Saturday, October 13, 2018

Bellanca 17-31ATC Viking, registered to Select Airplane LLC and operated by the pilot, N787TV: Fatal accident occurred April 24, 2017 near Jesse Viertel Memorial Airport (KVER), Boonville, Cooper County, Missouri

Analysis 

The commercial rated pilot was landing the airplane at the end of a personal local flight. The airport manager saw the airplane very low on final approach for runway 18. As the airplane continued toward the airport, it collided with power lines about 0.5 mile north of the runway's approach end. Weather conditions at the time of the accident included a clear sky with no obstructions to visibility. Examination of the airframe and engine did not reveal any anomalies that would have contributed to the accident. The pilot was familiar with the airport and was likely aware of the location of the power lines, which were well below a normal glideslope to the runway.

The pilot did not hold a medical certificate. An autopsy of the pilot revealed coronary artery disease and significant brain pathology. It is unlikely that the pilot's coronary artery disease contributed to the accident as it would not have impaired the pilot's judgment, vision, or decision-making. The pilot had scarring from a previous brain injury and severe damage to his left optic nerve to the extent that he was nearly blind in that eye. Given that the pilot failed to maintain proper altitude while operating in visual conditions and struck a potentially visible hazard, it is likely that his vision deficiency contributed to the accident.

Toxicology test results indicated that the pilot had used multiple psychoactive drugs before the accident, including cocaine, methamphetamine, clonazepam, and diphenhydramine. In addition to their psychoactive effects, these drugs are potent vasoconstrictors and can cause small arteries to spasm, cutting off blood flow to portions of vital organs. Although the neuropathologist who examined the pilot's brain believed the degree of cerebral hypoxic/ischemic damage he identified would take several hours to develop, the pilot was deceased by the time first responders arrived about 10 minutes after the witnessed crash. Therefore, this hypoxic/ischemic damage had to have begun before the accident and was likely caused by the pilot's misuse of cocaine and methamphetamine. This evolving brain ischemia may have played a role in the circumstances of the accident, but without specific information regarding the pilot's symptoms, its exact role cannot be determined. Although the pilot's stage of intoxication with methamphetamine or cocaine at the time of the accident is unknown, it is very likely that he was impaired by the combined effects of these drugs.

Probable Cause and Findings


The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot's impairment, due to his use of a combination of psychoactive drugs and a vision deficiency in his left eye, which resulted in a failure to maintain adequate altitude during final approach to landing and subsequent collision with power lines.

Findings

Aircraft

Altitude - Not attained/maintained (Cause)

Personnel issues

Illicit drug - Pilot (Cause)
OTC medication - Pilot (Cause)
Visual function - Pilot (Cause)
Predisposing condition - Pilot

Environmental issues
Wire - Ability to respond/compensate (Cause)
Wire - Awareness of condition (Cause)

Factual Information

History of Flight


Approach-VFR pattern final

Miscellaneous/other (Defining event)
Collision with terr/obj (non-CFIT)


Charles E. (Chuck) McCutcheon III 

Graduating from Fayette High School in 1968, Chuck McCutcheon held an associate degree in aviation from Moberly Area Community College. He also attended Central Methodist University. Chuck became a pilot at age 19 and continued his love for aviation until his final days. A certified flight instructor, he taught many mid-Missouri people how to fly, several of whom went on to work in commercial aviation. He was a commercial-rated pilot for both single and twin-engine airplanes. Chuck had a 10 year career as a professional pilot, serving several companies including Orscheln Industries, Edison Manufacturing, Health Systems Inc., and the University Flight for Life training team.

Bryan Scott Roth

Bryan served his nation honorably in the United States Army during Operation Desert Storm. Bryan was a talented musician and enjoyed playing the guitar, singing and writing music. He also loved the outdoors, especially fishing and hunting. 


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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Kansas City, Missouri
Lycoming Engines; Arlington, Texas

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/N787TV 





Location: Boonville, MO
Accident Number: CEN17FA164
Date & Time: 04/24/2017, 1339 CDT
Registration: N787TV 
Aircraft: BELLANCA 17 31ATC
Aircraft Damage: Substantial
Defining Event: Miscellaneous/other
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On April 24, 2017, at 1339 central daylight time, a Bellanca 17-31-ATC airplane, N787TV, collided with high tension power lines and impacted terrain during final approach to land at the Jesse Viertel Memorial Airport (VER), Boonville, Missouri. The commercial rated pilot and the passenger were fatally injured, and the airplane was substantially damaged. The airplane was registered to Select Airplane, LLC, and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the local flight that operated without a flight plan. The airplane departed VER that morning for an unknown destination and was returning when the accident occurred.

The airport manager at VER reported that he had seen the pilot fly in and out of the airport on numerous occasions and that the pilot often flew a low final approach. On the day of the accident, he saw the airplane "lower than usual" on final approach for runway 18. As the airplane continued toward the airport, he saw it contact power lines, abruptly pitch nose-low, and descend into the terrain. He immediately contacted emergency service and responded to the accident site.

Pilot Information

Certificate: Commercial
Age: 67, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Unknown
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  4840 hours (Total, all aircraft) 

The pilot's logbook was not available during the investigation. The pilot's total flight experience and date of last flight review are not known. On February 28, 2013, the pilot applied for a third-class medical certificate and reported having accrued 4,840 hours of total flight experience with 0 hours flown in the preceding 6 months. Due to pilot reported medical conditions, to include blood pressure, hypothyroidism, history of migraines and fibromyalgia, he was not issued a medical certificate, and, when he did not provide requested medical information to the Federal Aviation Administration (FAA), he was sent a denial letter in July 2013. Before the 2013 application for a medical certificate, his previous certificate was issued on April 29, 1996.

Aircraft and Owner/Operator Information

Aircraft Make: BELLANCA
Registration: N787TV
Model/Series: 17 31ATC ATC
Aircraft Category: Airplane
Year of Manufacture: 1973
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 73-31048
Landing Gear Type: Tailwheel
Seats:
Date/Type of Last Inspection: 01/28/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 1899.6 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C91  installed, activated, did not aid in locating accident
Engine Model/Series: TIO-540-K1E5
Registered Owner: SELECT AIRCRAFT, LLC
Rated Power: 310 hp
Operator: On file
Operating Certificate(s) Held: None 

The airplane had been modified via supplemental type certificate by the installation of a Main Turbo System turbocharger. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KVER, 716 ft msl
Distance from Accident Site: 1 Nautical Miles
Observation Time: 1135 CDT
Direction from Accident Site: 186°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 13 knots / 20 knots
Turbulence Type Forecast/Actual: /
Wind Direction: 160°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.79 inches Hg
Temperature/Dew Point: 24°C / -3°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Boonville, MO (VER)
Type of Flight Plan Filed: None
Destination: Boonville, MO (VER)
Type of Clearance: None
Departure Time:  CDT
Type of Airspace: 

At 1135, an automated weather reporting facility located at VER reported wind from 160° at 13 knots gusting to 20 knots, visibility 10 miles, clear sky, temperature 75°F, dew point 27°F, and an altimeter setting of 29.79 inches of mercury. 

Airport Information

Airport: JESSE VIERTEL MEMORIAL (VER)
Runway Surface Type: Asphalt
Airport Elevation: 715 ft
Runway Surface Condition: Dry
Runway Used: 18
IFR Approach: None
Runway Length/Width: 4000 ft / 75 ft
VFR Approach/Landing: Straight-in

VER is located xx miles southeast of Boonville, Missouri. It has one runway, runway 18/36. Runway 18 has a precision approach path indicator (PAPI) lighting system that coincides with a 3° glideslope.

Wreckage and Impact Information

Crew Injuries: 2 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 38.959167, -92.681389 

Examination of the accident site revealed damage to a single line in a set of unmarked power lines about 75 ft above ground level and about 0.5 mile north of the approach end of runway 18. Additional damage was noted to two power lines that were about 15 ft above ground level and about 110 ft south of the first power line. There was an impact crater on the north shoulder of a two-lane road located about 8 ft south of the second set of power lines.

Numerous fragments of acrylic glass were located near the impact crater. Scuffing on the road led to the main wreckage, which came to rest inverted on the south side of the two-lane road. The main wreckage consisted of the entire airplane. A portion of wire from one of the power lines was entangled with the lower portion of the fuselage and both wings. The landing gear was extended, and the flaps were partially down. Flight control continuity was established from the cockpit controls to the ailerons, elevators, and rudder. The fuel selector was in the right tank detent. The flap gauge displayed flaps at the "TAKE OFF" setting. The left wing exhibited damage and scuffing consistent from contact with a large gauge wire. The right wing was largely destroyed and shattered in multiple places.

An unmeasured amount of fuel was drained from the left fuel tank and collected in a container; the fuel appeared clear with a blue tint and tested negative for the presence of water using a water-detecting paste. The right fuel tank was breached, and an odor of fuel was present at the accident site the day after the accident.

The propeller remained attached to the engine. All blades displayed chord-wise scratches and leading-edge gouges. The propeller nose cone exhibited a strike mark consistent with a large gauge wire. Engine valve train continuity and compression were confirmed by turning the propeller by hand. All screens were clean of debris. No defects were noted with the turbocharger, magnetos, or engine-driven fuel pump. The fuel injection nozzles were examined, and the Nos. 4 and 5 injectors were partially obstructed with an unknown substance. No anomalies were detected with the engine.

Medical And Pathological Information

The Boone/Callaway County Medical Examiner's Office, Boone, Missouri, performed an autopsy on the pilot. The autopsy report noted significant coronary artery disease with stenosis of 60-70% in the left main, 40% in the circumflex, 60% in the left obtuse marginal, and 90% in both the left anterior descending and the right coronary arteries. The myocardium did not show any gross evidence of previous or acute ischemia. No microscopic evaluation of the heart was performed.

The autopsy report also noted scarring from previous brain contusions in the tips of both frontal lobes and the left temporal horn. The left optic nerve was severely scarred, and the neuropathologist who examined the pilot's brain stated that the pilot was nearly blind in that eye.

Investigators from the medical examiner's office reported that the pilot routinely wore an eye patch on the left eye; his strabismus (crossed eyes) was quite significant, and the patch apparently controlled the resulting vertigo. There was a benign arachnoid cyst in the left anterior and middle fossae, which was large enough to indent the surrounding brain tissue. Finally, there was acute cerebral edema (swelling) sufficient to cause early herniation of the cerebellar tonsils into the foramen magnum. This was specified further as acute hypoxic/ischemic damage in the hippocampus, medial left frontal cortex, medial-inferior left temporal cortex, and bilateral entorhinal cortex. The neuropathologist commented that it would have taken "a few hours" for these findings to develop after the injury began. However the pilot was found 10 minutes after the accident occurred by first reponders.

Toxicology testing performed by the St. Louis University Toxicology Laboratory, St. Louis, Missouri, identified methamphetamine (0.16 ug/ml) and its metabolite amphetamine and cocaine and its metabolite benzoylecgonine in the pilot's blood. Cocaine (0.050 ug/ml) and benzoylecgonine were also found in vitreous fluid.

Toxicology testing performed by the FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, identified clonazepam (0.011 ug/ml) and its active metabolite 7-aminoclonazepam (0.126 ug/ml); methamphetamine (0.22 ug/ml) and its active metabolite amphetamine (0.023 ug/ml); cocaine (0.033 ug/ml) and its three metabolites (benzoylecgonine, anhydroecgonine methyl ester, and ecgonine methyl ester); phenylpropanolamine; paroxetine (0.464 ug/ml); diphenhydramine (0.04 ug/ml); and quinine in the pilot's blood. 7-aminoclonazepam and ibuprofen were found in urine. Methamphetamine, amphetamine, benzoylecgonine, ecgonine methyl ester, paroxetine, and quinine were also identified in liver tissue.

Clonazepam is used to treat certain types of seizures or for panic disorder. This medication has the potential to impair the mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., flying, driving, and operating heavy machinery).

Methamphetamine is a schedule II stimulant drug used in the treatment of narcolepsy and obesity. Oral does used to medically treat these illnesses typically produce blood level in the range of 0.02 to 0.05 ug/ml. Those misusing the drug may reach levels of 2.0 ug/ml or higher.

Cocaine is a powerful stimulant drug. Anhydroecgonine methyl ester is formed when cocaine is smoked and is often an indicator of the use of "crack cocaine."

Phenylpropanolamine is a synthetic sympathomimetic medication that is approximately equivalent to ephedrine in its pharmacologic properties and is used as a stimulant, decongestant, and anorectic (weight loss) agent. Potential adverse side-effects include dizziness, heart palpitations, increased heart rate, and nervousness. It is also an integral ingredient used in the production of illegally-produced methamphetamine.

Paroxetine is a prescription medication used to treat depression, panic disorder, and social anxiety disorder. This medication has the potential to impair the mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., flying, driving, and operating heavy machinery).

Diphenhydramine is an over-the-counter antihistamine used to treat allergic conditions and as a sleep aid. This medication has the potential to impair the mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., flying, driving, and operating heavy machinery).

Quinine is a prescription medication used alone or with other medications to treat malaria. It is also available in non-prescription strength in tonic water. Ibuprofen is a non-steroidal anti-inflammatory drug.

NTSB Identification: CEN17FA164
14 CFR Part 91: General Aviation
Accident occurred Monday, April 24, 2017 in Boonville, MO
Aircraft: BELLANCA 17 31ATC, registration: N787TV
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 April 24, 2017, at 1339 central daylight time, a Bellanca 17-31 airplane, N787TV, collided with high tension power lines and impacted terrain while attempting to land at the Jesse Viertel Memorial Airport (VER), Boonville, Missouri. The pilot and passenger were both fatally injured and the airplane was substantially damaged. The airplane was owned and operated by Select Airplane, LLC, under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight that operated without a flight plan.

The airport manager witnessed the accident sequence. He reported that he saw the airplane very low on final approach for runway 18. As the airplane continued towards the airport, he saw it abruptly pitch nose low and descend into the terrain. He immediately contacted emergency service and went to provide aid.

Damage to the power lines were consistent with the airplane colliding with a power line from a set of power lines that were about 75 ft above ground level and about a ½ mile north of the approach end of runway 18. Additional damage to two power lines that were about 15 ft above ground level was found about 110 ft south of the first power line. A subsequent impact crater on the northern shoulder of a 2-lane road, was located about 8 feet south of the second set of struck power lines. The airplane had come to rest inverted on south side of the road, with the nose pointing towards the opposite direction of travel. All major components were located at the accident site.

Visual meteorological conditions prevailed for the accident.

The airplane was retained for further examination.

1 comment:

  1. Blind in one eye. Apparently smoking cocaine, ingesting meth, no medical. Amazing he made it that far. To bad for the passenger.

    ReplyDelete