Saturday, March 11, 2017

Cessna 150F, N8185F: Fatal accident occurred September 12, 2015 in Atco, Waterford Township, Camden County, New Jersey


David S. Sees


The National Transportation Safety Board traveled to the scene of this accident. 

Additional Participating Entities
Federal Aviation Administration / Flight Standards District Office; Philadelphia, Pennsylvania
Textron Aviation; Wichita, Kansas 
Continental Motors, Inc.; Mobile, Alabama

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Docket And Docket Items - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Data Summary -  National Transportation Safety Board:  https://app.ntsb.gov/pdf
 
David S. Sees: http://registry.faa.gov/N8185F


NTSB Identification: ERA15FA352

14 CFR Part 91: General Aviation
Accident occurred Saturday, September 12, 2015 in Atco, NJ
Probable Cause Approval Date: 03/08/2017
Aircraft: CESSNA 150, registration: N8185F
Injuries: 1 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 student pilot was conducting a local flight that consisted of traffic pattern work and landings and then several orbits in the area. After completing the orbits, the student flew near a friend's house, where he executed a left, 360° turn while flying at a low altitude despite being counseled against doing so by his flight instructor and the instructor's son, who was also a pilot. The instructor reported that the student had a habit of "making low passes." The student's friend waved to him, and he waved back, and then the friend and another witness noticed the airplane's bank angle increase while the airspeed was slowing. According to GPS data, while the airplane was flying about 58 mph, which is about the stall speed with the airplane at gross weight with the flaps retracted and a bank angle of about 20°, its nose pitched down, consistent with a stall/mush. Witnesses reported hearing the engine rev-up, hesitate briefly, then respond during the uncontrolled descent, but they reported it was "too late." The airplane impacted a wooded area, and its propeller cut some trees, consistent with the engine developing power at the time of impact.

Examination of the airplane revealed that the flaps were retracted, and there was no evidence of preimpact failure or malfunction of the flight controls for roll, pitch, or yaw. It is likely that the student, while maneuvering and turning the airplane while waving, which would have increased his workload, was unable to appropriately divide and prioritize his attention and allowed the airplane to exceed its critical angle of attack near its stall speed at too low of an altitude to recover.

Although toxicological evidence indicated that the pilot had used three sedating and/or impairing substances (amitriptyline, tetrahydrocannabinol, and diphenhydramine, the last two of which were at very low levels), the investigation could not determine whether they contributed to the accident or affected the student's aeronautical decision-making.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The student pilot's improper decision to intentionally maneuver at low altitude while waving to people on the ground, which led to the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall.

HISTORY OF FLIGHT

On September 12, 2015, about 1130 eastern daylight time, a privately owned and operated Cessna 150F, N8185F, collided with trees and terrain near Atco, New Jersey. The student pilot was fatally injured, and the airplane was destroyed. The airplane was being operated as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed about the time of the accident near the accident site, and no flight plan was filed. The flight originated about 1104 from Camden County Airport (19N), Berlin, New Jersey.

According to the student pilot's flight instructor, who was also the manager of 19N, he talked briefly to the student on the morning of the accident, but the student did not indicate his intentions for the flight. Sometime later, he observed the airplane being taxied and then departing.

According to data downloaded from an onboard GPS device, after departure, the student performed a full-stop landing to runway 05, followed by two full-stop landings to runway 23. He then returned to the approach end of runway 23, departed the traffic pattern, and flew about 4 nautical miles northeast of 19N, where he flew multiple orbits near a residential area at varying altitudes, averaging about 500 ft (about 400 ft above ground level [agl]). After he flew the orbits, he proceeded east of the airport, at which point, while flying about 400 ft above a residential area, the airplane turned left 360° with the groundspeed slowing during the turn; the last recorded groundspeed value was 58 mph.

Two witnesses (one of whom was a long-time friend of the pilot), who were located immediately adjacent to the accident site, noticed the airplane when it was in a left bank flying in a northeasterly direction between 100 and 150 ft above the tops of 70-ft-tall trees (they initially reported the airplane was flying in a southeasterly direction). They waved to the pilot, and he waved back. They reported that the airplane's bank angle then became steeper, followed by the airplane's nose pitching down. They then heard the engine rev-up, hesitate, then respond, but they reported that it was "too late." They heard the impact and called 911, and then ran to the site. They stated that first responders arrived quickly. Regarding the low pass, they indicated that the pilot would typically fly over, orbit, and then depart the area. None of the witnesses saw any smoke trailing the airplane nor did they see any parts separate while in flight.

The property owner where the airplane crashed reported the only sound his wife heard was associated with the impact.

PERSONNEL INFORMATION

The student pilot, age 65, was issued third-class medical and student pilot certificates in March 2010, April 2012, and July 3, 2014; all three certificates contained a limitation to wear corrective lenses. On the application for his last certificate, he listed a total flight time of 115 hours. His last solo signoff in a Cessna 150 airplane was dated August 1, 2015.

A review of the pilot's logbook revealed two entries in 1998. The next entry was dated March 8, 2010, which was 2 days after he purchased the airplane. The pilot flew consistently in 2010, but he only flew three times in 2011 and once in December 2012. The next logged flight was on August 1, 2015, which was a 0.9-hour-long dual flight in the accident airplane, and it was the only logged flight for 2015. The pilot logged a total flight time of about 69 hours, about 67 hours of which were in the accident airplane.

Additional flight time was logged in a black notebook located in the wreckage, but some pages of the notebook were missing. The first logged flight was February 25, 2013, and ended with a tachometer time of 6,159.3 hours, and the last logged flight was September 5, 2015, and ended with a tachometer time of 6,206.0 hours. Between these dates, the pilot accrued 46.7 hours. In the last 90 and 30 days, he logged 5.4 and 2.2 hours, respectively, all of which were in the accident airplane. Based on the time provided on his medical application (115 hours) and the student pilot's subsequent logged time (15.3 hours), the student pilot's estimated total flight time was 130.3 hours, 128.3 hours of which were in the accident airplane.

The student pilot's friend reported flying with the pilot in the accident airplane. The friend reported that, during one flight, the pilot performed a low pass over the same area where the accident occurred, although he could not recall the altitude. He reported that the pilot orbited twice and then returned to 19N.

According to the student pilot's instructor, who was formerly a Federal Aviation Administration (FAA) designated pilot examiner (DPE), he conducted the pilot's last 90-day flight check on August 1, 2015. During that flight, the pilot only performed traffic pattern work. He also indicated that he knew that the pilot had a habit of "making low passes" and, being a former DPE, he had numerous talks with the pilot about the hazards of performing low passes. He indicated that his son, who is a pilot for a major US airline, also had a discussion with the pilot about his tendency to perform low passes and maneuver at low altitudes. The instructor indicated that he had not contacted an FAA flight standards district office about the low-pass issue and that he had last discussed the issue with pilot about 1 month before the accident.

AIRCRAFT INFORMATION

The airplane was manufactured in 1966 by Cessna Aircraft Company. It was powered by a 100-horsepower Continental O-200-A engine and was equipped with a fixed-pitch McCauley 1A100/MCM 6950 propeller. According to FAA records, the pilot purchased the airplane on March 6, 2010.

A review of the maintenance records revealed that the airplane's last annual inspection was performed on August 1, 2015. The recording tachometer time at that time was 6,202.3 hours, and the recording tachometer time at the time of the accident was 6,206.4 hours.

According to the stalling speed chart in the Owner's Manual, the airplane's stall speed at gross weight with flaps up and 20° of bank is 57 mph calibrated airspeed (CAS) and with the same weight and flap position but with 40° of bank, the stall speed is 63 mph CAS.

METEOROLOGICAL INFORMATION

At 1154, South Jersey Regional Airport, Mount Holly, New Jersey, which was located about 10 nautical miles north of the accident site, reported wind variable at 6 knots, visibility 10 statute miles, few clouds at 2,600 ft, scattered clouds at 3,800 ft, broken clouds at 11,000 ft, temperature 25°, dew point 19° C, and altimeter setting 29.79 inches of mercury.

FLIGHT RECORDERS

The airplane was equipped with a Garmin Aera 500 portable GPS. It was shipped to the National Transportation Safety Board (NTSB) Vehicle Recorder Division for readout. A Garmin GPS 12 faceplate was located in the wreckage, but the internals were not observed.

WRECKAGE AND IMPACT INFORMATION

The wreckage was moved from the accident site with FAA approval but without NTSB consultation on the day of the accident and taken to 19N where it was secured. The recovery involved mechanically cutting the airplane to allow it to be loaded into a trailer.

The airplane crashed in a wooded area behind and near residences at an elevation of 116 ft and damaged several trees. Damage to a tree was noted about 44 ft agl. Closer examination of the tree trunk, which was 9 inches in diameter, revealed gray colored paint transfer marks on the smooth cut surface oriented on about an 18° angle from vertical. A second tree, located about 21 ft from the base of the first tree, exhibited damage about 22 ft agl. Further examination of the tree revealed scars along its trunk to ground level and black-colored transfer marks on the smooth cut surface. The airplane's resting position was oriented on a magnetic heading of 328°.

Following removal of the wreckage from the recovery trailer, extensive structural damage either by impact or during the recovery process was noted. The engine remained attached to the engine, and the propeller remained attached to the engine.

Examination of the fragmented cockpit revealed that both seats were separated from the seat tracks, but both seats were recovered. The pilot's lapbelt was found unbuckled, and both ends remained attached to the structure, but the webbings of the dual shoulder harness, which was unbuckled, were cut. Impact damage was noted to the pilot's seat, and damage was noted to the seat pin locking hole that was sixth from the front. An aft seat stop was in place on the outboard seat track. The fuel selector was positioned to "on," and the airspeed indicator was indicating 110 knots. Examination of the pilot's control yoke revealed that the GPS mount was attached, and the left grip was fractured. The throttle was extended about 1/4 inch, and the mixture, carburetor heat, and primer controls were full in. The flap selector was in the middle position, and the ignition switch was in the right position; the key was bent right. The oil temperature was off-scale low, the oil pressure was 0, and tachometer indicated 0 rpm.

Examination of both wings revealed extensive full-span chordwise crushing to the leading edges. Both flaps and ailerons remained attached. The left wing was fractured about 5 ft inboard from the tip, and the right wing was also fractured at the juncture of the flap/aileron. Semicircular indentations were noted on the leading edges of both wings. Examination of the left wing primary fuel vent, vent drain hole, and both fuel tank outlet fittings revealed no obstructions.

Examination of the elevator and aileron flight control cables revealed continuity from the cockpit attachment point to the control surface except where they were cut during recovery. The right arm of the forward elevator bellcrank was bent and fractured, but the control cable remained attached. The left arm of the aft rudder bellcrank exhibited bending overload, and the right rudder cable exhibited tension overload near the aft bellcrank. The rudder flight control cables aft of the baggage compartment were cut. The elevator trim pushrod was pulled from the elevator's lower surface attachment point, and the elevator trim tab actuator was extended 2.0 inches as measured from the housing to the center of the rod attachment bolt, which equates to 10° tab trailing edge up (the maximum tab trailing-edge-up limit is 10°).

Examination of the flap control system revealed that the flap actuator remained attached inside the wing. No threads were noted extended at the actuator, consistent with the flaps being retracted. Both flap push/pull rods remained connected to their respective flap bellcrank and flap attachment points, and the flap control cables exhibited evidence of tension overload at each wing root.

Examination of the fuel supply and vent system revealed that the left fuel supply tube was cut at the pilot seat area and that the right fuel supply tube was fractured at the wing root. Continuity was noted from the left and right fuel supply lines at the cut and fractured locations, respectively, through the fuel selector valve to about 7 inches forward of the valve where the tube was bent and fractured. Continuity was noted from the fractured line forward of the fuel selector to the fuel strainer inlet fitting, which was fractured. The outlet fitting of the fuel strainer was fractured, and the fuel strainer bowl, which was safety-wired, was fractured at the bottom. Following removal of the bowl, corrosion and organic material was noted inside; the fuel screen was clean. No obstructions were found in the flexible fuel supply line from the fuel strainer to the carburetor. The crossover fuel vent line was noted to be bent and deformed in several places but remained connected to the right fuel tank. The flexible hose at the right tank fitting had slices on the upper surface, and the flexible hose was cut/torn at the left tank attachment point.

The empennage was structurally separated, but the vertical and horizontal stabilizers, both elevators, elevator trim tab, and rudder remained attached to their respective attachment points. Impact damage was noted to both horizontal stabilizers and to the vertical stabilizer, which was bent 90° to the right. The forward vertical stabilizer attachment points remained attached to the horizontal stabilizer, and the right aft vertical stabilizer attachment point was fractured consistent with overload. The left aft vertical stabilizer attachment pulled out of the aft spar of the horizontal stabilizer.

Examination of the engine revealed crankshaft continuity. Valve train continuity could not be confirmed during rotation of the crankshaft because the four bolts attaching the crankshaft gear to the crankshaft were sheared. During hand rotation of the propeller, crankshaft rotation was noted to the aft end of the crankshaft and connecting rod, and piston movement was noted.

Examination of the propeller revealed that the No. 1 blade was bent aft about 10° beginning about 10 inches from the hub. The outer third span of the blade exhibited "S" bending of the trailing and leading edges of the blade with curling of the blade tip. The No. 2 blade was bent aft about 45° beginning 8 inches from the hub, and the leading edge near the tip was twisted toward low pitch.

MEDICAL AND PATHOLOGICAL INFORMATION

The Gloucester County Medical Examiner's Office performed a postmortem examination of the pilot. The cause of death was reported to be "multiple injuries." The only finding of natural disease was a 3/8-inch scar in the midsection posterior wall of the left ventricle.

NMS Labs, Willow Grove, Pennsylvania, conducted forensic toxicology testing of specimens from the pilot, and no positive findings were reported. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, also performed forensic toxicology testing on specimens from the pilot. According to the FAA toxicology report, the results were negative for carbon monoxide and volatiles; testing for cyanide was not performed. Unquantified amounts of amitriptyline, diphenhydramine, nortriptyline, tetrahydrocannabinol (THC/marijuana) and tetrahydrocannabinol carboxylic acid (marijuana) were detected in the liver specimen. An unquantified amount of diphenhydramine was detected in the blood below the lower end of the therapeutic range. The blood also contained 0.126 ug/ml or ug/g amitriptyline, 0.065 ug/ml or ug/g nortriptyline, and 0.046 ug/ml tetrahydrocannabinol carboxylic acid. No THC was detected in the blood.

Amitriptyline is a tricyclic antidepressant that causes sedation, which is more pronounced when initiating the drug or increasing the dose. Commonly marketed with the name Elavil, its usual therapeutic levels are between 0.0050 and 0.2000 ug/ml. Nortriptyline is an active metabolite also available by prescription with the trade name Pamelor. These medications may also be used to treat insomnia and as adjunct medications in the treatment of chronic pain. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter with the trade names Benadryl and Unisom. Diphenhydramine carries the following Federal Drug Administration warning: "may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). Compared to other antihistamines, diphenhydramine causes marked sedation; this is the rationale for its use as a sleep aid. Altered mood and impaired cognitive and psychomotor performance may also be observed. In fact, in a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100%." Tetrahydrocannabinol carboxylic acid is the major metabolite of THC, the active component in marijuana. Both diphenhydramine and THC may have hangover effects when their levels in the blood are very low or undetectable.







































NTSB Identification: ERA15FA352 
14 CFR Part 91: General Aviation
Accident occurred Saturday, September 12, 2015 in Atco, NJ
Aircraft: CESSNA 150F, registration: N8185F
Injuries: 1 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 September 12, 2015, about 1119 eastern daylight time, a Cessna 150F, N8185F, registered to and operated by a private individual, collided with trees then terrain following in-flight loss of control near Atco, New Jersey. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight. The airplane was destroyed, and the student pilot, the sole occupant, was fatally injured. The last departure location and time were not determined.

Earlier that day, the pilot and airplane were observed at Camden County Airport (19N), Berlin, New Jersey, and also at the Ocean City Municipal Airport (26N), Ocean City, NJ, although the last departure point was not determined.

Witnesses near the accident site, who were friends with the pilot, reported observing the airplane flying over their property in a southeasterly direction between 100 and 150 feet above the tops of trees estimated to be 70 feet tall. The airplane was in a left bank, and one witness waved to the pilot who waved back using his hand. The witness reported the left bank angle then became steeper, followed by the nose pitching down. While descending, the engine was heard to rev up. The airplane contacted trees then the ground adjacent to a house.

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