Saturday, July 22, 2017

Cessna 140, N90123: Fatal accident occurred December 06, 2015 in Keytesville, Chariton County, Missouri

Andrew Joseph Beautte

Dawn Lynn Harl



The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office;  Kansas City, Missouri
Textron Aviation; Wichita, Kansas

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

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

Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf

http://registry.faa.gov/N90123


NTSB Identification: CEN16FA054 
14 CFR Part 91: General Aviation
Accident occurred Sunday, December 06, 2015 in Keytesville, MO
Probable Cause Approval Date: 07/20/2017
Aircraft: CESSNA 140, registration: N90123
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 and one passenger departed at an unknown time from an unknown location into dark night conditions that were forecast to be marginal visual flight rules to instrument flight rules conditions. A witness observed the airplane circling overhead, and stated that the appearance of the airplane's exterior lights suggested that it was flying in clouds or fog. During the airplane's third orbit, the exterior lights became brighter as it descended out of the clouds, then abruptly descended to ground contact. An examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation of the airplane.

The pilot's logbooks were not recovered, and his total flight experience could not be determined. The pilot had a history of substance abuse and dependence involving methamphetamine, including multiple arrests and convictions related to drug use. However, he was reportedly in recovery at the time of his last medical examination in 2012. Toxicological testing on the pilot was positive for methamphetamine and its metabolite, amphetamine, at levels which suggested recreational use. Symptoms of recreational methamphetamine use follow a typical pattern. In the early phase, users experience euphoria, excitation, exhilaration, hallucinations, delusions, psychosis, increased alertness, a heightened sense of well-being, and poor impulse control. All of the symptoms caused by high doses of methamphetamine are impairing, but the fact that the noninstrument-rated pilot chose to take off without a weather briefing at night and flew into low clouds before losing control indicates the pilot was deliberately attempting a flight beyond his capabilities. Consistent with his very highly elevated blood levels, this suggests his poor decision-making was influenced by the euphoria and grandiosity conferred by the early phase effects of methamphetamine. Witness observations of the airplane circling in clouds or fog then descending to ground contact suggest that the impaired pilot most likely experienced spatial disorientation and a subsequent loss of airplane control.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The non-instrument-rated pilot's decision to operate in dark night conditions with low clouds, which resulted in a loss of control due to spatial disorientation. Contributing to the accident was the pilot's use of methamphetamine, which impaired his decision-making abilities.

Andrew Joseph Beautte


HISTORY OF FLIGHT

On December 6, 2015, about 2110 central standard time, a Cessna 140 airplane, N90123, impacted terrain near Keytesville, Missouri. The pilot and passenger were fatally injured, and the airplane was substantially damaged. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight . Instrument meteorological conditions prevailed in the area, and the flight operated without a flight plan. The flight's point of origin and destination could not be determined.

A witness saw the airplane approach from the northeast and begin to make clockwise turns overhead. The diameter of the turns was estimated to be between ¼- and ½-mile wide. The lights of the airplane were visible overhead, but it appeared as though the airplane was in the clouds or fog. During the third overhead circle, the airplane's lights became brighter, as though it had flown out of the clouds, and the airplane turned south away from the witness. The airplane then abruptly descended toward terrain, and the witness heard the sound of an impact . The witness reported that the engine sounded normal before impact. He remarked that, due to the clouds, the stars were not visible; however, he could clearly see the lighted top of a 400-ft-tall tower.

The pilot was not in radio contact with any air traffic control facility.

PERSONNEL INFORMATION

The pilot's logbook was not located during the course of the investigation, and his total flight experience and time flown at night could not be determined. The pilot did not hold an instrument rating and his instrument experience and training received are also not known. .

On his application for his medical certificate, the pilot reported having no flight time. He also reported a convictions for driving under the influence on February 29, 2012, and possession of a controlled substance on May 14, 2001, February 10, 2005, and July 14, 2008. In addition, he reported last using methamphetamines on October 28, 2011.

AIRCRAFT INFORMATION

The airplane's maintenance logbooks were not recovered during the investigation and the date of the last annual inspection could not be determined. In addition, it is unknown if any recent maintenance was performed on the airplane.

METEOROLOGICAL INFORMATION

The 2115 automated weather observation at Marshall Memorial Municipal Airport (MHL), located about 30 nautical miles southwest of the accident site, included wind from 350° at 4 knots, ceiling broken at 300 ft above ground level, temperature 39°F, dew point 37°F, and an altimeter setting of 30.33 inches of mercury. These conditions were likely representative of those at the accident site at the time of the accident. An AIRMET was valid for the area of the accident site from 2100 to 0300, with forecast ceilings below 1,000 ft and visibility below 3 miles with mist and fog. There was no record of the pilot obtaining a weather briefing from an access-controlled source before the flight.

The National Weather Service (NWS) Surface Analysis Chart for 2100 depicted a low pressure system to the east of the accident site over Indiana with an occluded front extending southward and turning into a cold front across Kentucky, Tennessee, Mississippi, into Louisiana, and off the Texas Gulf coast. An extensive area of low clouds extended from the low to the west and over the accident site. The station models in northern Missouri indicated northwest winds at 10 knots or less, overcast skies, with temperatures around 40°F with temperature-dew point spreads of less 6°F.

The NWS Weather Depiction Chart for 2200 depicted an extensive area of instrument flight rules (IFR) conditions over Minnesota, Wisconsin, Michigan, Iowa, Illinois, and northern Missouri, with marginal visual flight rules (MVFR) conditions surrounding the area and extending into central and eastern Missouri and over the accident site. The closest reporting station indicated overcast clouds with a ceiling at 2,100 ft. The Low-Level Significant Weather Prognostic Chart at the time expected MVFR to IFR conditions over northern Missouri.

The North American Mesoscale (NAM) numerical model for 2100 indicated a relative humidity greater than 80% from the surface to 3,000 ft, with an expected cloud base at 50 ft above ground level. The model depicted surface conditions with wind from 320° at 5 kts, temperature 3.6°C (38.5°F), dew point 3.5°C (38.3°F), and relative humidity of 99%. The model supported fog and low stratiform clouds. The Geostationary Operational Environmental Satellite system (GOES-13) infrared image at 2115 indicated an area of low stratiform clouds and/or deep fog extended over northern Missouri and Iowa and over eastern Missouri and Illinois with cloud tops near 2,000 ft.



WRECKAGE AND IMPACT INFORMATION

The wreckage was located in an open hayfield. Impact signatures were consistent with a near-vertical impact with the terrain. All major components of the airplane were found at the accident site. Flight control continuity was established from the flight controls to their respective control surfaces. Both wings displayed accordion crushing along the entire length of their leading edges. The flaps appeared to be in the retracted position. The fuel selector was found in the right fuel tank position. Both wing fuel tanks contained fuel. The airspeed indicator read in excess of 160 mph. The altimeter Kollsman window read 30.00 inches.

The engine's upper spark plugs were removed and displayed normal wear. Engine continuity and compression were confirmed throughout the engine. One blade of the propeller was curled and displayed leading edge polishing of the blade. The other blade was missing several inches of its tip. No anomalies were detected with the airframe and engine.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was conducted on the pilot by the Boone/Callaway County Medical Examiner's Office, Springfield, Missouri, as authorized by the Chariton County Coroner. The cause of death was listed as blunt force injuries sustained in an aircraft accident, and the report stated that methamphetamine use may have contributed to the accident. In addition, thickening of the left ventricle of the heart was described in the autopsy report.

The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology on specimens from the pilot. Testing was negative for carbon monoxide and ethanol. The following drugs were detected:

Amphetamine detected in liver
0.536 (ug/ml, ug/g) amphetamine detected in blood
8.49 (ug/ml, ug/g) methamphetamine detected in liver
5.07 (ug/ml, ug/g) methamphetamine detected in blood

Methamphetamine is a Schedule II controlled substance and is used medically to treat attention-deficit/hyperactivity disorder and narcolepsy. Prescribed oral doses typically produce blood levels in the range of 0.02-0.05 ug/ml. Recreational users seeking intense euphoria snort, smoke, or inject the drug, and may often reach blood levels above 2.00 ug/ml. Methamphetamine levels reach peak blood concentration differently depending on mode of administration. Peak blood methamphetamine concentrations occur shortly after injection and a few minutes after smoking it. Peak blood concentrations of its psychoactive metabolite, amphetamine, occur around 10 hours after methamphetamine use.

ADDITIONAL INFORMATION

Spatial Disorientation
The Airplane Flying Handbook (FAA-H-8083-3A) stated, "…the VFR pilot is, in effect, in IMC anytime he or she is inadvertently, or intentionally for an indeterminate period of time, unable to navigate or establish geographical position by visual reference to landmarks on the surface. These situations must be accepted by the pilot involved as a genuine emergency, requiring appropriate action…If the natural horizon were to suddenly disappear, the untrained instrument pilot would be subject to vertigo, spatial disorientation, and inevitable control loss."

The FAA Pilot's Handbook of Aeronautical Knowledge, chapter 16, "Aeromedical Factors," stated, "Under normal flight conditions, when there is a visual reference to the horizon and ground, the sensory system in the inner ear helps to identify the pitch, roll, and yaw movements of the aircraft. When visual contact with the horizon is lost, the vestibular system becomes unreliable. Without visual references outside the aircraft, there are many situations in which normal motions and forces create convincing illusions that are difficult to overcome…Unless a pilot has many hours of training in instrument flight, flight should be avoided in reduced visibility or at night when the horizon is not visible. A pilot can reduce susceptibility to disorienting illusions through training and awareness, and learning to rely totally on flight instruments."



NTSB Identification: CEN16FA054
14 CFR Part 91: General Aviation
Accident occurred Sunday, December 06, 2015 in Keytesville, MO
Aircraft: CESSNA 140, registration: N90123
Injuries: 2 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 December 6, 2015, about 2110 central standard time, a Cessna 140G airplane, N90123, impacted terrain near Keytesville, Missouri. The private pilot and passenger were both fatally injured. The airplane was substantially damaged. The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. The flight operated without a flight plan. The flight's point of origin and destination are not known.

A witness saw the airplane approach from the northeast and begin to make clockwise turns overhead. The diameter of the turns was estimated to be between ¼ and ½ mile wide. The lights of the airplane were visible overhead but appeared as though the airplane was in the clouds or fog. On the third circle overhead the airplane's lights became brighter as though it had flown out of the clouds and the airplane turned towards the south away from the witness. The airplane then abruptly descended towards the terrain and the sound of an impact was heard. Prior to the accident, the witness reported that the engine sounded normal. He remarked that due to the clouds, the stars were not visible, however he was able to clearly see the lighted top of a 400' tall tower.

The wreckage was located in an open hay field. Impact signatures were consistent with a near vertical impact with the terrain. All major components of the airplane were found at the accident site. The airplane was examined and moved to a secure location.

The nearest aviation weather stations were 35+ nautical miles from the accident and did not reflect the weather described by the witness. A weather study will be conducted for the accident site.

At 2115, an automated weather reporting station located 37 nautical miles from the accident site reported a calm wind, visibility 7 miles, a clear sky, temperature 41° Fahrenheit (F), dew point 41° F, and a barometric pressure of 30.30 inches of mercury. At 2135, it reported wind from 300° at 4 knots, visibility 5 miles with mist, a broken ceiling at 700 feet, temperature 40° F, dew point 40° F, and a barometric pressure of 30.30 inches of mercury.

No comments: