Friday, March 16, 2018

Cessna 177 Cardinal, N2810X: Fatal accident occurred January 31, 2017 in Price, Rusk County, Texas

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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Dallas, Texas
Textron Aviation; Wichita, Kansas
Eagle Sky Patrol; Deadwood, South Dakota

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

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

http://registry.faa.gov/N2810X


 Cody Stewart


Location:Price, TX 
Accident Number: CEN17FA095
Date & Time: 01/31/2017, 1540 CST
Registration: N2810X
Aircraft: CESSNA 177
Aircraft Damage: Destroyed
Defining Event: Low altitude operation/event
Injuries: 1 Fatal
Flight Conducted Under:  Part 91: General Aviation - Aerial Observation 

Analysis 

The commercial pilot was conducting an aerial observation flight of pipelines in visual meteorological conditions. According to the operator, the pilot was transitioning the airplane to the east between two pipelines, which were about 112 miles apart. During the flight the airplane's left wing contacted the top guy-wire of a 449-ft tall communications tower. The airplane impacted terrain and a post-impact fire consumed the airplane.

Although the wreckage was significantly fragmented and damaged by fire, examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operations. Separated sections of the left wing were found between the communications tower and main wreckage. Portions of the wing exhibited wire strike markings consistent with the diameter of the tower guy-wire, and white paint marks consistent with the left wing's paint color were found on the top guy-wire about 430 ft above ground level (agl). GPS data indicated that, for the last 10 minutes of flight, the airplane's altitude varied between 219 and 552 ft agl. The last data point showed the airplane at 403 ft. GPS data and wreckage and impact information are consistent with the pilot failing to maintain clearance from the communications tower guy-wire while flying a long-distance transition flight at low altitude.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain clearance from a communications tower guy-wire. Contributing to the accident was the pilot's decision to conduct a long distance transition flight at a low altitude. 

Findings

Aircraft
Altitude - Not attained/maintained (Cause)

Personnel issues
Identification/recognition - Pilot (Cause)
Decision making/judgment - Pilot (Factor)

Environmental issues
Tower/antenna (incl guy wires) - Effect on operation (Cause)

Factual Information

History of Flight

Maneuvering-low-alt flying
Low altitude operation/event (Defining event)

Collision with terr/obj (non-CFIT)

On January 31, 2017, at 1540 central standard time, a Cessna 177 single-engine airplane, N2810X, impacted wooded terrain after striking a communications tower guy-wire near Price, Texas. The commercial pilot sustained fatal injuries, and the airplane was destroyed. The airplane was registered to and operated by Eagle Sky Patrol, Deadwood, South Dakota, as a Title 14 Code of Federal Regulations (CFR) Part 91 aerial observation flight. Visual meteorological conditions prevailed near the accident site at the time of the accident and a flight plan was not filed. The flight departed from Athens Municipal Airport (F44), Athens, Texas, at 1509.

According to the operator, the pilot departed from Houston Southwest Airport, Houston, Texas, on the morning of the accident to perform aerial observation of pipelines. After performing a portion of the planned aerial observation flight, the pilot refueled the airplane at F44. After departure and while transitioning to the east between two pipelines, which were about 112 miles apart, the airplane's left wing contacted the top guy-wire of a 449-ft tall communications tower. The airplane impacted terrain and a post-impact fire consumed most of the airplane. GPS data showed that, for the last 10 minutes of flight, the airplane's altitude varied between 219 and 552 ft above ground level (agl). The last data point showed the airplane at 403 ft agl.

A witness, who was located at his residence adjacent to the accident site, reported he heard an airplane engine "rev up", an initial explosion, and a secondary explosion. Two additional witnesses reported observing the airplane "tumbling end over end" and crashing in a wooded area. 

 Cody Stewart

Pilot Information

Certificate: Commercial
Age: 24, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification:  Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 01/18/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 1700 hours (Total, all aircraft), 1000 hours (Total, this make and model) 

According to the operator, the pilot was hired in July 2016, and had flown about 200 hours per month since that time. Per the pilot's resume submitted at the time of his hire, the pilot had 715.5 total flight hours, 629.8 hours of which were as pilot-in-command. 

Aircraft and Owner/Operator Information

Aircraft Manufacturer: CESSNA
Registration: N2810X
Model/Series: 177
Aircraft Category: Airplane
Year of Manufacture: 1967
Amateur Built: No
Airworthiness Certificate: Normal; Utility
Serial Number: 17700210
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 06/06/2016, Annual
Certified Max Gross Wt.: 2350 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:  5941.02 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C91  installed, not activated
Engine Model/Series: O-320-E2D
Registered Owner: EAGLE SKY PATROL INC
Rated Power: 160 hp
Operator: EAGLE SKY PATROL INC
Operating Certificate(s) Held: None 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: RFI, 442 ft msl
Observation Time: 1555 CST
Distance from Accident Site: 6 Nautical Miles
Direction from Accident Site: 80°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 24°C / 1°C
Lowest Ceiling: None
Visibility: 10 Miles
Wind Speed/Gusts, Direction: 11 knots/ 15 knots, 190°
Visibility (RVR):
Altimeter Setting: 29.98 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Precipitation
Departure Point: Athens, TX (F44)
Type of Flight Plan Filed: None
Destination: Frierson, LA
Type of Clearance: None
Departure Time: 1509 CST
Type of Airspace:  Class G 



Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 1 Fatal
Latitude, Longitude:  32.130833, -94.954167 (est) 

Separated sections of the left wing were located between the communications tower and the main wreckage. Portions of the left wing, near wing station 110.00, exhibited wire strike markings consistent with the diameter of the tower guy-wire. A tower employee who responded after the accident to check the condition of the tower, observed white paint marks which were consistent with the left wing's paint color on the top guy-wire about 430 ft. agl. The main wreckage came to rest about 820 ft east of the tower in wooded terrain, and consisted of the right wing, a portion of the left wing, fuselage, empennage, and engine.

A majority of the main wreckage was consumed by a post-impact fire. The propeller had separated from the engine crankshaft and came to rest adjacent to the main wreckage. One propeller blade exhibited twisting at the blade tip, and one propeller blade exhibited S-shape bending. A tree trunk, adjacent to the main wreckage, exhibited a 6-inch-wide cut consistent with contact from a propeller blade. The engine crankshaft flange was rotated by hand, and mechanical continuity was established throughout the engine and accessories. Thumb compression was noted on the Nos. 1 and 3 cylinders. The oil sump screen was absent of debris.

Flight control continuity was confirmed from the cockpit controls to the elevator, rudder, right flap, and the left flap actuator. The left flap was disconnected from the flap actuator during the accident sequence. The aileron cables were attached to the aileron bell cranks in the wing. The left aileron cables exhibited broomstrawing features in the wing area that contacted the guy-wire. The flaps were in the retracted position based on the actuator measurement.

The firewall fuel strainer was partially consumed by fire, and the filter was absent of debris. The fuel selector handle displayed thermal damage, but remained attached to the fuel selector valve, which was in the "both" position.

Due to the post-impact fire, no paperwork recognizable as visual flight rules (VFR) sectional maps, was found within the wreckage area. 

Medical And Pathological Information

The Forensic Medical Management Services, Tyler, Texas, performed an autopsy on the pilot. The listed cause of death was "blunt impact injuries as a result of an accident."

The Federal Aviation Administration's (FAA) Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on the pilot. The tests were negative in cavity blood for all screened drugs, carbon monoxide, and alcohol. 

Additional Information

The operator's representative, who responded to the accident site, stated that the company's minimum altitude was 500 ft agl during transitional flight between pipelines. The National Transportation Safety Board (NTSB) investigator-in-charge (IIC) requested copy of the operator's procedures manual; however, the company did not provide a copy for review.

According to the Federal Communications Commission (FCC) Antenna Structure Registration, the communications tower that was struck was referenced as FCC Registration Number 1297752 and was constructed on January 4, 2016. Another tower, FCC Registration Number 1047526, which was located about 0.48 miles south-southwest of the accident tower, was dismantled on August 10, 2016.

The Memphis VFR sectional chart, effective from September 15, 2016, to March 30, 2017, depicted the FCC 1047526 tower obstruction and noted that the elevation of the tower's top was 873 ft mean sea level and 460 ft agl, but it did not depict the FCC 1297752 tower. The Memphis VFR sectional chart effective from March 30, 2017, to September 14, 2017, depicted tower information according to obstacle data available as of February 2, 2017, which included the FCC 1047526 and 1297752 towers.

The NTSB IIC and an NTSB air traffic control specialist asked the FAA about the Memphis VFR sectional chart and the procedures for updating sectional charts for new obstructions. The FAA responded, in part, that it received data from a large variety of sources. The data changes are then analyzed and processed until the information cutoff date, which is 56 days before the sectional chart effective date. The depiction of the tower information near the accident site on the Memphis VFR sectional chart effective from September 15, 2016, to March 30, 2017, was correct according to data that were provided at that time to the FAA for publication. The FAA was notified in November 2016 of a new tower (FCC 1297752) located about 1/2 mile north of the original tower depicted on the chart. However, at that time, the FAA had not yet received confirmation of the dismantlement of the FCC 1047526 tower.

The FAA added that the FAA's Obstruction and Evaluation Group (OEG) obtained notification of tower construction and dismantling from tower owners or sponsors, and the information was passed to the FAA's Charting Office (AJV-5). Per 14 CFR Part 77 section 11, Supplemental Notice Requirements, tower owners must file a supplemental notice with the FAA when the construction or alteration is higher than 200 ft agl at its site, within a time limit specified by the FAA, or if no time limit is specified, the notice of construction must be submitted within 5 days after the structure reaches its greatest height. AJV-5 received updates from many sources, not just OEG, for making changes to sectional charts. AJV-5 had a quality control process in place to ensure the accuracy of the changes to the charts, and because of that, there was a time delay.

For the FCC 1297752 tower involved in this accident, the FAA stated,


"The owner of this new tower notified the OEG via the supplemental form about the construction on November 2, 2016. This date is long past the construction date of January [2016] and well past the July 21 [2016] cutoff date for the September [2016] chart. The information on the supplemental form submitted in November was not completely correct so another supplemental form was submitted in February 2017 to correct the wrong information. OEG was aware of the tower because of [a] study back in October 2015, and the sponsor is to notify the OEG within 5 days of construction and that did not happen in this case. Once the OEG has the information for constructing or dismantling a tower, then that information is passed onto AVJ-5."



NTSB Identification: CEN17FA095
14 CFR Part 91: General Aviation
Accident occurred Tuesday, January 31, 2017 in Price, TX
Aircraft: CESSNA 177, registration: N2810X
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 January 31, 2017, at 1540 central standard time, a Cessna 177 single-engine airplane, N2810X, impacted wooded terrain after striking a cellular tower guy-wire near Price, Texas. The commercial pilot, who was the sole occupant, sustained fatal injuries, and the airplane was destroyed. The airplane was registered to and operated by Eagle Sky Patrol, Deadwood, South Dakota, as a 14 Code of Federal Regulations Part 91 aerial observation flight. Visual meteorological conditions prevailed at the time of the accident and a flight plan was not filed. The flight departed an unknown location at an unknown time.

According to the operator, the pilot departed from a Houston, Texas, area airport about "sunrise" on the morning of the accident to perform aerial observation of pipelines. After performing a portion of the planned aerial observation flight and prior to the accident, the pilot refueled the airplane at an unknown location. While transiting between two pipelines, which were about 112 miles apart, the airplane's left wing contacted the top guy-wire of a 445-foot tall cellular tower. The airplane impacted terrain and a post-impact fire consumed the airplane. 

A witness, who was located at his residence adjacent to the accident site, reported he heard an airplane engine "rev up", an initial explosion, and a secondary explosion. Two additional witnesses reported observing the airplane "tumbling end over end" and crashing in a wooded area.

Separated sections of the left wing were located between the cellular tower and the main wreckage. Portions of the left wing showed wire strike markings consistent with the diameter of the cellular tower guy-wire. A cellular tower employee who responded to check the condition of the tower, observed white paint marks on the top guy-wire, which were consistent with the paint color of the left wing. The main wreckage came to rest about 820 feet east of the cellular tower in wooded terrain, and consisted of the right wing, a portion of the left wing, fuselage, empennage, and engine. A majority of the main wreckage was consumed by a post-impact fire. The propeller separated from the engine crankshaft and came to rest adjacent to the main wreckage. One propeller blade exhibited twisting at the blade tip, and one propeller blade exhibited S-shape bending.

At 1555, the Rusk County Airport (RFI), Henderson, Texas, automated weather observing system, located about 5.5 miles east of the accident site, reported the wind from 190 degrees at 11 knots, gusting to 15 knots, visibility 10 miles, sky clear, temperature 24 degrees Celsius, dew point 1 degree Celsius, and an altimeter setting of 29.98 inches of mercury. 

The U.S. Naval Observatory reported the sunrise on the morning of the accident in Houston was at 0712.

7 comments:

  1. My understanding is any tower below 200 ft doesn't even need to be reported to the FAA. This one seems to have been properly reported is eerily similar to this crash:

    https://www.flyingmag.com/news/ag-plane-crash-leads-67-million-wrongful-death-verdict

    Sadly the lessons from that crash seems to have been repeated here. Hopefully there will be tangible legal consequences that will make any tower sponsor think twice about doing it so hastily commercial pilots with all the possible information obtained in due diligence will still not know about it.

    ReplyDelete
  2. Seems similar to:

    https://www.flyingmag.com/news/ag-plane-crash-leads-67-million-wrongful-death-verdict

    ReplyDelete
  3. It's easy to see how this kind of job will be easily replaced by airborne and ground roving drones. Ultimately it was too low, too slow, and nowhere to go.

    "After departure and while transitioning to the east between two pipelines, which were about 112 miles apart, the airplane's left wing contacted the top guy-wire of a 449-ft tall communications tower."

    "The operator's representative, who responded to the accident site, stated that the company's minimum altitude was 500 ft agl during transitional flight between pipelines. The National Transportation Safety Board (NTSB) investigator-in-charge (IIC) requested copy of the operator's procedures manual; however, the company did not provide a copy for review."

    ReplyDelete
  4. Yes...200hrs a week, if true, leads to the "same ole same ole" attitude which misses things that REALLY MATTER.

    ReplyDelete

  5. We live in a blameless society, it's always someone else's fault. He was VFR, visual flight rules, see and avoid. He should've been transitioning at 1000 feet minimum, he was not surveying a pipeline when he the tower and had no business at 449'. End of story.

    ReplyDelete

  6. It is very sad to see. The young one who perished made a number of critical mistakes that contributed to their demise.

    I feel badly for the demise of such a young fellow. He had so many years ahead of him.

    If you want to advance the drone business then obtain all the equipment and permits you need, perfect your patrol methods and submit a proposal to the pipeline operator. If you can get a contract then more power to you.

    it is a simple case of put-up or shut-up.

    I would submit if Kathryn's Report listed all the drone crash incidents per day like manned flight I think it would be a better perspective on the safety and success record of aviation as a whole.

    What I (and perhaps everyone) really want to see is a sting of days where no one crashes at all, drone or other. It takes money, training and an improvement in the commitment to conform to already existing standards without compromise.

    All aviation in various forms depends on it.









    ReplyDelete