Saturday, April 15, 2017

Cessna 172E Skyhawk, N5423T: Chandler Municipal Airport (KCHD), Maricopa County, Arizona

http://registry.faa.gov/N5423T





CHANDLER, AZ (3TV/CBS 5) -

A fire broke out at the Chandler Municipal Airport on Saturday afternoon.

Fire crews were able to contain the fire to two hangars. 

At least one plane appeared to be charred, and the roof of one hangar showed heavy damage. There was also a big mess of foam left behind in the wake of the fire.

One firefighter suffered a minor injury to his arm and was transported to Chandler Regional Medical Center.

Chandler Municipal is one of the nation’s 50 busiest general aviation airports. It serves as a base for charter, transport, and sightseeing excursions, and is home to training institutions.

Original article can be found here: http://www.fox10tv.com

Piper PA-28-140 Cherokee, N56897: Accident occurred September 23, 2015 at Elko Regional Airport (KEKO), Nevada

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

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

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Reno, Nevada 
Piper Aircraft; Vero Beach, Florida 

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

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

http://registry.faa.gov/N56897

NTSB Identification: WPR15LA266
14 CFR Part 91: General Aviation
Accident occurred Wednesday, September 23, 2015 in Elko, NV
Probable Cause Approval Date: 05/23/2017
Aircraft: PIPER PA 28, registration: N56897
Injuries: 1 Serious, 1 Minor.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

The private pilot stated that, shortly after takeoff, the airplane would not maintain a positive rate of climb. The pilot reported that he had previously experienced this on hot days, so he continued to make small control corrections in anticipation of the airplane gaining altitude; however, once it reached about 200 ft above ground level, the airplane began to sink. The pilot then decided to retard the throttle and perform a forced landing into a field. The airplane landed hard, resulting in substantial damage.

The airplane was operating in a high density altitude environment and at the upper limit of its takeoff performance envelope at the time of the accident. Additionally, the pilot did not lean the engine’s fuel mixture control before takeoff as recommended by the engine and airframe manufacturers’ operating instructions; therefore, the engine was likely not producing full power, which resulted in the airplane’s inability to climb. Further, the engine’s spark plugs exhibited carbon fouling signatures consistent with an overly rich fuel-to-air mixture. Postaccident examination revealed no mechanical anomalies that would have precluded normal operation.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to sufficiently lean the engine’s fuel-to-air mixture for the given density altitude, which resulted in reduced engine power output and the airplane’s inability to climb.




HISTORY OF FLIGHT

On September 23, 2015, about 1328 Pacific daylight time, a Piper PA 28/140, N56897, collided with terrain shortly after takeoff from Elko Regional Airport, Elko, Nevada. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91. The private pilot sustained minor injuries, the passenger sustained serious injuries, and the airplane was substantially damaged. The cross-country flight departed Elko about 1326, with a planned destination of Nampa Municipal Airport, Nampa, Idaho. Visual meteorological conditions prevailed, and no flight plan had been filed.

The pilot stated that he and the passenger had departed from their home field of Kidwell Airport, Cal-Nev-Ari, Nevada, about 0715 that morning. He intended to start the day early, due to the hot weather conditions en route. They stopped at Perkins Field Airport, Overton, Nevada, where they serviced the airplane to capacity with fuel, and then flew north towards Ely, Nevada. Having reached Ely and passed through Ruby Ridge Pass at an altitude of 8,800 ft mean sea level (msl), the engine began to run slightly "rough"; this had never happened before. The pilot adjusted the fuel mixture towards the lean position, the engine smoothed out, and an increase of 200 rpm was observed. He reported that he typically operated the engine at full rich fuel mixture during takeoff and cruise.

Having reached Elko, the pilot serviced the airplane with the addition of 15 gallons of fuel in the left tank, and 10 gallons in the right tank. He specifically did not want to fill the tanks to capacity as they were close to their destination, and he was concerned about performance degradation in the high temperature and elevations. The passenger was in the front right seat, and there were two bags in the back seats, both less than 10 pounds in weight.

He then started the engine about 1320, and the run-up was uneventful. The engine was operating normally and he began the takeoff roll on runway 12, as the other runway (6/24) was closed for construction. He had flown in and out of Elko before, and surmised that the length of runway 12 (3,012 ft), while adequate for takeoff, left him with minimal options should an emergency occur.

The airplane accelerated normally, and shortly after rotation, the controls began to feel "mushy"; He had experienced this before in hot weather conditions. He continued the initial climb, and gently applied control inputs, and anticipated that the airplane would regain a positive climb rate like it had in the past. However, the airplane would not climb more than 200 ft above ground level (agl). Having crossed the street at the end of the runway the airplane began to descend. As the descent continued he flew over warehouses, and he decided to retard the throttle and land straight ahead in a field. Just prior to impact he pulled the yoke aft to reduce airspeed and resultant energy forces. The airplane landed hard in the field, shearing off both main landing gear, and crumpling the fuselage just aft of the cabin.

The pilot reported that at no time did the engine make any coughing or sputtering sounds, and that it kept operating normally throughout.

Witnesses who observed the airplane takeoff all recounted similar observations, as it appeared to be flying slowly after rotation, and did not gain significant altitude. One witness stated that the nose of the airplane was unusually high as it began to descend out of view behind buildings. None of the witnesses observed smoke or vapors emitting from the airplane during flight.

METEOROLOGICAL INFORMATION

At 1356, the automated surface weather facility at Elko Airport reported wind variable at 5 knots, gusting to 18 knots, 10 miles visibility, temperature at 27° C, dew point -6° C, and an altimeter setting at 30.13 inches of mercury.

AIRPORT INFORMATION

The airport was located at an elevation of 5,139.8 ft msl. The closed runway, 6/24, was 7,455 ft long.

Runway 12/30 had a limitation that takeoffs were only permitted on runway 12, and landings only on runway 30. The Federal Aviation Administration (FAA) Airport Facilities Directory reported that runway 30 slopped steeply upwards.

The density altitude at field elevation about the time of the accident was about 7,400 ft.

TESTS AND RESEARCH

The airplane was recovered, and examined by the NTSB Investigator-in-Charge, and representatives from the FAA and Piper Aircraft.

The examination revealed that the engine fuel mixture control was in the full-forward (full rich) position. The top spark plugs were removed and examined. All electrodes exhibited "normal", to "normal-worn" out wear signatures, indicative of normal service life when compared to the Champion Aviation AV-27 Check-a-Plug chart. Plugs 1, 3, and 4 exhibited dark grey discoloration and sooting, and plug 2 was coated in black soot consistent with "carbon fouled" when compared to the Champion chart.

No mechanical malfunctions or failures were observed during the examination. A full examination report is contained within the accident docket.

Airplane Performance

The airplane performance chart located in the Piper Pilot's Operating Manual, defined that at a gross weight of 1,950 pounds, with zero wind, flaps 0, on a paved level and dry runway, and a density altitude of 7,000 ft, the takeoff distance would be about 1,550 ft; with a distance to clear a 50 ft obstacle of about 3,300 ft. At the maximum gross weight of 2,150 pounds, the takeoff and clearance distances increased to 1,700 and 3,600 ft respectively. A notation on the chart stated, "EXTRAPOLATION OF CHART ABOVE 7,000 FT IS INVALID".

The "Operating Instructions/TAKEOFF" section of the operating manual was found in the airplane, and made the following recommendation,

"NOTE: Mixture full rich except a minimum amount of leaning is permitted for smooth engine operation when taking off at high elevation."

Lycoming Engines Service Instruction No. 1094D "Fuel Mixture Leaning Procedures", dated March 25, 1994, made the following recommendations,

"For 5,000 ft density altitude and above or high ambient temperatures, roughness or reduction of power may occur at full rich mixture. The mixture may be adjusted to obtain smooth engine operation. For fixed pitch propeller, lean to maximum RPM at full throttle prior to take-off where airports are 5,000 ft density altitude or higher. Limit operation at full throttle on the ground to a minimum."




NTSB Identification: WPR15LA266
14 CFR Part 91: General Aviation
Accident occurred Wednesday, September 23, 2015 in Elko, NV
Aircraft: PIPER PA 28, registration: N56897
Injuries: 1 Serious, 1 Minor.

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 may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

On September 23, 2015, about 1328 Pacific daylight time, a Piper PA 28/140, N56897, collided with terrain shortly after takeoff from Elko Regional Airport, Elko, Nevada. The airplane was registered to, and operated by, the pilot under the provisions of 14 Code of Federal Regulations Part 91. The private pilot sustained minor injuries, the passenger sustained serious injuries, and the airplane was substantially damaged. The cross-country flight departed Elko about 1326, with a planned destination of Nampa Municipal Airport, Nampa, Idaho. Visual meteorological conditions prevailed, and no flight plan had been filed.

The pilot stated that he and the passenger had departed from their home field of Kidwell Airport (1L4), about 0715 that morning. They stopped at Perkins Field (U08) for fuel, and again at Elko for fuel just prior to the accident. The pilot reported that the engine run-up was uneventful, and they departed on runway 12, because the longer runway (5/23) was closed for maintenance.

Shortly after getting airborne, the airplane did not maintain a positive rate of climb. The pilot reported that this had happened in the past on hot days, so he continued to make small control corrections in anticipation of the airplane gaining altitude. However, once it reached about 200 ft above ground level, the airplane began to sink. After crossing over an adjacent highway and a group of warehouses, the pilot decided to retard the throttle and perform a forced landing into a field.

WTIC-AM Halts Traffic Reports From Air

WTIC-AM has halted the use of its trusty and venerable traffic plane, moving to ground-based technology such as cameras that beam key information to commuters via apps and smartphone data and video.

The Farmington-based CBS news and talk radio station said in an emailed statement it discontinued airborne traffic reports April 3. It's instead using a "system of live cameras that's more accurate, more comprehensive and allows for full online and social media integration."

"Typical aviation coverage only allows us to monitor one specific area at a time, which makes it less relevant in a society of smart phones, cars and roads," the station said in the statement.

More data is available "through the use of this camera system allowing us to monitor real-time travel conditions 24/7," WTIC said.

It did not provide details on the location of cameras or what prompted the shift.

Derrick Hinds, communications manager of the Radio Television Digital News Association, said some stations "have been scaling back" traffic reports from the air over the past decade. He cited the cost of maintaining a helicopter or plane, pilots' pay, fuel and other expenses.

In large media markets, airborne traffic reports may still be common, but elsewhere, "it's gradually been dropping," he said.

Traffic apps such as Waze, Google Maps and state Department of Transportation TV monitors and pavement sensors installed by transportation officials can steer motorists along faster routes and away from potential delays caused by traffic jams or construction.

Unmanned drones that relay aerial photos also are replacing planes and helicopters piloted by humans, Hinds said. Drones are cheaper than traditional alternatives, he said. And no injuries or fatalities result from occasional crashes.

Mike Alan who started flying a red-striped Cessna Cutlass over central Connecticut in 1980, reported for years for WTIC-AM. He was joined by Mark "the Shark" Christopher, who drove WTIC's Car One. Christopher reported for WTIC-FM.

Alan listened to air traffic control at Brainard Airport, monitored traffic below, and communicated with other traffic reporters while reporting to listeners every 10 minutes, according to a 2002 profile in The Hartford Courant.

"For me, this is my office," he said of his plane at the time.

The loss of instantly recognizable on-air traffic reporters that add to a radio station's brand is one drawback of a radio station's decision to quit traffic reporting from above, Hinds said.

"They become an additional personality on the station if you can use them," he said.

Original article can be found here:   http://www.courant.com

Taylorcraft BC12-D, N43616: Accident occurred August 16, 2015 at Libby Airport (S59), Lincoln County, Montana

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

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

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


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

Additional Participating Entity:

Federal Aviation Administration Flight Standards District Office;  Salt Lake City, Utah

http://registry.faa.gov/N43616

NTSB Identification: WPR15LA246
14 CFR Part 91: General Aviation
Accident occurred Sunday, August 16, 2015 in Libby, MT
Probable Cause Approval Date: 05/23/2017
Aircraft: TAYLORCRAFT BC12 D, registration: N43616
Injuries: 2 Uninjured.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

The private pilot of the tailwheel-equipped airplane stated that, during the landing roll, the airplane began to veer to the left. The pilot used both brake and rudder inputs in an effort to return to the runway centerline; however, despite the pilot's attempts to regain directional control, the airplane continued off the left side of the runway and ground looped. Postaccident examination of the left landing gear and braking system revealed no evidence of mechanical malfunction or failure that would have precluded normal operation.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to maintain directional control during the landing roll, which resulted in a runway excursion.

On August 16, 2015, about 1915 mountain daylight time, a Taylorcraft BC-12D, N43616, experienced a brake system malfunction during the landing roll at the Libby Airport, Libby, Montana. A private individual owned the airplane and the pilot was operating it under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot and passenger were not injured; the airplane sustained substantial damage. The cross-country personal flight departed from a remote grass airstrip in Yaak, Montana about 1845 with a planned destination of Libby. Visual meteorological conditions prevailed and the pilot had not filed a visual flight rules (VFR) flight plan.

The pilot stated that after completing the approximate 20 minute flight, he configured the airplane to land on runway 33 at the Libby Airport. Upon touchdown, the airplane began to veer to the left. The pilot used both the brake and rudder inputs in an effort to return to the runway center. Despite the pilot's attempts to regain directional control, the airplane continued off the left side of the runway and ground looped. The airplane incurred substantial damage to the wing spar.

The pilot further stated that the loss of directional control was precipitated by a landing gear malfunction. He opined that the left brake likely seized after touchdown, which was evident from the skidmark on the runway surface. The brake system was the original cable-operated drum brake. The left landing gear was locked immediately after the accident, but after several hours was free to turn again. A Federal Aviation Administration (FAA) certified airframe and powerplant mechanic examined and disassembled the left landing gear. He stated the examination of the braking system revealed no evidence of mechanical malfunction or failure that would have precluded normal operation. He further stated that he could smell a burned odor from the brake, but they functioned normally.

Bakeng Duce 1976-CZ, N122BD: Accident occurred April 15, 2017 near Oliver Springs Inc. Airport (TN08), Anderson County, Tennessee



Federal Aviation Administration / Flight Standards District Office; Nashville, Tennessee

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/N122BD

NTSB Identification: GAA17CA236
14 CFR Part 91: General Aviation
Accident occurred Saturday, April 15, 2017 in Oliver Springs, TN
Probable Cause Approval Date: 06/20/2017
Aircraft: ZEILER BAKENG DUCE 1976 CZ, registration: N122BD
Injuries: 1 Minor.

NTSB investigators used data provided by various entities, including, but not limited to, the Federal Aviation Administration and/or the operator and did not travel in support of this investigation to prepare this aircraft accident report.

The pilot reported that, during approach, while flying from the rear seat of the tandem-seat, high-wing airplane, he “needed to lose speed and altitude.” He placed the airplane in a right-wing-low, forward slip, and he added that the airplane had poor forward visibility at slower speeds. He aligned the airplane with the center of the runway and “pulled the nose up slightly to slow [down],” and a “wind gust” came from the right and “pushed” the airplane over the trees. He “saw [the] tree tops coming up fast under [his] left wing,” and “out of shear instinct, [he] banked slightly right to avoid going in nose first.” The airplane collided with the tree tops.

The airplane sustained substantial damage to both wings and the empennage.

The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation.
The automated weather observation system about 3 nautical miles from the accident site, about the time of the accident, reported that the wind was variable at 3 knots. The pilot landed to the southwest.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot’s unstabilized approach and failure to go around, which resulted in impact with trees.

The pilot reported that during approach, while flying from the rear seat of the tandem seat, high-wing airplane, he "needed to lose speed and altitude". He placed the airplane in a right-wing low, forward slip, and he added that the airplane had poor forward visibility at slower speeds. He aligned the airplane with the center of the runway and "pulled the nose up slightly to slow [down]," and a "wind gust" came from the right and "pushed" the airplane over the trees. He "saw [the] tree tops coming up fast under [his] left wing", and "out of shear instinct, [he] banked slightly right to avoid going in nose first". The airplane collided with the tree tops.

The airplane sustained substantial damage to both wings and the empennage.

The pilot reported that there were no pre-accident mechanical failures or malfunctions with the airplane that would have precluded normal operation.


The automated weather observation system about 3 nautical miles from the accident site, about the time of the accident, reported the wind variable at 3 knots. The pilot landed to the southwest.
=========

MARLOW—The pilot of a small experimental or ultralight aircraft was reported to be okay after a crash in Anderson County near Oliver Springs on Saturday afternoon, authorities said.

The pilot was reported to have walked away from the crash and declined medical treatment.

Authorities said federal officials have been notified of the crash of the registered aircraft.

The precise location of the crash wasn’t clear, but Oak Ridge Today received reports that it was near Ray Drive and Oak Circle in Oliver Springs and north of Green Acres Mobile Home Park off Oliver Springs Highway, just east of Highway 62 (the road that connects Oak Ridge and Oliver Springs).

The cause of the crash isn’t clear.

Oak Ridge Today has received a report that the pilot has a small private airstrip, but we haven’t been able to independently confirm that.

Original article can be found here: http://oakridgetoday.com

ANDERSON COUNTY - Anderson County authorities responded to a small plane crash outside the city limits of Oliver Springs Saturday afternoon.

According to the Anderson County Sheriff's Department, a man flying an ultralight aircraft crashed near the Oliver Springs airport.

No deaths or injuries were reported, and the pilot was able to walk away from the crash and refused medical treatment on the scene. 

The ACSO could not say how the plane crashed. The investigation has been turned over federal authorities. 

Original article can be found here: http://www.wbir.com

Controlled Flight into Terrain (CFIT): Cessna 310H, N1099Q; fatal accident occurred September 05, 2015 in Silverton, Colorado






Aviation Accident Final Report - National Transportation Safety Board

Investigator In Charge (IIC): Gallo, Mitchell

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Salt Lake City, Utah
Textron Aviation; Wichita, Kansas
Continental Motors; Mobile, Alabama 

Investigation Docket - National Transportation Safety Board:


NTSB Identification: CEN15FA400
14 CFR Part 91: General Aviation
Accident occurred Saturday, September 05, 2015 in Silverton, CO
Probable Cause Approval Date: 04/19/2017
Aircraft: CESSNA 310H, registration: N1099Q
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.

The airplane owner, who was a noninstrument-rated private pilot and did not hold a multiengine airplane rating, was conducting a visual flight rules (VFR), personal cross-county flight in the multiengine airplane. Before the accident flight, the pilot flew the airplane to an intermediate airport to refuel. A review of air traffic control (ATC) radio transmissions between the pilot and an air traffic controller between 0911 and 0938 showed that, during the approach for landing, the pilot misidentified in every transmission the make and model airplane he was flying, referring to his airplane as a Piper Comanche instead of a Cessna 310. Further, he did not provide correct responses to the controller's instructions (for example, he reported he was set up for the left base leg instead of right base leg as instructed), and he provided inaccurate information about the airplane's position, including its distance and direction from the airport. 

A witness stated that, after the airplane landed and while it was taxiing, it almost hit another airplane and golf carts, and it was taxied close enough to the fuel pumps that it "knocked" a ladder with one of its propellers. The witness said that the pilot was not "observant about his surroundings." While at the intermediate airport, the pilot requested an abbreviated weather briefing for a VFR flight from that airport to the destination airport. However, the pilot incorrectly identified the destination airport as "L51," which was depicted on the VFR sectional chart for the Amarillo area but referred to the maximum runway length available at the destination airport not the airport itself. L51 was an airport identifier assigned to an airport in another state and located north of the accident location and in a direction consistent with the airplane's direction of travel at the time of the acident. 

During the departure for the accident flight, the pilot taxied to and attempted to take off from an active runway without any radio communications with or clearance from ATC, which resulted in a runway incursion of an air carrier flight on final approach for landing to the runway. The air carrier initiated a missed approach and landed without further incident. The controller reported that the runway incursion was due to the accident pilot's loss of "situational awareness." Radar data showed that, after the airplane departed, it turned northward and away from a course to the intended destination airport. The northward turn and track was consistent with a course to an airport in another state. According to meteorological information, as the flight progressed northward, it likely encountered instrument meteorological conditions (IMC) while flying into rain showers. The wreckage was found in rising mountainous terrain, and the accident wreckage distribution was consistent with a low-angle, high-speed impact. Given that postaccident examination of the airplane revealed no mechanical anomalies that would have precluded normal operation, it is likely that the noninstrument-rated pilot did not see the rising mountainous terrain given the IMC and flew directly into it. 

The pilot had told person(s) that he flew F-4 Phantoms, but a military identification card showed that the pilot was a retired Marine lance corporal. Although the pilot's logbook showed that he had accumulated 150 hours of multiengine airplane flight time, there was no record of the actual flights showing the accumulation of 150 multiengine airplane hours or any record that he had flown military aircraft. The logbook did not show that the pilot had received any flight training in the accident airplane. The logbooks also showed that he had flown numerous flights in the airplane with passengers without proper certification and that he had not had a recent flight review as required by Federal Aviation Regulations (FARs). The pilot's logbook showed that he had once made low-altitude (10 ft above the ground) passes over a parade in the same airplane. The airplane had not received an annual inspection for continued airworthiness as required by FARs. The pilot's noncompliance with FARs and the logbook entries indicate that he had a history of poor decision-making and piloting errors, which was reflected in his behavior and actions while landing at the intermediate airport and during the taxi and takeoff phases of the accident flight. 

Although the pilot had a number of medical problems that potentially could have interfered with his ability to safely operate the airplane, including spinal cord injuries, diabetes, and psychiatric issues, and was taking medications to treat them, these conditions and medications likely would not have interfered with his navigational skills and his ability to communicate on the radio or affected his decision-making. Although the available medical information was limited by the degree of damage to the body, there was no evidence of a medical condition or effects of a medication that contributed to this accident. Although ethanol was detected in the pilot's tissues, it likely resulted from postmortem production.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The noninstrument-rated pilot's improper judgment and his failure to maintain situational awareness, which resulted in the flight's encounter with instrument meteorological conditions and controlled flight into terrain during cruise flight.

Members of the San Juan County and La Plata County search and rescue teams at the scene of the plane crash on September 7th, 2015. The Colorado Air National Guard helicopter that airlifted them to the remote location is in the background.

HISTORY OF FLIGHT

On September 5, 2015, about 1408 mountain daylight time a Cessna 310H, N1099Q, impacted mountainous terrain near Silverton, Colorado. The private pilot, a pilot-rated passenger, and two passengers were fatally injured. The airplane was destroyed by impact forces. The airplane was registered to and operated by the pilot as a 14 Code of Federal Regulations Part 91 a personal flight. Instrument meteorological conditions (IMC) prevailed at the time of the accident, and no flight plan had been filed. The pilot was not using air traffic control (ATC) services. The flight departed from Flagstaff Pulliam Airport (FLG), Flagstaff, Arizona, about 1150 and was destined for Tradewind Airport (TDW), Amarillo, Texas.

A fuel receipt from the Big Bear City Airport (L35), Big Bear, California, showed that 20.04 gallons of fuel was purchased for the airplane on September 4, 2015.

The pilot's daughter stated that the airplane was kept at L35 during the summer and afterward at Barstow-Daggett Airport (DAG), Daggett, California. She said that her father departed from L35 on September 5, 2015, about 0615 PDT, and arrived at DAG about 0630 PDT to pick up the passengers. He was then going to fly to Amarillo, Texas, following Interstate 40, where they were going to have dinner and then return the same day. She said that her father did not call her after he refueled and departed Flagstaff and that she called for help on September 6 because she had not heard from him. She said that there was another pilot aboard and that they had a GPS. She said that her father did not know anyone in Colorado or Montana.

A part-time Unicom operator at L35 said that the pilot talked about conducting the flight about 1 week before the accident. The pilot asked "a lot of different pilots to go along as copilot" and asked him to go on the flight. The Unicom operator did not know what time the pilot departed on September 5, but "it was pretty early in the morning" when the pilot left to pick up passengers. The Unicom operator stated that the pilot purchased the airplane "not too long ago," that the airplane radios were "very old," and that the "instruments were not all that good." 

The pilot's initial contact with an air traffic control (ATC) facility on the day of the accident occurred during a visual approach to FLG. A rerecording of provided radio transmissions between the pilot and an FLG air traffic controller between 1011 and 1038 follows:

N1099Q: "Flagstaff traffic this is Piper Comanche N1099Z I'm sorry quebec we're approximately thirty miles miles west of the field anybody know what how the weather is down there you socked in there cause we are flying over the top here."

FLG tower: "Comanche 1099Q flagstaff tower we are open. The uh the ATIS is also broadcasting we're 900 broken, 1,600 broken, 2,400 overcast, visibility 10." 

N1099Q: "Oh thank you I just turned the ATIS then. I appreciate it thank you Flagstaff."

N1099Q: "Flagstaff tower 1099Q about to land we are we are approximately 10 miles west of the airport." 

FLG tower: "Comanche uh 99Q flagstaff tower the uh we're IFR at the airport 900 broken 1600 broken visibility 10."

1099Q: "We are now approximately 8,000 feet we have visibility looks like greater than 10 miles." 

FLG tower: "Comanche 99Q I concur with the visibility uh are you requesting something special."

FLG tower: "Comanche 99Q the field is now VFR the uh ceiling is well I have a scattered layer of 1,200 ceiling 1,600 report a right base for runway 21."

N1099Q: "Report right base for runway 21 will do quebec."

FLG tower: "Comanche 99Q uh verify you have information charlie."

N1099Q: "Copy that we have we got a little bit of a … here."

FLG tower: "Comanche 99Q roger the wind is 220 at 8 temperature 16 density altitude is 8,400 dew point 13 and the altimeter 30.26."

N1099Q: "30.36 thank you."

FLG tower: "altimeter 30.26 26."

N1099Q: "Flagstaff tower this is quebec were gonna report left base runway 21 I just want to confirm that quebec."

FLG tower: "Comanche 99Q are you set up for a right base or a left base you're coming from the west you said."

N1099Q: "Oh its showing left base on my uh GPS left traffic on runway 21."

FLG tower: "Comanche 99Q uh we can make whichever way you want I just need to know which direction you're coming from."

N1099: "Well we're comin we're we're coming from 270 right now." 

FLG tower: "From 270 you should be west of the…airport where was the destination you left from."

N1099Q: "Well we can report let's see the winds are from uh what."

FLG tower: "Comanche 99Q the wind is 240 at 6 just report base."

N1099Q: "Well… we're…right now…"

FLG tower: "Comanche 99Q that came in broken and unreliable."

N1099Q: "The winds are 210."

FLG tower: "Wind 210 at 8."

FLG tower: "Comanche 99Q how far from the airport are you."

N1099Q: "We're downwind 21 left we're settin up for uh base for 21 left."

FLG tower: "Okay we only have runway 21 okay I see you now you are on a left downwind runway 21 cleared to land wind 210 at 8."

FLG tower: "Comanche 99Q runway 21 cleared to land."

N1099Q: "…the end of the runway now…on the downwind we'll make base to final."

FLG tower: "Comanche 99Q runway 21 cleared to land."

N1099Q: "Cleared to land runway 21."

FLG tower: "N99Q are you going to uh wiseman aviation the FBO."

N1099Q: "Yes we want to gas up can we exit."

FLG tower: "N99Q continue on the runway turn right alpha seven self-serve fuel will be towards the base of the rotating beacon if you want the uh FBO it's a green building near the uh rotating beacon."

N1099Q: "Okay I see the rotating beacon I guess we can make a right taxi here."

FLG tower: "N99Q you make right turn alpha seven that will get you more direct."

N1099Q: "Gotcha alpha seven."

N1099Q: "Flagstaff…down and clear of runway taxi to fuel pump."

N1099Q: "Yep."

N1099Q: "Quebec gettin ready to touchdown here runway 21 here flagstaff."

A fixed-base operator (FBO) employee at FLG stated that, during the airplane's taxi to the fuel pumps, the airplane almost hit an "Eclipse jet," and he thought it was going to hit golf carts that were near the FBO building. When the airplane arrived, it taxied close enough to the self-serve fuel pumps that it "knocked" a ladder with one of its propellers. He said that the pilot was not "observant about his surroundings." The airplane had white "house letters" painted on its side similar to those on fighter or Air Force aircraft. The house letters had "pilot" followed by a name, which he could not remember seeing, and "copilot" followed by "God." The airplane "looked clean.". The employee stated that the pilot told him that he hoped there were no more clouds, there was no more weather, and that he wanted 75 gallons of fuel for the airplane. The pilot pointed east and added that it should be 2 more hours to their destination. The employee thought the destination was Amarillo but was certain that it was in Texas.

The FBO employee said he showed the pilot how to use the fuel pump. The pilot gave the fuel order and payed for the fuel with cash. A passenger helped fuel the airplane at the self-serve fuel pump; he added about 15 gallons of fuel to the left and right wing fuel tanks (auxiliary fuel tanks) and put the fuel caps back on. The wing tip fuel tanks (main fuel tanks) were topped off. 

The FBO employee stated that another passenger said that he bought a "brand new GPS" and could not get "ADAS[Automated Weather Observing System Data Acquisition System]" to work and thought he also said, "oh well we'll figure it out later."

At 1054, the pilot called Lockheed Martin Flight Services (LMFS) while at FLG and requested an abbreviated weather briefing for a visual flight rules flight from FLG to Amarillo, Texas. The pilot told the weather briefer that the Amarillo, Texas, airport identifier was "L51"; this was not the correct identifier for Tradewind Airport. The correct identifier was TDW; the L51 airport identifier was assigned to Heller Farm Airport, Winifred, Montana. Despite providing the weather briefer with the wrong airport identifier, the briefer did provide information for the flight to Amarillo. The pilot received the latest weather information in the briefing, which included Airmen's Meteorological Information for mountain obscuration, convective outlooks (the briefer mentioned that there was no convective activity yet but told the pilot to stay updated via Flight Watch), the terminal aerodrome forecast for Rick Husband Amarillo International Airport, Amarillo, Texas, the Meteorological Terminal Aviation Routine Weather Report for Tucumcari Municipal Airport, Tucumcari, New Mexico, and the winds aloft at 9,000 and 12,000 ft between the departure and destination airports. No record was found indicating that the accident pilot received or retrieved any other weather information before or during the flight.

The FBO employee at FLG stated that, after the airplane was fueled, it taxied past the FLG ATC tower without making any radio communications with ATC. The airplane taxied onto a runway while an "air shuttle" was landing, and the air shuttle (SkyWest 2992) had to abort its landing. The pilot then turned the radio on and taxied off the runway and onto a taxiway near the air carrier ramp. A FLG airport rescue and firefighting (ARFF) employee drove to the airplane to talk to the pilot. The ARFF personnel told the left front pilot seat occupant that he had to move the airplane because it was blocking an air carrier ramp entrance. The employee said that FLG ATC had a "lengthy conversation" with the pilot after he had taxied the airplane off the runway and was told to call the FLG ATC tower. The employee said that he overheard on the FLG ATC frequency the air shuttle pilot asking about the airplane, and FLG ATC responded by saying it was "a case of situational awareness."

According to an Air Traffic Mandatory Occurrence Report, SkyWest 2992, CRJ2/L, was on the instrument landing system (ILS) runway 21 approach and was cleared to land on runway 21. The accident airplane was observed northbound on taxiway A without authorization from the FLG tower. N1099Q turned right onto the connecting taxiway A2 continuing toward runway 21. At that time, the tower controller issued go-around instructions to SkyWest 2992 on about 1 1/2 mile final and coordinated missed approach instructions with Phoenix Approach. The accident airplane continued onto runway 21 and initiated the takeoff roll and then established communication with the tower. The tower controller instructed the accident pilot to cancel takeoff and exit the runway. SkyWest 2992 was vectored back to the ILS approach course and landed without further incident.

The FLG ATC tower controller stated that, during his telephone conversation with the accident pilot following the runway incursion, the pilot "kind of missed the point," "came up with excuses" for the runway incursion, and did not know there was another airplane "out there" during the runway incursion. The controller stated that, when he told the pilot that there was an airliner on final, and it was at that point that the pilot "realized the gravity of the situation." The pilot then said that he had been flying for 50 years and nothing like this happened before. The controller said it "seemed" that the pilot "really didn't register" what had happened. The controller added that he did not remember having to repeat questions that he asked the pilot. The pilot did not seem upset nor did the pilot ask questions in response to the questions asked by the controller. The controller said that, during the second takeoff attempt, the accident airplane settled onto the runway after it had lifted off and then climbed out with a left turn.

The ARFF employee stated that the accident airplane taxied from the FBO to taxiway A2, held at A2, and then taxied onto an active runway with a commercial regional airplane on short final without any radio contact to ATC. The employee said that the accident pilot transmitted that he did not have the airplane's radio turned on or "something to that effect" and stated that they were going to take off. The employee said that the radio transmissions from the accident pilot were "screwy" and "lacked organization and context, and was not current."The employee said that it seemed like the pilot had spent a lot of time around uncontrolled airports. The employee said that during the airplane's second takeoff attempt, the airplane remained low over runway 21 for a long time and that, about 1,000 ft from the departure end of the runway, the airplane pulled up, "not steep," and entered a left turn to the east and headed northeast.

The flight was not receiving ATC services and was not assigned a transponder squawk code. The airplane used a squawk code of 1200 based upon ATC recordings and the arrival/departure times to and from FLG. The radar track of an airplane with a squawk code correlating to those times was plotted to provide an overview of the flight and is shown in figure 1.

Figure 1. A radar plot of an airplane flight track consistent with the accident airplane. The plot shows a turn toward the north. 

PERSONNEL INFORMATION

Pilot/Airplane Owner Information

The pilot, age 71, held a private pilot certificate with a single-engine land airplane rating. The pilot's most recent FAA third-class airman medical certificate was issued December 17, 2013, with the limitation that he must wear corrective lenses for near and distant vision. At that time, the pilot reported a total flight time of 1,000 hours, 200 hours of which were in last 6 months. There was no military record received showing that the pilot had any flight experience in military airplanes.

The pilot's daughter stated that her father flew F-4 Phantoms. An L35 employee reported that he believed that the pilot said he flew F-4 Phantoms in the military and transitioned to helicopters and was injured in Vietnam. A Department of Defense (DOD)/Uniformed Services identification card that belonged to the pilot was recovered from the accident site. The card showed that he served in the US Marine Corps at grade "E3," which according to DOD's Enlisted Rank Insignias was a grade of Lance Corporal.

The L35 employee said the pilot told him the he was a doctor and "had an MD." He stated that he researched the things told to him by the pilot, and none of it was true. He said the pilot had "some speech issues" and that he had a "high pitched garbled voice." He said that pilot could not "keep a fluent conversation" without having an "issue with talking." He said that the pilot's aircraft radio transmissions were "very short," which "concerned" him and L35 staff. He said "there were a lot of circumstances that concerned people about his [the pilot's] flying."

A review of the pilot's FAA airman record revealed that, on July 18, 2009, the pilot failed the practical portion of the examination in his first attempt for a private pilot certificate with a single-engine land airplane rating. Upon reexamination for the certificate/rating, he was to be reexamined on the following: IX. Basic Instrument Maneuvers, V. Performance Maneuver, and VII. Navigation. At the time of the examination, the pilot reported a total time of 301 hours and a total instruction time received of 52 hours. On September 21, 2009, the pilot successfully passed his second attempt and was issued a private pilot certificate with a single-engine land rating. At the time of reexamination, the pilot reported a total time of 305 hours and a total instruction time received of 55 hours. No record was found indicating that the pilot had been issued a multiengine airplane rating or that he had flown military aircraft..

The pilot's logbook, which was recovered from the accident site by first responders, had flight entries beginning July 7, 2007, and ending August 15, 2015. The logbook showed that the pilot's total flight time in single and multiengine airplanes was 801.9 hours, 255.6 hours of which were in single-engine airplanes and 217.7 hours of which were in multiengine airplanes. The first logbook page entry of a multiengine airplane flight time was dated January 6, 2013, in a Piper PA-23-250, N54155 and it showed a total multiengine flight time of 10.5 hours. The page also showed that the pilot's a total multiengine flight time for previous flights was 150 hours; however, there were no logbook entries documenting flights in multiengine airplanes before the page indicating that he had 150 hours of multiengine flight time. The pilot's logbook showed a total flight time in night conditions of 17.0 hours, of 0.2 hour of which was in the accident airplane. The most recent flight entry in night conditions was dated December 2, 2014, in the accident airplane for 0.1 hour. 

The accident airplane's Application for Registration to the pilot was dated June 27, 2014. The Aircraft Bill of Sale shows the airplane title was transferred to the pilot on July 2, 2014, from Aerobanc of America, Inc. The first flight entry in the pilot's logbook for the airplane was dated July 3, 2014. No record was found indicating that the pilot had received training in the airplane after its purchase/registration. The pilot's logbook contained a total of 72 flight entries for the airplane with a total flight time of 35.4 hours. During this period, the logbook's remarks sections had entries that showed the pilot had flown with passengers. There was one logbook entry dated March 7, 2015, for a flight in the airplane that had the following remark: "I let [name of pilot-rated passenger] fly part way back."

A logbook entry showed that the pilot's most recent flight review, as required by Part 61.56, was dated July 17, 2013, with a departure and destination of Apple Valley Airport, Apple Valley, California. The flight was in a Piper PA-28-180 with a flight time of 1.0 hour, a ground instruction time of 1.0 hour, and the remarks, "FAR 61.56 FLT. REVIEW VFR PROCEDURES." The flight review was conducted by the same flight instructor that had provided the pilot-rated passenger's flight review. Title 14 CFR Section 61.56(c) stated that a flight review must have been accomplished within the 24 calendar months preceding the month in which a pilot acts as pilot-in-command in an aircraft for which that pilot is rated. The pilot was overdue for his flight review by about 2 months.

A logbook entry dated July 4, 2012, showed a flight from DAG to DAG in a Piper PA-28-180 that was 1.0 hours in duration. The remarks section for the flight had the following entry: "Flew over parade 10 feet off ground made six passes." A logbook entry dated July 4, 2013, showed a flight from DAG to DAG in a Piper PA-28-180 that was 2.0 hour long. The remarks section for the flight had the following entry: "Landed on Rt. 66 4 July Parade. With Mayor." A logbook entry dated November 2, 2013, showed a flight from DAG to "Rt.66," in a Piper PA-28-180 that was 0.2 hour long. The remarks section for the flight had the following entry: "Flew to the barn landed on RT. 66 for auto show." According to 14 CFR 91.119, "Minimum safe altitudes," a pilot should not operate an aircraft at an altitude of 500 feet above the surface, except over open water or sparsely populated areas. In those cases, the aircraft may not be operated closer than 500 feet to any person, vessel, vehicle, or structure. 

A logbook entry dated June 14, 2014, showed a flight in a Piper PA-28-180 that was 2.0-hour long and included five landings from "DAG" to "Big Bear" with the remarks: "Young Eagles." Regarding this entry, the L35 employee reported that nothing at the time made him question the pilot's flying ability. He said the pilot wanted to fly in the Young Eagles program and that they have a large Young Eagles program at L35. He said that they had asked the pilot to produce the required paperwork for the Young Eagles program, but the pilot never produced the paperwork, so the program representative decided about 8 to 10 months before the accident to not allow the pilot to fly in the Young Eagles program.

A logbook entry dated August 15, 2015, showed a 0.3-hour-long flight in the accident airplane "L35" to "L35." The remarks section for the flight stated: "Big Bear airshow. made it. speed passes over runway." Regarding this entry, the L35 employee stated that there was "some issue" with the pilot during the Big Bear Airport air show. When the airport opened for departures, the pilot departed with passengers. Upon the pilot's return to the airport, he turned the airplane onto the final leg of the airport traffic pattern and did not have the airplane radio on. The shows's air boss cleared another airplane to depart from the active runway while the accident pilot was flying his airplane on short final. He stated that, instead of the pilot offsetting the airplane to the side of the runway during the go-around, the pilot performed a "low-level left turn over the crowd" with the landing gear and flaps extended. 

The pilot had no previous FAA record of accident(s), incidents(s), or enforcement(s) actions.A search of publically available information of airman certificate information from on the FAA's website, FAA.govGOV, using only the pilot/airplane owner's first and last name, revealed that the pilot/airplane owner only held a private pilot certificate with a single-engine land rating.

Pilot-Rated Passenger Information

The pilot-rated passenger, age 67, held a private pilot certificate with a single-engine land airplane rating. His most recent FAA third-class airman medical certificate was issued May 28, 2015, with the limitation that he must wear corrective lenses. At that time, he reported 1,000 hours of flight experience.

On March 25, 2003, the pilot-rated passenger successfully passed, on his first attempt, an examination for a private pilot certificate with a single-engine land airplane rating. At the time of examination the pilot-rated passenger reported a total time of 168 hours, and a total instruction time received of 90 hours.

The pilot-rated passenger's logbook, which was recovered from the accident site by first responders, had flight entries beginning February 26, 2009, and ending August 31, 2015. The logbook showed that his total flight time in all aircraft was 785.5 hours, all of which was in single-engine airplanes.

A logbook entry showed that the pilot-rated passenger's most recent flight review as required by Part 61.56 was dated June 11, 2015. The flight review was conducted by the same flight instructor who had provided the pilot's flight review.

The pilot-rated passenger's logbook showed a total flight time in night conditions of 17.0 hours. The most recent flight entry in night conditions was dated January 5, 2011. 

The pilot-rated passenger had no previous FAA record of accident(s), incident(s), or enforcement action(s).

AIRCRAFT INFORMATION

The accident airplane was a 1963 twin-engine Cessna 310H, serial number 310H-0099, airplane. It was powered by a Continental IO-470-VOCD, serial number 455693, engine and a Continental IO-470-D, serial number 79334, engine. The airplane was equipped with two 51-gallon capacity main fuel tanks and two 15.5-gallon capacity auxiliary fuel tanks. 

According to FAA airworthiness records, the most recent airworthiness certificate for the airplane was a Special Airworthiness Certificate dated April 11, 2006. The Special Airworthiness Certificate was a Special Flight Permit for the purpose of "Out of Annual Inspection – Maintenance." The airplane did not have a current airworthiness certificate at the time of the accident. A standard airworthiness certificate remains valid as long as the aircraft meets its approved type design, is in a condition for safe operation and maintenance, and preventative maintenance and alterations are performed in accordance with Parts 21, 43, and 91.

The pilot's daughter provided copies of the aircraft logbooks . These copies showed that the airplane's last annual inspection was dated May 1, 2014, at a Hobbs time of 1,541.3 hours and a total time in service of 5,367.3 hours.

Logbook entries annotated the left engine as serial number 455693 and the right engine as serial number 79334 and noted that the most recent annual inspections of the left and right engines were dated May 1, 2014. At the time of the inspections, the left engine had a time since major overhaul of 1,241.6 hours; the Hobbs time was not annotated. The right engine had a time since major overhaul of 858.4 hours and a Hobbs time of 1,541.3 hours.

Title 14 CFR 43.7 states that every airplane is required to undergo an annual inspection: "no person may operate an aircraft unless, within the preceding 12 calendar months, it has had an annual inspection and has been approved for return to service by a person authorized by Part 43.7."

METEOROLOGICAL INFORMATION

Astronomical Data

The astronomical data obtained from the United States Naval Observatory for the accident site on the day of the accident indicated that civil twilight began 0618, sunrise was 0645, sun transit was 1310, sunset was 1935, and civil twilight ended 2001.

Weather Information

Telluride Regional Airport (TEX), located 12 miles north-northwest of the accident site at an elevation of 9,070 ft mean sea level (msl) was the closest official weather station to the accident site. TEX had an Automated Weather Observing System, and its reports were not supplemented. 

At 1415, TEX reported wind from 190 degrees at 5 knots, 10 miles visibility, present weather thunderstorms in the vicinity, sky condition scattered clouds at 4,700 ft above ground level (agl), broken ceiling at 6,000 ft agl, broken skies at 7,000 ft agl, temperature of 17° C, dew point temperature of 7° C, and an altimeter setting of 30.34 inches of mercury. Remarks: automated station with a precipitation discriminator, lightning distant northwest, temperature 17.4° C, dew point temperature 6.6° C.

Closer to the accident site, observations from the nonofficial surface stations within 12 miles of the accident site reported gusting wind between 8 and 39 mph. The strongest wind was at the nonofficial surface stations closest to the accident site altitude and near the tops of the mountains between 10,000 and 12,000 ft. In addition, these stations reported rain showers in the vicinity and had relative humidity values greater than 80 percent around the accident time. These stations were above 10,000 ft, and the high relative humidity values were consistent with cloud cover at or above 10,000 ft and mountain obscuration due to clouds, precipitation, and mist. Figure 2 shows the three-dimensional Grand Junction, Colorado, weather surveillance radar-88 Doppler base reflectivity from the scan initiated at 1406 and the ATC Flight Track. 

Figure 2. Three-dimensional Grand Junction, Colorado, weather surveillance radar-88 Doppler base reflectivity from the scan initiated at 1406 and the ATC Flight Track. Blue and green colored areas depict reflectivity of greater than 10 decibels (dBZ) and greater than 20 dBZ, respectively.

AIRPORT INFORMATION

TDW was located about 482.7 nautical miles on a true course of 087° from FLG. The VFR sectional chart for the Amarillo area, shown in figure 3, depicted an airport identifier of TDW, not L51 as stated by the pilot, next to the airport name. L51 is shown once, but it referred to the maximum runway length available at TDW, which was 5,100 ft.

Figure 3. The VFR sectional chart depicting the airport identifier for Tradewind as TDW with L 51 as the maximum runway length for the airport.

As noted previously, L51 was the designator for Heller Farm Airport, Winifred, Montana, which was located about 586 nautical miles on a heading 354° from the accident site. 

WRECKAGE AND IMPACT INFORMATION

The accident site was located at latitude 37.76° north, longitude 107.84° west at an elevation of 11,500 ft. The wreckage path was estimated to be about 1,050 ft long along an estimated northerly direction in up-sloping mountainous terrain. See figures 4 and 5 for photographs of the wreckage.

Figure 4. Aerial view taken the day after the accident by first responders showing a white-colored object, which was a portion of the aircraft fuselage, resting on the face of up-sloping terrain. The photo also shows the cloud height at the time first responders arrived on-scene. The view of the western ridgeline averaged about 12,000 ft msl.

Figure 5. A photograph of the main wreckage, which was destroyed by impact forces with no evidence of soot or fire. The airplane wings, horizontal and vertical stabilizers, engines, and propellers were located at accident site.

Wreckage Examination

The largest piece of recovered wreckage was the tail section, which had the horizontal and vertical stabilizers attached. There was no evidence of soot or fire on the pieces of wreckage. Both engines were separated from the airframe. The propellers from both engines were separated from their hubs and displayed chordwise gouging/scratching and S-shaped bending/twisting. Accident impact damage to the airframe, accessories, and both engines precluded functional operational testing of these components/systems. 

The instrument panel was destroyed by impact forces, and none of the instruments were attached. The electrical, lighting, and ignition switches were destroyed.

The altimeter face was separated from its case, and the altimeter altitude indicator needles were not intact. The altimeter setting window of the face was intact and indicated a setting of 30.40 inches of mercury. 

The attitude indicator unit was separated from the instrument panel and crushed. The attitude indicator display was internally separated and loose within the unit and did not yield an attitude. The gyro within the attitude indicator was removed, and it showed circumferential scoring on the gyro and the gyro's housing.

The horizontal situation indicator heading select bug and compass both displayed about a 360° heading.

An oxygen bottle, consistent with a pilot oxygen system, was recovered, and its airworthiness/servicing was unknown due to the impact damage. A handheld GPS was not found/recovered from the accident site. The Hobbs meter and tachometers were destroyed.

The airplane's two fuel selector valve assemblies were separated from the airframe. One valve had its fuel selector control separated due to impact forces and was positioned to "off." The second valve was positioned to "main." 

Examination of the flight control system revealed that the flight control cables were attached to the control horns/bell cranks. Separated sections of the flight control cables exhibited broom straw features. 

Examination of both engines revealed no preimpact anomalies that would have precluded normal operation. 

MEDICAL AND PATHOLOGICAL INFORMATION 

The NTSB's Chief Medical Officer reviewed the pilot's and pilot-rated passenger's FAA medical case reviews, toxicology results, autopsy reports, the investigator's reports, and the audio tapes of the ATC conversations in Flagstaff. The pilot/airplane owner's personal medical records were obtained and reviewed. 

Pilot/Airplane Owner

The pilot's last aviation medical examination was dated December 17, 2013. According to the records, he was 70 inches tall, weighed 165 pounds, and had reported no chronic medical conditions and no medications to the FAA. He had reported a number of previous surgical procedures and a disability related to a military gunshot wound but the aviation medical examiner noted "no residual." 

Rocky Mountain Forensic Services, PLLC, performed an autopsy of the pilot. The autopsy report noted the cause of death was "multiple injuries" and the manner of death was "accident." Examination of the body for natural disease was limited by the severity of the pilot's injuries; no organs were available for evaluation. 

The FAA's Bioaeronautical Research Laboratory performed toxicology testing on the only available specimen, which was muscle, from the pilot. The testing identified ethanol at 0.015 gm/dl as well as citalopram and its metabolite N-desmethylcitalopram. Federal Aviation Regulations, Section 91.17 (a), prohibits any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dl or more ethanol in the blood. Detected ethanol may be to the result of ingestion or microbial activity in the body after death.

Citalopram is an antidepressant that carries a warning: "May impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." However, it has not been shown to degrade performance in psychological testing experiments using healthy volunteers.

According to records obtained from the pilot's Veteran's Administration Hospital, in January 2013, he was documented as having multiple chronic medical conditions including spinal stenosis, hypothyroidism, depressive disorder, posttraumatic stress disorder, panic disorder, gastroesophageal reflux disease, esophageal stricture, chronic neck pain, paraplegia, peptic ulcer disease, type 2 diabetes, and emphysema. In a single note from an outside physician, the pilot's paraplegia was documented as relating to a motor vehicle accident in 1996.

The Veterans Administration records show that, in January 2015, the pilot was hospitalized for being unable to swallow. Eventually, he had a gastrostomy tube placed for feeding. He was admitted for a rotator cuff repair in March, 2015, and remained in the hospital for rehabilitation until May 2015. During that time, the feeding tube was removed. His active medications as of July 2015 included albuterol, formoterol, citalopram, hydromorphone (4mg tab every 4 active hours), aspart insulin (short acting), glargine insulin (long acting), levothyroxine, lidocaine patch, prazosin, and zolpidem.

Albuterol and formoterol are beta-agonists available as inhaled medication for the short-term treatment of wheezing and the longer term prevention of wheezing, respectively. Hydromorphone is an opioid analgesic Schedule II controlled substance available by prescription that is commonly marketed with the name Dilaudid and carries a warning about central nervous system depression so severe it may cause respiratory failure.

The pilot was on two forms of injected insulin: aspart, which is short acting, and glargine, which is long acting. Their common names are Novolog and Lantus, respectively. Levothyroxine is a replacement thyroid hormone typically used to treat hypothyroidism; it is commonly marketed with the name Synthroid. Lidocaine is a local anesthetic available in patch format to treat localized pain. Prazosin is a blood pressure medication commonly marketed with the name Minipress. Zolpidem is a short-acting sleep aid commonly marketed with the name Ambien and carries a warning about sedation and changes in judgment or behavior.

Finally, in a visit from September 1, 2015, the pilot was described as having a T12 spinal cord injury, "in a wheelchair but able to transfer."

Pilot-Rated Passenger

The pilot-rated passsenger's last aviation medical exam was dated May 28, 2015. At that time, he was 67 inches tall and weighed 255 pounds. He had previously reported high blood pressure to the FAA and reported using atenolol and naproxen as medications. 

Rocky Mountain Forensic Services, PLLC, performed an autopsy Rocky Mountain Forensic Services, PLLC. The autopsy reported the cause of death was "multiple injuries" and the manner of death was "accident." Examination of the body for natural disease was limited by the severity of the pilot's injuries; no organs were available for evaluation. 

The FAA's Bioaeronautical Research Laboratory performed toxicology testing on the only available specimen from the pilot-rated passenger, which was muscle. The testing identified ethanol at 0.043 gm/dl, as well as atenolol, diphenhydramine, and D-methamphetamine.

Atenolol is a medication used to treat high blood pressure and prevent recurrent heart attacks. It is commonly marketed with the name Tenorman. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid. It is available over the counter under 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; it is also classed as a CNS depressant and 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%."

Methamphetamine is a Schedule II controlled substance and is available in low doses by prescription to treat attention deficit hyperactivity disorder, attention deficit disorder, obesity, and narcolepsy. It is also commonly available as a street drug. Even in prescription form, methamphetamine can cause a host of physiological and psychoactive effects.