complained to his optometrist of vision problems with halos around stars. Annual exams documented progression of bilateral cataracts and vitreous opacities in the 4 years before the accident. Cataracts can cause halos around points of light (glare) and degrade night vision. A witness, who was based at the pilot’s home airport, reported that the pilot recently had problems taxiing on a familiar lighted runway and taxiway at night. The witness reported that he had to drive his truck onto the taxiway and use the truck’s headlights to allow the pilot to find his way off the runway. Based on the pilot’s 4-year history of progressive bilateral cataracts, complaints of halos around stars at night, prior difficulty operating the airplane at night on his lighted home airport runway, and his unsuccessful attempts to land on this unfamiliar runway at night, it is likely that cataracts degraded his ability to see clearly at night and resulted in his inability to safely operate the airplane during the accident sequence.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s failure to maintain adequate clearance from trees while on approach, which subsequently led to a loss of airplane control. Also causal was the pilot’s continued operation of the airplane at night with a diagnosed medical condition that degraded his night vision. 

 









HISTORY OF FLIGHT

On December 26, 2013, about 1820 Pacific standard time, a Cessna 172K, N251JM, was destroyed when it impacted terrain while maneuvering near the Fresno Chandler Executive Airport (FCH), Fresno, California. The airplane was registered to a private individual and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. The private pilot and his passenger sustained fatal injuries. Dark night visual meteorological conditions prevailed, and no flight plan was filed for the personal flight. The cross-country flight originated from Tehachapi, California at 1643, with an intended destination of FCH.

Information provided by the Federal Aviation Administration (FAA) revealed that the pilot was receiving Visual Flight Rules (VFR) flight following with Air Traffic Control (ATC). When the flight was about 10 miles south of the airport, the pilot notified ATC that he had the airport in sight. Subsequently, ATC canceled flight following and approved the pilot to change frequencies at 1802.

Multiple witnesses located adjacent to the accident site and airport reported observing the accident airplane enter the airport traffic pattern for runway 30. A witness located on the ramp area of the airport stated that the airplane initially captured his attention when it landed hard about midway down the runway, then proceeded to takeoff. Witnesses observed the airplane continue on a northwesterly heading and maneuver for landing on runway 12, where they observed the airplane flying at a high rate of speed about 10 to 15 feet above ground level (agl). The witnesses stated that the airplane entered a climb about three-quarters of the way down the runway and continued to the southwest where a series of turns were performed. Witnesses further stated that they then observed the airplane approach runway 30. Two witnesses located about mid-field on the airport reported observing the airplane fly along the runway about 100 feet agl, and noted that the left wing navigation light appeared to be inoperative. The witnesses stated that as the airplane neared the departure end of runway 30 at an altitude of about 400 feet agl, it rolled to the left and descended in a vertical attitude below their line of sight behind a row of hangars.

Review of airport security camera recordings revealed that 3 cameras, pointed at various locations on the airport, captured the lights of an airplane maneuvering over the runway, consistent with the accident airplane. The recordings depicted the runway lights turning on at 1811:54.

The first camera, located on the air traffic control tower, includes a view of the ramp, runway, and general area to the southeast. At 1813:44, lights of an airplane enter the right side of the cameras view angle, traveling towards the approach end of runway 30. The airplane was observed making a left turn, consistent with aligning with runway 30, and descending towards the runway. The airplane exited the view of the camera at 1814:29, at an altitude that appeared to be just above the runway surface. At 1816:58, the lights of the accident airplane traveled into view of the camera from the left, in an area consistent with runway 12, at a low altitude. The airplane appeared to enter a climb and continued on runway heading before initiating a left turn, and then traveled out of view of the camera at 1818:02. Lights of the airplane reappeared in the cameras view from the left at 1818:26. The airplane appeared to be in a descent, and in a right turn to align with runway 30. The airplane then continued to descend toward the runway. Two bright flashes from the airplane were observed 1819:23. The airplane continued to fly along the runway heading, and appeared to be in a climb until it traveled out of view of the camera at 1819:36.

A second camera, located adjacent to the airport administration building, includes a view of part of the runway, taxiway, airport administration building, and general area to the north. At 1814:24, lights of an airplane enter the camera view from the right side, at a low altitude, traveling on a heading consistent with runway 30. The lights of the airplane momentarily were blocked from view of the camera as they traveled behind the airport administration building, until they reappeared a short time later. The lights of the airplane appeared to be ascending above an area consistent with the runway, entered a right turn, followed by a left turn, until it exited the left side of the camera view at 1815:24. The airplane reappeared within the left side of the cameras view at 1816:37, and subsequently appeared to be in a right descending turn, aligned with runway 12. Lights consistent with the wing tip navigation lights (right wing) and the landing light on the left wing were observed. The airplane continued to descend out of view behind the airport administration building, and reappeared shortly thereafter in a climb from behind the administration building, until it exited the cameras view at 1817:03. At 1819:32, the airplane reentered the cameras view from the right, traveling along a heading consistent with runway 30. The airplane appeared to be in a level attitude before it entered a slight climb and a left turn. The airplane traveled out of the left side of the cameras view angle at 1820:02.

A third camera, located on the airport administration building, includes a view of the airport fuel pumps, runway, taxiway, air traffic control tower, and general area to the northwest. Review of the recorded video revealed that lights of an airplane entered the camera view at 1814:44 from the right side. The airplane's lights continued along runway 30, entered a climbing right turn, followed by a left turn, and then continued to travel outside of the cameras view at 1815:46. The airplane reappeared at 1816:04 on the left side of the cameras view. It then appeared to turn right and align with runway 12 while descending. The airplane continued traveling along runway 12 in a wings level attitude until it exited the cameras view at 1816:53. At 1819:50, the lights of the accident airplane entered the view of the camera from the right, and traveled on a heading consistent with runway 30 heading before a left turn was observed. Shortly thereafter, the lights of the airplane descended rapidly toward the ground.

PERSONNEL INFORMATION

The pilot, age 72, held a private pilot certificate with an airplane single-engine land rating. A third-class airman medical certificate was issued to the pilot on May 15, 2013, with the limitations stated "must possess glasses for near vision." The pilot reported on his most recent medical certificate application that he had accumulated 1,500 total flight hours. Review of the pilot's logbook, which was located within the wreckage, and was fire damaged, revealed that as of the most recent logbook entry, dated February 1, 2013, the pilot had accumulated a total of 1,459.34 total hours of flight time, of which 25.3 hours were at night. The pilot's most recent flight review was completed on January 22, 2013.

A witness located at the pilot's home airport reported that approximately 3 weeks prior to the accident, about 1900 local time (after sunset), he heard the pilot flying within the airport traffic pattern for about 30 minutes. The witness started his vehicle, and observed the accident pilot about 20 feet above the ground, landing on runway 11 at the Tehachapi Airport. The witness observed landing light coming towards his location on runway 29 and queried the pilot using a hand held radio if he was coming to his hangar, since his normal parking area was in the opposite direction. The pilot replied "…no, I am trying to find the taxi way." The witness stated that he asked the pilot what he meant by "…trying to find the taxiway," and the pilot responded, "I can't find the exit off the runway." The witness instructed the pilot to remain in his current location. He then utilized his vehicle headlights to illuminate the taxiway, and assisted the pilot to exit off of the runway. The witness further stated that the pilot taxied off the runway, said thanks, and continued to parking. He added that at the time, the runway and taxiway lights were illuminated.

AIRCRAFT INFORMATION

The four-seat, high-wing, fixed-gear airplane, serial number (S/N) 17259188, was manufactured in 1970. It was powered by a Lycoming O-320-E2D engine, serial number L-28066-27A, rated at 150 horsepower. The airplane was also equipped with a fixed pitch propeller.

Review of the airframe and engine logbooks revealed that the most recent annual inspection was completed on January 11, 2013, at a tachometer time of 1,050.4 hours, airframe total time of 3,706.1 hours, and an engine time since major overhaul of 876.2 hours.

METEOROLOGICAL INFORMATION

A review of recorded data from the Fresno Yosemite International Airport (FAT) automated weather observation station, located 6 miles northeast of the accident site, revealed at 1953, conditions were wind from 320 degrees at 3 knots, visibility 5 miles, haze, clear sky, temperature 10 degrees Celsius, dew point 3 degrees Celsius, and an altimeter setting of 30.24 inches of mercury.

AIRPORT INFORMATION

The Fresno Chandler Executive Airport is a non-towered airport that features a single asphalt runway, 12/30, which is 3,627 feet in length and 75 feet wide. Runway 30 was equipped with a 4-light precision approach path indicator (PAPI) light system, oriented on a 3-degree glideslope and a 438-foot displaced threshold. The edges of the runway were marked by white runway lights. Two strobe lights on either side of the runway at the threshold were observed. Red lights from the threshold to the approach end of the runway surface (the entire displaced area of the threshold) were observed. Green lights were observed at the runway threshold (marking the beginning of the actual runway). The common traffic advisory frequency (CTAF) is 123.00. The runway lighting system is controlled by the CTAF frequency after airport operation hours. The reported field elevation is 279 feet mean sea level.

The NTSB IIC, with assistance of a Fresno Police Department Helicopter, flew a visual flight rules approach to runway 30, with the PAPI indicating 2 white and 2 red lights the day following the accident. Throughout the entire approach, the descent was normal and no irregularities were noted. The IIC noted that as the helicopter passed over the tree that the accident airplane struck, the helicopter's altitude was about 100 feet above the tree.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site revealed that the airplane impacted terrain about 490 feet southwest of the departure end of runway 30. The airplane came to rest upright on an approximate heading of about 328 degrees magnetic. All major structural items of the airplane were located within about 50 feet of the main wreckage, except for a portion of the outboard left fiberglass wingtip. Two trees, located immediately to the southwest of main wreckage, were about 15 feet in height, and had numerous branches separated. Three pine trees located about 10 feet north of the main wreckage, and about 50 feet in height were not damaged. Two yard lights, about 10 feet in height and located 12 feet to the west of the main wreckage, were not damaged. A fence, about 6 feet in height, located about 2 feet east of the main wreckage, was not damaged. Two sets of power lines, located about 40 and 110 feet east of the main wreckage, were not damaged. However, a small cable, similar to a telephone or cable TV cable that extended from the farthest east set of power lines to a residential house located about 67 feet west of the main wreckage, was damaged. The orientation of the cable, from the power pole to the house, extended directly over the accident site.

In a secondary location, located about 1,406 feet southeast of the approach end of runway 30, multiple paint chips, landing light cover lens fragments, and a portion of the left fiberglass wingtip was located. A tree, about 62 feet in height, exhibited numerous broken branches about 40 to 45 feet above the ground.

Examination of the main wreckage revealed that the right wing was mostly intact and exhibited fire damage throughout. The leading edge was buckled and compressed aft throughout its span to aft of the forward wing spar. The wing chord at the wing tip was reduced to about 18 inches and 4 feet outboard of the fuel cell. The wing structure and flap from the fuel tank to the wing root was consumed by fire. The remaining portion of the flap and aileron remained attached to the wing via their respective mounts. The flap was in the retracted position.

The left wing was mostly intact and exhibited fire damage throughout. The leading edge was buckled and compressed aft throughout its span to the forward wing spar. Additional fire damage was observed at the wing root and area surrounding the fuel tank. The flap and aileron remained attached to the wing via their respective mounts. The flap was in the retracted position. The left wing tip was separated.

The fuselage, about three feet forward of the horizontal stabilizer, was mostly consumed and melted by fire. The left and right horizontal stabilizer and elevator remained attached via their respective mounts. The outboard leading edge of the left horizontal stabilizer exhibited impact damage. The right outboard portion of the right horizontal stabilizer, about 20 inches from the tip, was buckled and partially bent upwards. The vertical stabilizer was intact, and the rudder remained attached. The top portion of the rudder was partially separated.

Flight control continuity was established throughout the airframe from all primary control surfaces to the cockpit controls. The elevator trim actuator position was found to be unreliable due to the cables being pulled by first responders. The flap motor was found separated, and the flap jack screw was found in a position consistent with the flaps being in the retracted position. The flap jackscrew moved freely by hand when rotated.

The engine remained partially attached to the engine mount structure, and exhibited thermal damage to the accessory housing area. The number one and number four cylinders exhibited impact damage to the bottom part of the cylinder. The vacuum pump and both magnetos remained attached via their respective mounts. The alternator and starter were separated from the engine. The propeller and crankshaft propeller flange were separated. The area of fracture exhibited 45-degree shearlips and torsional overload signatures.

The cylinder rocker box covers, magnetos, top spark plugs, and vacuum pump were removed. The crankshaft was rotated by hand utilizing a drive tool attached to the accessory pad
from which the vacuum pump was removed. Rotational continuity was established and thumb compression was obtained on all cylinders in proper firing order. All intake and exhaust rocker arms lift action was observed. No evidence of any catastrophic mechanical malfunction was observed. All cylinders were examined internally using a lighted borescope. No evidence off foreign object ingestion or detonation was observed. The intake and exhaust valves, piston faces, and cylinder combustion domes were unremarkable.

The left magneto was intact. The magneto driveshaft was rotated by hand and impulse coupling engagement was rotated. When the driveshaft was rotated, spark was produced on all four posts. The right magneto was intact and exhibited fire damage. The magneto driveshaft was rotated by hand and no spark was produced. The magneto was disassembled, and the internal areas of the magneto exhibited fire damage. The ignition harness was fire damaged.

The top spark plugs exhibited light gray coloration within the electrode area, and were free of mechanical damage. The spark plugs exhibited signatures of normal operation.

The upper portion of the carburetor remained attached to the engine. The carburetor bowl was displaced from the carburetor assembly. The throttle and mixture control cables were secure at their respective control arms. The carburetor float assembly was impact damaged. Various fuel lines were impact and fire damaged.

The vacuum pump was intact and fire damaged. The vacuum pump was removed and the drive coupler was intact and undamaged. The vanes and rotor were undamaged.

The propeller remained attached to the propeller flange. One propeller blade was bent aft about 80 degrees along a small radius bend about 12 inches outboard of the propeller hub. The outboard 4 inches of the blade tip was curled aft about 45 degrees. Leading edge polishing was observed. The opposing blade was missing the outboard two inches of the blade tip. The remaining three inches of the blade tip was bent forward about 45 degrees. The propeller blade was bent and twisted aft about 45 degrees along a large radius bend, which started about 18 inches outboard of the blade hub. The blade exhibited leading edge polishing.

MEDICAL AND PATHOLOGICAL INFORMATION

The Fresno County Coroner conducted an autopsy on the pilot on December 28, 2013. The medical examiner determined that the cause of death was "…multiple…injuries due to blunt impact." The autopsy report revealed that evaluation of the heart was limited due to the extent of injury but identified mild to moderate coronary artery disease. The left main and left anterior descending coronary artery had up to 40% narrowing, and the right coronary artery up to 20% narrowing from atherosclerosis. The autopsy did not identify heart muscle fibrosis (scarring).

The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report, carbon monoxide, cyanide, volatiles, and drugs were tested, and had positive results for unspecified levels of Bupropion in the muscle and liver.

Review of the autopsy, toxicology tests, FAA Medical Certification File, and the pilot's medical records by NTSB Medical Officer, revealed the pilot received his first medical certificate in April 2003. According to his most recent medical certification examination, dated May 15, 2013, he was 72 inches tall, and weighed 251 pounds. The pilot marked "NO" to all blocks in section 18 of the application for a medical certificate including, "Have you ever in your life been diagnosed with, had or do you presently have"… "c. Eye or vision trouble except glasses" and "d. Mental disorders of any sort, depression, anxiety, etc." The Aviation Medical Examiner (AME) issued the pilot a third-class medical certificate with the following limitation: Must have available glasses for near vision.

Review of personal medical records from March 2010 through November 2013, revealed that the pilot had a history of high cholesterol, gout, high blood pressure, and major depression in complete remission. Records from the pilot's last visit on November 23, 2013, identified his medications as simvastatin, allopurinol, lisinopril, hydrochlorothiazide, and bupropion. On that date, the records noted, "mood, memory and judgment normal."

Simvastatin is used to treat high cholesterol, and is marketed as Zocor. Allopurinol is used to treat gout, and is marketed as Zyloprim. Lisinopril and hydrochlorothiazide are used to treat high blood pressure, and are marketed as Prinivil and Esidrix (respectively). Bupropion is used to treat depression and help people quit smoking; it is marketed with the additional names Wellbutrin and Zyban.

According to additional records from the pilot's optometrist, he began annual visits to his optometrist in May 2010 because he was seeing halos around stars at night. That exam identified bilateral cataracts with trace nuclear sclerosis (yellowing and opacification of the central zone of the lens) in the left lens and 1+ nuclear sclerosis in the right lens. At that time, his corrected distance visual acuity was 20/20 in both eyes; his corrected visual acuity remained unchanged on all following examinations. The pilot's last eye exam was dated November 14, 2013 and the optometrist recorded bilateral cataracts with 1+ nuclear sclerosis, bilateral vitreous floaters, and a right vitreous opacity.

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