Sunday, May 13, 2018

Air Tractor Inc AT-502B, N502WC, operated by Farm Air Flying Services and Air Tractor AT-502B, N5044N, operated by Growers Air Service: Fatal accident occurred July 23, 2016 in Zamora, Yolo County, California

Analysis

Both agricultural application airplanes were returning to their respective home bases after completing application operations when they collided in-flight at an altitude less than 500 ft agl. Following the collision, one of the airplanes (N502WC) descended to ground contact, fatally injuring the pilot. The pilot of the second airplane (N5044N) performed a forced landing to a field. That pilot reported that he did not see the other airplane until immediately before the collision.

Examination of the engine and flight control systems of both airplanes revealed no mechanical anomalies that would have precluded normal operation including the ability to maneuver the airplanes away from each other.

The deceased pilot had at least therapeutic levels of two impairing medications, cyclobenzaprine and hydrocodone, at the time of the accident. In addition, he had low levels of two sedating antihistamines, chlorpheniramine and diphenhydramine. These four drugs, in combination, would likely have slowed his psychomotor functioning and decreased his attentiveness to the flight environment. Therefore, it is likely that the fatally injured pilot's use of a combination cyclobenzaprine, hydrocodone, and two sedating antihistamines, contributed to his inability to successfully see and avoid the other airplane.

Based upon the sun's position and the statement from the second pilot, the sun was likely in the eyes of the deceased pilot. There was no evidence of the deceased pilot performing any evasive maneuver prior to the collision, which suggests that he never visually acquired the other airplane prior to the collision. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The failure of both pilots to maintain an adequate visual lookout, which resulted in a midair collision. Also causal was the pilot's use of two sedating antihistamines and two impairing medication and the effect of sun glare on his visual lookout, which likely led to his inability to successfully see and avoid the other airplane.

Findings

Personnel issues
Lack of action - Pilot (Cause)
Monitoring other aircraft - Pilot (Cause)
Prescription medication - Pilot (Cause)

Environmental issues
Bright light - Ability to respond/compensate (Cause)


Javone Logan Cowan

Javone was born in Roseville, California on November 19, 1990. Carried by angels, he crossed over and left his life here on July 23, 2016, in a plane crash. He graduated from East Nicolaus High School in 2009. He then went on to Ag - Flight, Inc, a professional AG pilot training School in Georgia to become a Crop Duster. After finishing his flight school, he went on to Wyoming and Utah to work. After a year or so, he returned, and was given his first flight job in CA., at Avag, INC. Javone then went to work for Farm Air, Inc. and has worked there since 2013. Javone loved his life, his family and his flying! Blue Skies and Tailwinds until we meet again.


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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Sacramento, California
Air Tractor, Inc.; Olney, Texas

N502WC  Aviation Accident Final Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf

N502WC Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N502WC

N502WC Aviation Accident Factual Report - National Transportation Safety Board 

Location: Zamora, CA
Accident Number: WPR16FA148A
Date & Time: 07/23/2016, 0745 PDT
Registration: N502WC
Aircraft: AIR TRACTOR INC AT 502B
Aircraft Damage: Substantial
Defining Event: Midair collision
Injuries: 1 Fatal
Flight Conducted Under: Part 137: Agricultural 

HISTORY OF FLIGHT

On July 23, 2016, about 0745 Pacific daylight time (PDT), two Air Tractor AT-502Bs, N502WC, and N5044N, collided in-flight near Zamora, California. The commercial pilot of N502WC was fatally injured; the airplane sustained substantial damage. The commercial pilot of N5044N received minor injuries; the airplane sustained substantial damage. N502WC was operated by Farm Air Flying Services, and N5044N was operated by Growers Air Service. Both flights were operated under the provisions of Title 14 Code of Federal Regulations Part 137 as aerial application flights. Visual meteorological conditions prevailed, and company flight plans had been filed for both flights.

The pilot of N502WC had finished spraying mosquito repellant and was traveling eastbound en route to Farm Air Flying Services.

The pilot of N5044N had finished spraying a rice field and was traveling southbound en route to Growers Air Service.

During a postaccident interview, the pilot of N5044N reported that he could not recall his altitude but stated that it would normally have been at least 500 ft above ground level (agl). He added that he observed N502WC on his right side traveling toward him when he maneuvered his airplane and ascended; however, N502WC contacted the undercarriage of his airplane and subsequently collided with terrain. The pilot of N5044N was unable to maintain altitude and subsequently performed a forced landing to an open field. According to the pilot of N5044N, the pilot of N502WC would have been traveling toward the sun and likely did not see him before the collision.

PERSONNEL INFORMATION

N502WC

The pilot, age 25, held a commercial pilot certificate with a rating for airplane single engine land. He also held a mechanic certificate with airframe and powerplant ratings. His most recent second-class Federal Aviation Administration (FAA) medical certificate was issued on March 30, 2016, with no limitations. On the application for that certificate, the pilot reported 2,250 total hours of flight experience, with 450 hours in the previous 6 months.

Acccording to the pilot's logbook, the most recent flight review was performed on February 16, 2016. He received a logbook endorsement under Title 14 CFR Part 61.56 – Flight Review.

N5044N

The pilot, age 64, held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA second-class medical certificate was issued on October 1, 2015, with the limitation for wear corrective lenses. The pilot had been flying for Growers Air Services for the past 27 years. His flight experience was not determined.

AIRCRAFT INFORMATION

Both airplanes were painted yellow with blue trim.

N502WC

The airplane, serial number 502B-2830, was manufactured in 2012; and equipped with a 750-shaft horsepower Pratt & Whitney Canada PT6A-34AG engine, serial number PCE-PH0774. The most recent annual inspection was completed on May 1, 2016, at an airframe total time of 967.5 hours.

N5044N

The airplane, serial number 502B-0452, was manufactured in 1997, and equipped with a 750-shaft horsepower Pratt & Whitney Canada PT6A-34AG engine, serial number PCE-PH0416. The airplane Hobbs hour meter indicated a time of 1533.8 hours' time-in-service. The airplane logbooks were not made available for review.

METOROLOGICAL INFORMATION

According to the sun position chart sunrise was at 0600. The sun's azimuth at 0745 was 64°, at an elevation of 18° above the horizon.

WRECKAGE AND IMPACT INFORMATION

The National Transportation Safety Board Investigator-in-charge (NTSB IIC), an FAA inspector, and a representative from Air Tractor, Inc., responded to both accident sites. The accident sites were separated by about 2/3 mile.

N502WC came to rest partially intact in an organic rice field on a magnetic heading of 280°. The vertical stabilizer and rudder separated from the empennage and were not located. The propeller hub, with propeller blades attached, had separated and was located near the main wreckage. The top portion of the nose and cockpit canopy had separated from the airplane. The main landing gear remained attached to the airplane's undercarriage. The airplane was equipped with an AmSafe inflatable restraint (airbag) system. The airbags were found deployed in the fuselage wreckage.

N5044N landed in a plowed open field in an upright position. The airplane remained intact except for the landing gear and spray equipment, which had separated from the airplane. Both wings remained attached to the fuselage. The left wing sustained damage the length of the wing, and the aileron was damaged. The wing tip had blue paint transfer on the underneath portion of the wing. The airplane came to rest on a 100° magnetic heading. Flight control continuity was established from the cockpit to all flight controls surfaces. The airplane was equipped with an AmSafe inflatable restraint (airbag) system that had not deployed during the collision or subsequent forced landing.

Neither airplane exhibited any mechanical malfunctions or anomalies that would have precluded normal operation.

MEDICAL AND PATHOLOGICAL INFORMATION

The County of Sacramento, Department of Coroner, Sacramento, California, performed a postmortem examination of the pilot of N502WC. The cause of death was reported as multiple injuries.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology testing on specimens of the pilot of N502WC. Carbon monoxide and cyanide testing were not performed; volatiles testing reported no ethanol detected in urine. Tested-for-drugs yielded positive results.

According to the NTSB medical officer, the pilot had reported no chronic medical conditions and no medication use to the FAA. The FAA issued the pilot a second-class medical certificate without limitations.

The County of Sacramento, Department of the Corner, recovered three loose white oblong tablets, two of which were broken in half; the tablets were located in the pilot's pants pocket. The tablets had the imprint "M367" on them, which is consistent with acetaminophen and hydrocodone 325 mg/10mg.

Postaccident toxicology testing identified hydrocodone at 46 ng/ml (0.046 ug/ml) and its metabolite dihydrocodeine at 10 ng/ml (0.010 ug/ml) in femoral blood. In addition, there were two sedating antihistamines, chlorpheniramine and diphenhydramine, found in subclavian and heart blood respectively. The levels presented for each were below the calibration curve of the instruments and below the lower end of the therapeutic ranges. Chlorpheniramine was also confirmed in the liver and diphenhydramine was confirmed in urine. Sertraline and its metabolite Demethylsertraline were found in liver and lung tissue. Tramadol and its metabolite O-desmethyltramadol were found in urine but not in blood. Hydrocodone was detected in heart blood but could not be quantified due to technical difficulties. Its active metabolite, dihydrocodeine, was quantified at 0.016 ug/ml in heart blood. Both the hydrocodone and the dihydrocodeine, and another metabolite, hydromorphone, were identified in urine. An opioid unrelated to the others, morphine, was also found in urine, but not in blood.

Chlorpheniramine and diphenhydramine, two sedating antihistamines are available as over-the-counter allergy product and sleep aid respectively. Chlorpheniramine has the following warning, "when using this product, drowsiness may occur, avoid alcoholic beverages; alcohol, sedatives, and tranquilizers may increase drowsiness; use caution when driving a motor vehicle or operating machinery." According to the NTSB medical officer, Diphenhydramine is classified as a CNS depressant, and this is the rationale for its use as a sleep aid. Possible side-effects could potentially be altered mood and impaired cognitive and psychomotor performance. In a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100°.

Cyclobenzaprine is a prescription medication used to treat muscle spasm. It is considered potentially impairing and carries this warning, "Cyclobenzaprine HC1 may enhance the effects of alcohol, barbiturates, and other central nervous system depressants." Cyclobenzaprine does undergo a significant post mortem redistribution, it moves back into blood from storage sites after death, as a result, levels identified in heart blood during postmortem may be many times higher than ante mortem levels.

Sertraline is a prescription antidepressant also marketed under the name Zoloft. While not considered directly impairing, depression is associated with significant cognitive degradation. The FAA requires pilots being treated for depression to undergo additional evaluation beyond the usual medical certification.


The autopsy also revealed the use of several opioids; Tramadol, hydrocodone, and morphine. Tramadol is available through a prescription as a Schedule IV controlled substance. The coroner's laboratory identified hydrocodone and its active metabolite dihydrocodeine in femoral blood. Hydrocodone is a Schedule II controlled substance and is available by prescription. This drug is considered to have a high potential for abuse and users are warned, that "profound sedation, respiratory depression, coma, and death may result from concomitant use of hydrocodone bitartrate and acetaminophen tablets with benzodiazepines or other CNS depressants. The therapeutic range for hydrocodone is considered between 0.0100 and 0.0500 ug/ml. the specimen used by the coroner was from femoral blood, the level 0.046 ug/ml best represents the pilot's ante mortem drug level. Dihydrocodeine is an active metabolite of hydrocodone.


According to the NTSB medical officer, the morphine found in the pilot's urine but not in blood may represent previous use of morphine, codeine, or heroin. Drugs found only in urine, but not in other body tissue are generally considered to no longer have any direct psychoactive effects.


N5044N


The pilot of N5044N, received minor injuries and was transported to the hospital. He reported the use of simvastatin to lower cholesterol on his most recent FAA medical certificate application. No postaccident toxicology testing was performed on the surviving pilot.


TESTS AND RESEARCH


Two onboard devices used to control agricultural spray operations based on vendor-and user-prescribed maps were shipped to the NTSB Vehicle Recorder Division: A Hemisphere Satloc G-4 that was installed on N502WC, and a Satloc M3 CPU that was installed on N5044N.


The Satloc G-4 sustained minor damage, and recorded data for the accident flight between 0624:48 and 0739:49 PDT


The Satloc M3 CPU Data Recovery sustained minor damage, but data retrieved from the compact flash card contained only ground operations from 0531 and 0532 (time zone not verified) on the day of the accident. According to the manufacturer, the Satloc M3 was an older generation unit that only copied data from volatile memory to non-volatile memory when a new log was started.


Data recovered from N502WC (the airplane with the Satloc G-4 installed was overlaid on a Google Earth image). Data ended as the airplane was traveling eastbound about 143 mph. The overlay showed that N502WC flew two racetrack-type patterns over fields. Following the second pattern, the accident airplane headed east at 284.3 ft agl traveling 145.19 mph at 0739:17. About 13 seconds later, the accident airplane was traveling 145.22 mph at an altitude of 337.7 ft. agl. The last recorded log was at 0739:459 at an altitude of 433.9 ft agl, and airspeed of 143.16 mph.


ADDITIONAL INFORMATION


Regarding collision avoidance, the FAA Airplane Flying Handbook states,


"All pilots must be alert to the potential for midair collision and near midair collisions… this concept requires that vigilance shall be maintained at all times, by each person operating an aircraft regardless of whether the operation is conducted under instrument flight rules (IFR) or visual flight rules (VFR)… most midair collision accident and reported near midair collision incidents occur in good VFR weather conditions and during the hours of daylight. Most of these accident/incidents occur within 5 miles of an airport and/or near navigation aids."


The NTSB released a Special Investigation Report on the Safety of Agricultural Aircraft Operations; NTSB/SIR-14/01 PB2014-105983. To view the entire investigative report go to: https://ntsb.gov/safety/safety-studies/Pages/SIR1401.aspx


The NTSB has released two safety alerts that address midair collisions and preventions. To view the safety alerts in their entirety go to: https://ntsb.gov/safety/safety-alerts/Pages/default.aspx


SA-045: See and Be Seen: Your Life Depends on it


SA-058: Prevent Midair Collisions: Don't Depend on Vision Alone


The National Agricultural Aviation Association (NAAA) emails weekly a fly safe newsletter and publishes a Professional Operating Guidelines manual. Chapter 4 safety, section 4.3 Subsection C, titled Safe Piloting Techniques; recommends that the pilot ferry the airplane to and from application sites above 500 ft agl and remain clear of congested areas, and to see and avoid other aircraft and obstructions. 


Pilot Information


Certificate: Commercial

Age: 25, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Center
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed:
Medical Certification: Class 2 Without Waivers/Limitations
Last FAA Medical Exam: 03/01/2016
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time: (Estimated) 2250 hours (Total, all aircraft), 0 hours (Total, this make and model), 450 hours (Last 90 days, all aircraft) 

Aircraft and Owner/Operator Information


Aircraft Manufacturer: AIR TRACTOR INC

Registration: N502WC
Model/Series: AT 502B B
Aircraft Category: Airplane
Year of Manufacture: 2012
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 502B-2830
Landing Gear Type: Tailwheel
Seats:
Date/Type of Last Inspection: 05/01/2016, Annual
Certified Max Gross Wt.:
Time Since Last Inspection: 968 Hours
Engines:  Turbo Prop
Airframe Total Time: 967.5 Hours as of last inspection
Engine Manufacturer: Pratt and Whitney Canada
ELT: Not installed
Engine Model/Series: 502B-2830
Registered Owner: SIB AG AERO LLC
Rated Power: 750 hp
Operator: Farm Air Flying Services
Operating Certificate(s) Held: Agricultural Aircraft (137)

Meteorological Information and Flight Plan


Conditions at Accident Site: Visual Conditions

Condition of Light: Day
Observation Facility, Elevation: KSMF, 23 ft msl
Observation Time: 1453 UTC
Distance from Accident Site: 11 Nautical Miles
Direction from Accident Site: 128°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 22°C / 14°C
Lowest Ceiling: None
Visibility:  10 Miles
Wind Speed/Gusts, Direction: Calm
Visibility (RVR):
Altimeter Setting: 29.94 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: VERONA, CA (38CL)
Type of Flight Plan Filed: Company VFR
Destination: VERONA, CA (38CL)
Type of Clearance: None
Departure Time:  PDT
Type of Airspace:

Airport Information


Airport: Riego Flight Strip Airport (38CL)

Runway Surface Type: N/A
Airport Elevation: 21 ft
Runway Surface Condition: Unknown
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None

Wreckage and Impact Information


Crew Injuries: 1 Fatal

Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 38.802778, -121.767500 (est)

N5044N  Aviation Accident Final Report - National Transportation Safety Board:  https://app.ntsb.gov/pdf


N5044N   Investigation Docket - National Transportation Safety Board:  https://dms.ntsb.gov/pubdms


http://registry.faa.gov/N5044N

N5044N  Aviation Accident Factual Report - National Transportation Safety Board 



Analysis 

Both agricultural application airplanes were returning to their respective home bases after completing application operations when they collided in-flight at an altitude less than 500 ft agl. Following the collision, one of the airplanes (N502WC) descended to ground contact, fatally injuring the pilot. The pilot of the second airplane (N5044N) performed a forced landing to a field. That pilot reported that he did not see the other airplane until immediately before the collision.

Examination of the engine and flight control systems of both airplanes revealed no mechanical anomalies that would have precluded normal operation including the ability to maneuver the airplanes away from each other.

The deceased pilot had at least therapeutic levels of two impairing medications, cyclobenzaprine and hydrocodone, at the time of the accident. In addition, he had low-levels of two sedating antihistamines, chlorpheniramine and diphenhydramine. These four drugs, in combination, would likely have slowed his psychomotor functioning and decreased his attentiveness to the flight environment. Therefore, it is likely that the fatally injured pilot's use of a combination cyclobenzaprine, hydrocodone, and two sedating antihistamines, contributed to his inability to successfully see and avoid the other airplane.

Based upon the sun's position and the statement from the second pilot, the sun was likely in the eyes of the deceased pilot. There was no evidence of the deceased pilot performing any evasive maneuver prior to the collision, which suggests that he never visually acquired the other airplane prior to the collision. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The failure of both pilots to maintain an adequate visual lookout, which resulted in a midair collision. Also causal was the other pilot's use of two sedating antihistamines and two impairing medication and the effect of sun glare on his visual lookout, which likely led to his inability to successfully see and avoid the other airplane. 

Findings

Personnel issues
Delayed action - Pilot (Cause)
Monitoring other aircraft - Pilot (Cause)

Prescription medication - Pilot of other aircraft (Cause)

Location: Zamora, CA
Accident Number: WPR16FA148B
Date & Time: 07/23/2016, 0745 PDT
Registration: N5044N
Aircraft: AIR TRACTOR INC AT 502B
Aircraft Damage: Substantial
Defining Event: Midair collision
Injuries: 1 Minor
Flight Conducted Under: Part 137: Agricultural 

HISTORY OF FLIGHT

On July 23, 2016, about 0745 Pacific daylight time (PDT), two Air Tractor AT-502Bs, N502WC, and N5044N, collided in-flight near Zamora, California. The commercial pilot of N502WC was fatally injured; the airplane sustained substantial damage. The commercial pilot of N5044N received minor injuries; the airplane sustained substantial damage. N502WC was operated by Farm Air Flying Services, and N5044N was operated by Growers Air Service. Both flights were operated under the provisions of Title 14 Code of Federal Regulations Part 137 as aerial application flights. Visual meteorological conditions prevailed, and company flight plans had been filed for both flights.

The pilot of N502WC had finished spraying mosquito repellant and was traveling eastbound en route to Farm Air Flying Services.

The pilot of N5044N had finished spraying a rice field and was traveling southbound en route to Growers Air Service.

During a postaccident interview, the pilot of N5044N reported that he could not recall his altitude but stated that it would normally have been at least 500 ft above ground level (agl). He added that he observed N502WC on his right side traveling toward him when he maneuvered his airplane and ascended; however, N502WC contacted the undercarriage of his airplane and subsequently collided with terrain. The pilot of N5044N was unable to maintain altitude and subsequently performed a forced landing to an open field. According to the pilot of N5044N, the pilot of N502WC would have been traveling toward the sun and likely did not see him before the collision.

PERSONNEL INFORMATION

N502WC

The pilot, age 25, held a commercial pilot certificate with a rating for airplane single engine land. He also held a mechanic certificate with airframe and powerplant ratings. His most recent second-class Federal Aviation Administration (FAA) medical certificate was issued on March 30, 2016, with no limitations. On the application for that certificate, the pilot reported 2,250 total hours of flight experience, with 450 hours in the previous 6 months.

According to the pilot's logbook, the most recent flight review was performed on February 16, 2016. He received a logbook endorsement under Title 14 CFR Part 61.56 – Flight Review.

N5044N

The pilot, age 64, held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent FAA second-class medical certificate was issued on October 1, 2015, with the limitation for wear corrective lenses. The pilot had been flying for Growers Air Services for the past 27 years. His flight experience was not determined.

AIRCRAFT INFORMATION

Both airplanes were painted yellow with blue trim.

N502WC

The airplane, serial number 502B-2830, was manufactured in 2012; and equipped with a 750-shaft horsepower Pratt & Whitney Canada PT6A-34AG engine, serial number PCE-PH0774. The most recent annual inspection was completed on May 1, 2016, at an airframe total time of 967.5 hours.

N5044N

The airplane, serial number 502B-0452, was manufactured in 1997, and equipped with a 750-shaft horsepower Pratt & Whitney Canada PT6A-34AG engine, serial number PCE-PH0416. The airplane Hobbs hour meter indicated a time of 1533.8 hours' time-in-service. The airplane logbooks were not made available for review.

METOROLOGICAL INFORMATION

According to the sun position chart sunrise was at 0600. The sun's azimuth at 0745 was 64°, at an elevation of 18° above the horizon.

WRECKAGE AND IMPACT INFORMATION

The National Transportation Safety Board Investigator-in-charge (NTSB IIC), an FAA inspector, and a representative from Air Tractor, Inc., responded to both accident sites. The accident sites were separated by about 2/3 mile.

N502WC came to rest partially intact in an organic rice field on a magnetic heading of 280°. The vertical stabilizer and rudder separated from the empennage and were not located. The propeller hub, with propeller blades attached, had separated and was located near the main wreckage. The top portion of the nose and cockpit canopy had separated from the airplane. The main landing gear remained attached to the airplane's undercarriage. The airplane was equipped with an AmSafe inflatable restraint (airbag) system. The airbags were found deployed in the fuselage wreckage.

N5044N landed in a plowed open field in an upright position. The airplane remained intact except for the landing gear and spray equipment, which had separated from the airplane. Both wings remained attached to the fuselage. The left wing sustained damage the length of the wing, and the aileron was damaged. The wing tip had blue paint transfer on the underneath portion of the wing. The airplane came to rest on a 100° magnetic heading. Flight control continuity was established from the cockpit to all flight controls surfaces. The airplane was equipped with an AmSafe inflatable restraint (airbag) system that had not deployed during the collision or subsequent forced landing.

Neither airplane exhibited any mechanical malfunctions or anomalies that would have precluded normal operation.

MEDICAL AND PATHOLOGICAL INFORMATION

The County of Sacramento, Department of Coroner, Sacramento, California, performed a postmortem examination of the pilot of N502WC. The cause of death was reported as multiple injuries.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology testing on specimens of the pilot of N502WC. Carbon monoxide and cyanide testing were not performed; volatiles testing reported no ethanol detected in urine. Tested-for-drugs yielded positive results.

According to the NTSB medical officer, the pilot had reported no chronic medical conditions and no medication use to the FAA. The FAA issued the pilot a second-class medical certificate without limitations.

The County of Sacramento, Department of the Corner, recovered three loose white oblong tablets, two of which were broken in half; the tablets were located in the pilot's pants pocket. The tablets had the imprint "M367" on them, which is consistent with acetaminophen and hydrocodone 325 mg/10mg.

Postaccident toxicology testing identified hydrocodone at 46 ng/ml (0.046 ug/ml) and its metabolite dihydrocodeine at 10 ng/ml (0.010 ug/ml) in femoral blood. In addition, there were two sedating antihistamines, chlorpheniramine and diphenhydramine, found in subclavian and heart blood respectively. The levels presented for each were below the calibration curve of the instruments and below the lower end of the therapeutic ranges. Chlorpheniramine was also confirmed in the liver and diphenhydramine was confirmed in urine. Sertraline and its metabolite Demethylsertraline were found in liver and lung tissue. Tramadol and its metabolite O-desmethyltramadol were found in urine but not in blood. Hydrocodone was detected in heart blood but could not be quantified due to technical difficulties. Its active metabolite, dihydrocodeine, was quantified at 0.016 ug/ml in heart blood. Both the hydrocodone and the dihydrocodeine, and another metabolite, hydromorphone, were identified in urine. An opioid unrelated to the others, morphine, was also found in urine, but not in blood.

Chlorpheniramine and diphenhydramine, two sedating antihistamines are available as over-the-counter allergy product and sleep aid respectively. Chlorpheniramine has the following warning, "when using this product, drowsiness may occur, avoid alcoholic beverages; alcohol, sedatives, and tranquilizers may increase drowsiness; use caution when driving a motor vehicle or operating machinery." According to the NTSB medical officer, Diphenhydramine is classified as a CNS depressant, and this is the rationale for its use as a sleep aid. Possible side-effects could potentially be altered mood and impaired cognitive and psychomotor performance. In a driving simulator study, a single dose of diphenhydramine impaired driving ability more than a blood alcohol concentration of 0.100%.

Cyclobenzaprine is a prescription medication used to treat muscle spasm. It is considered potentially impairing and carries this warning, "Cyclobenzaprine HC1 may enhance the effects of alcohol, barbiturates, and other central nervous system depressants." Cyclobenzaprine does undergo a significant post mortem redistribution, it moves back into blood from storage sites after death, as a result, levels identified in heart blood during postmortem may be many times higher than ante mortem levels.

Sertraline is a prescription antidepressant also marketed under the name Zoloft. While not considered directly impairing, depression is associated with significant cognitive degradation. The FAA requires pilots being treated for depression to undergo additional evaluation beyond the usual medical certification.

The autopsy also revealed the use of several opioids; Tramadol, hydrocodone, and morphine. Tramadol is available through a prescription as a Schedule IV controlled substance. The coroner's laboratory identified hydrocodone and its active metabolite dihydrocodeine in femoral blood. Hydrocodone is a Schedule II controlled substance and is available by prescription. This drug is considered to have a high potential for abuse and users are warned, that "profound sedation, respiratory depression, coma, and death may result from concomitant use of hydrocodone bitartrate and acetaminophen tablets with benzodiazepines or other CNS depressants. The therapeutic range for hydrocodone is considered between 0.0100 and 0.0500 ug/ml. the specimen used by the coroner was from femoral blood, the level 0.046 ug/ml best represents the pilot's ante mortem drug level. Dihydrocodeine is an active metabolite of hydrocodone.

According to the NTSB medical officer, the morphine found in the pilot's urine but not in blood may represent previous use of morphine, codeine, or heroin. Drugs found only in urine, but not in other body tissue are generally considered to no longer have any direct psychoactive effects.

N5044N

The pilot of N5044N, received minor injuries and was transported to the hospital. He reported the use of simvastatin to lower cholesterol on his most recent FAA medical certificate application. No postaccident toxicology testing was performed on the surviving pilot.

TESTS AND RESEARCH

Two onboard devices used to control agricultural spray operations based on vendor-and user-prescribed maps were shipped to the NTSB Vehicle Recorder Division: A Hemisphere Satloc G-4 that was installed on N502WC, and a Satloc M3 CPU that was installed on N5044N.

The Satloc G-4 sustained minor damage, and recorded data for the accident flight between 0624:48 and 0739:49 PDT

The Satloc M3 CPU Data Recovery sustained minor damage, but data retrieved from the compact flash card contained only ground operations from 0531 and 0532 (time zone not verified) on the day of the accident. According to the manufacturer, the Satloc M3 was an older generation unit that only copied data from volatile memory to non-volatile memory when a new log was started.

Data recovered from N502WC (the airplane with the Satloc G-4 installed was overlaid on a Google Earth image). Data ended as the airplane was traveling eastbound about 143 mph. The overlay showed that N502WC flew two racetrack-type patterns over fields. Following the second pattern, the accident airplane headed east at 284.3 ft agl traveling 145.19 mph at 0739:17. About 13 seconds later, the accident airplane was traveling 145.22 mph at an altitude of 337.7 ft. agl. The last recorded log was at 0739:459 at an altitude of 433.9 ft agl, and airspeed of 143.16 mph.

ADDITIONAL INFORMATION

Regarding collision avoidance, the FAA Airplane Flying Handbook states

"All pilots must be alert to the potential for midair collision and near midair collisions… this concept requires that vigilance shall be maintained at all times, by each person operating an aircraft regardless of whether the operation is conducted under instrument flight rules (IFR) or visual flight rules (VFR)… most midair collision accident and reported near midair collision incidents occur in good VFR weather conditions and during the hours of daylight. Most of these accident/incidents occur within 5 miles of an airport and/or near navigation aids."

The NTSB released a Special Investigation Report on the Safety of Agricultural Aircraft Operations; NTSB/SIR-14/01 PB2014-105983. To view the entire investigative report go to: https://ntsb.gov/safety/safety-studies/Pages/SIR1401.aspx

The NTSB has released two safety alerts that address midair collisions and preventions. To view the safety alerts in their entirety please go to: https://ntsb.gov/safety/safety-alerts/Pages/default.aspx

SA-045: See and Be Seen: Your Life Depends on it

SA-058: Prevent Midair Collisions: Don't Depend on Vision Alone

The National Agricultural Aviation Association (NAAA) emails weekly a fly safe newsletter and publishes a Professional Operating Guidelines manual. Chapter 4 safety, section 4.3 Subsection C, titled Safe Piloting Techniques; recommends that the pilot ferry the airplane to and from application sites above 500 ft agl and remain clear of congested areas, and to see and avoid other aircraft and obstructions. 

Pilot Information

Certificate: Commercial
Age: 64, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 10/01/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  

Aircraft and Owner/Operator Information

Aircraft Manufacturer: AIR TRACTOR INC
Registration: N5044N
Model/Series: AT 502B B
Aircraft Category: Airplane
Year of Manufacture: 1997
Amateur Built: No
Airworthiness Certificate: Restricted
Serial Number: 502B-0452
Landing Gear Type: Tailwheel
Seats:
Date/Type of Last Inspection: Unknown
Certified Max Gross Wt.:
Time Since Last Inspection:
Engines: Turbo Prop
Airframe Total Time:
Engine Manufacturer: Pratt and Whitney Canada
ELT: Not installed
Engine Model/Series: 502B-0452
Registered Owner: GROWERS AIR SERVICE INC
Rated Power: 750 hp
Operator: GROWERS AIR SERVICE INC
Operating Certificate(s) Held: Agricultural Aircraft (137) 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KSMF, 23 ft msl
Observation Time: 1453 UTC
Distance from Accident Site: 11 Nautical Miles
Direction from Accident Site: 128°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 22°C / 14°C
Lowest Ceiling: None
Visibility: 10 Miles
Wind Speed/Gusts, Direction: Calm
Visibility (RVR):
Altimeter Setting: 29.94 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: DAVIS, CA (69CL)
Type of Flight Plan Filed: Company VFR
Destination: DAVIS, CA (69CL)
Type of Clearance: None
Departure Time:  PDT
Type of Airspace:

Airport Information

Airport: Riego Flight Strip Airport (38CL)
Runway Surface Type: N/A
Airport Elevation: 21 ft
Runway Surface Condition: Dry; Rough
Runway Used: N/A
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: Forced Landing 

Wreckage and Impact Information

Crew Injuries: 1 Minor
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Minor
Latitude, Longitude:  38.802778, -121.767500 (est)



NTSB Identification: WPR16FA148A
14 CFR Part 137: Agricultural
Accident occurred Saturday, July 23, 2016 in Zamora, CA
Aircraft: AIR TRACTOR INC AT 502B, registration: N502WC
Injuries: 1 Fatal, 1 Minor.

NTSB Identification: WPR16FA148B
14 CFR Part 137: Agricultural
Accident occurred Saturday, July 23, 2016 in Zamora, CA
Aircraft: AIR TRACTOR INC AT 502B, registration: N5044N
Injuries: 1 Fatal, 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 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 July 23, 2016, about 0745 Pacific daylight time, an Air Tractor AT-502B, N502WC, and an Air Tractor AT-502B, N5044N, collided in-flight near Zamora, California. N502WC was operated by Farm Air under the provisions of 14 Code of Federal Regulations Part 137 as an aerial application flight. The commercial pilot, the sole occupant, was fatally injured and the airplane was destroyed. N5044N was operated by Growers Air Service, and was operated as an aerial application flight under the provisions of 14 Code of Federal Regulations Part 137. The commercial pilot, the sole occupant, received minor injuries and the airplane sustained substantial damage. Visual meteorological conditions prevailed and company flight plans had been filed for both flights.

The pilot of N502WC had finished spraying mosquito repellant, and was traveling eastbound en route to Farm Air's base.

The pilot of N5044N had finished spraying a rice field, and was traveling southbound en route to Growers Air Service.

The pilot of N5044N was interviewed by the National Transportation Safety Board Investigator-in-Charge (IIC). The pilot reported that he could not recall his altitude, and opined it would normally have been at least 500 feet agl. He stated that he observed N502WC on his right side traveling toward him when he maneuvered the airplane and ascended. However, N502WC made contact with the undercarriage of his airplane. N502WC subsequently collided with terrain. The pilot of N5044N stated that he was losing altitude and landed off airport in an open field.

The NTSB IIC, a Federal Aviation Administration (FAA) inspector, and a representative from Air Tractor, Inc., responded to the accident sites. The accident sites were about a half mile from each other.

N502WC came to rest mostly intact in an organic rice field on a magnetic heading of 280 degrees. The vertical stabilizer and rudder separated from the empennage and has yet to be located. The propeller hub with propeller blades had separated and was located near the main wreckage. The top portion of the nose and the canopy for the cockpit had separated from the airplane. One of the main landing gear for N502WC remained attached to the airplane's undercarriage at its relative normal location.

N5044N landed in a plowed open field in an upright position. The airplane remained intact with the exception of the landing gear and spray equipment, which had separated from the airplane. The airplane came to rest on a 100-degree magnetic heading. Flight control continuity was established. Both airplanes were recovered for further examination.

Cessna 310F, N6770X, registered to and operated by Lashbrook Inc: Fatal accident occurred May 05, 2016 at North Little Rock Municipal Airport (KORK), Pulaski County, Arkansas

Analysis

The commercial pilot was conducting a checkride in the multi-engine airplane with an airline transport pilot-certificated designated pilot examiner. The pilot reported that, during the initial climb after takeoff, the left engine experienced a partial loss of power. At this time, the airplane was climbing at its single-engine best rate-of-climb speed (Vyse). The pilot reported that he was able to maintain control of the airplane with partial right rudder and right aileron inputs, and chose not to shut down and secure the engine because it was still providing "positive thrust." The examiner reportedly agreed with the decision to keep the engine running and to make left turns in the traffic pattern due to the increased number of landing options in that direction. The left turns, toward the partially running left engine, would have decreased the directional control of the airplane. While on the downwind leg of the traffic pattern, the left engine lost further power, and the pilot then attempted to feather the left propeller. Although he moved the left propeller control full aft, the propeller did not feather. Radar data indicated a continual loss of airspeed as the airplane turned from the upwind to downwind leg and from the downwind leg toward the airport. The airplane reached a maximum altitude about 255 ft above ground level on the downwind leg. As it turned toward the airport, the airplane collided with terrain in a 45° left bank and slight nose-down pitch attitude and was subsequently destroyed by a postcrash fire.

The postaccident airframe, engine, and propeller examinations did not reveal any evidence of a mechanical malfunction that would have prevented normal operation; however, the airplane sustained significant postimpact fire damage, which prevented a full assessment of the fuel system and its configuration at the time of the accident. Examination of left propeller determined it was not in a feathered position at the time of impact, and that both blades appeared to be at or near the start lock position.

The propeller was equipped with start locks that engaged below 800 rpm to prevent feathering of the blades during engine shutdown on the ground. In the event of an in-flight engine shutdown, the propeller must be feathered before engine speed decays to 800 rpm. It is likely that the pilot allowed the left engine rpm to decay below the start lock engagement speed, which prevented the propeller from feathering and, instead, remain windmilling. This would have resulted in a large amount of parasitic drag and a significant decrease of the airplane's single-engine climb performance. Due to the windmilling propeller, it is likely that the airplane would not have been able to maintain altitude even if the pilot had maintained Vyse; however, the pilot should have maintained this speed to minimize altitude loss and maintain controllability of the airplane. As the pilot maneuvered the airplane back toward the airport, he allowed the airspeed to decay such that the airplane no longer had the flight control authority to counteract the yaw and roll produced by the operating right engine, which resulted in a loss of control at a 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 promptly feather the left propeller upon the initial loss of engine power shortly after takeoff and his failure to maintain airspeed while maneuvering with one engine inoperative, which resulted in a loss of control at a low altitude. Also causal was the partial loss of left engine power during initial climb for reasons that could not be determined because examination of the airplane did not reveal any evidence of mechanical malfunction that would have precluded normal operation. 

Findings

Aircraft
Propeller feather/reversing - Incorrect use/operation (Cause)
Airspeed - Not attained/maintained (Cause)
Engine out capability - Not attained/maintained (Cause)

Personnel issues
Delayed action - Pilot (Cause)
Use of equip/system - Pilot (Cause)
Aircraft control - Pilot (Cause)

Factual Information

History of Flight

Initial climb
Loss of engine power (partial) (Defining event)

Approach-VFR pattern base
Loss of control in flight
Collision with terr/obj (non-CFIT)

Post-impact
Explosion (post-impact)
Fire/smoke (post-impact)



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

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Little Rock, Arkansas
Textron Aviation; Wichita, Kansas
Continental Motors Inc; Mobile, Alabama
Hartzell Propeller; Piqua, Ohio
United States Air Force Safety Center; Kirtland AFB, New Mexico

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/N6770X




Aviation Accident Factual Report - National Transportation Safety Board

Location: North Little Rock, AR
Accident Number: CEN16FA172
Date & Time: 05/05/2016, 1331 CDT
Registration: N6770X
Aircraft: CESSNA 310F
Aircraft Damage: Destroyed
Defining Event: Loss of engine power (partial)
Injuries: 1 Fatal, 1 Serious
Flight Conducted Under: Part 91: General Aviation - Instructional 

On May 5, 2016, about 1331 central daylight time, a Cessna 310F twin-engine airplane, N6770X, impacted terrain following a loss of control during approach for landing at North Little Rock Municipal Airport (ORK), North Little Rock, Arkansas. The designated pilot examiner was fatally injured and the commercial pilot sustained serious injuries. The airplane was destroyed by a postimpact fire. The airplane was registered to and operated by Lashbrook, Inc., under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Day visual meteorological conditions (VMC) prevailed, and no flight plan was filed for the local instructional flight, which was originating at the time of the accident.

The accident occurred during an airline transport pilot checkride administered by a Federal Aviation Administration (FAA) designated pilot examiner. The pilot successfully completed the oral examination before the flight. Following the oral examination, the pilot and examiner discussed the planned sequence for the checkride, which was to depart ORK under visual flight rules, conduct maneuvers south of the airport, then conduct multiple instrument approach procedures to a nearby airport before returning to ORK. The pilot reported that he and the examiner also agreed to work together if an actual emergency occurred during the flight. The pilot stated that he and the examiner did not identify any anomalies with the airplane during the preflight inspection. He noted that the fuel tanks were filled before the flight, and that the fuel samples collected during the preflight inspection did not contain water or particulates.

The pilot stated that the left engine started uneventfully. The examiner used a fuel crossfeed procedure to start the right engine using the left fuel auxiliary pump. The pilot did not recall why the examiner performed the crossfeed engine start or if he was simply demonstrating the procedure. Following the right engine start, the pilot repositioned the fuel selectors to a normal configuration (left engine using fuel from the left fuel tank, right engine using fuel from the right fuel tank). The pilot stated that he visually verified the correct position of the fuel selectors and felt the associated handle detents. He then verbally confirmed the positions of the fuel selectors before taxiing the airplane from the ramp. The before-takeoff engine runup was uneventful, during which the pilot did not identify any anomalies with either engine or their respective propellers. The pilot completed the before-takeoff checklist, which included verifying that both auxiliary fuel pumps were in the normal "ON" position, before he taxied the airplane onto runway 5 for takeoff.

The pilot performed a normal takeoff from runway 5 and retracted the landing gear during initial climb on the upwind leg. He stated that, during initial climb about 700 ft mean sea level (msl), there was a noticeable change in engine sound and the airplane began to yaw left. He reported that the airplane was climbing at 111 mph (single-engine best rate-of-climb speed, Vyse) when the left engine experienced a partial loss of power to 2,200 rpm. He applied partial right rudder and right aileron inputs to correct for the resulting left yaw. He told the examiner that the left engine was still providing "positive thrust" and stated that they both agreed to keep the left engine running. The pilot stated that the airplane was able to climb to 800 ft msl, at which point he and the examiner agreed to make left turns in the traffic pattern due to the increased number of landing options located immediately north and northwest of the airport. The pilot reported that he was able to maintain 800 ft msl during the left turn from the upwind leg to downwind leg.

The pilot stated that the left engine lost additional power during the downwind leg and eventually was unable to provide positive thrust, at which time he decided to feather the left propeller and shut down the engine. The pilot recalled moving the left engine throttle to the idle-stop and moving the left propeller control full-aft; however, he did not recall if he moved the left mixture control to the fuel cutoff position. The pilot postulated that the left propeller did not feather, because full right rudder and right aileron inputs were still required to maintain control of the airplane. The pilot then made a left turn from the downwind leg toward the airport. He stated that, during the left turn, the airplane's airspeed continued to decrease, and that the airplane collided with terrain in a 45° left bank and slight nose-down pitch attitude. After the accident, he was able to exit the airplane from the left cabin door with moderate burns to his head and left leg. He made multiple attempts to extricate the unresponsive examiner from the burning wreckage, during which he sustained serious burns to his face and arms.

According to available radar track data, the airplane appeared on radar at 800 ft msl at 1329:43, shortly after it had departed runway 5 and did not climb above 800 ft msl during the remainder of the flight. The airplane continued on the upwind leg for about 24 seconds before it entered a left turn to a southwest heading of 225°. The left turn to the downwind leg took about 29 seconds to complete, which corresponded to an average turn rate of about 6° per second and a turn radius of about 1/3 mile. After completing the left turn to the downwind leg, the airplane continued southwest at 800 ft msl until the final recorded radar return at 1330:56. The final radar return was about 0.28 miles northeast of the runway 17 displaced threshold and 845 ft north of the initial impact with the ground.

Airplane performance calculations based on available radar track data and meteorological data indicated that the airplane initially maintained a true airspeed between 98 mph and 111 mph during the upwind leg from runway 5; however, the true airspeed decreased to 97 mph during the left turn to the downwind leg. During the final 20 seconds of recorded radar data, the true airspeed continued to decrease to as low as 89 mph.

A witness reported seeing the airplane take off from runway 5 and climb to about 500 ft above ground level (agl) before it began to descend in a nose-up pitch attitude. The witness stated that he did not hear any anomalies with the airplane's engines. He reported that the airplane momentarily entered a steep-banked left turn before it reduced its bank angle to maintain a shallow left turn. The witness stated that the airplane continued to descend during the left turn until he lost sight of the airplane behind a hangar. Believing the airplane was going to crash, the witness drove his truck toward the airplane's last observed position. When he reacquired the airplane, it was still flying in a shallow left turn north of the airport at a slow speed. Although the witness could not hear the airplane's engines from inside his truck, he observed that both propellers were still rotating. The witness stated that the airplane appeared to fly over the water department's storage tanks in what he believed was an attempt to land in a grass area east of runway 17. The witness took a photograph of the airplane shortly before it impacted the ground and burst into flames. According to the file metadata, the photo was captured at 1330:59. A review of the photo established that the airplane was in a 45° left-wing-down bank and a slight nose-low pitch attitude. Additionally, the airplane was on a southerly heading at or below treetop level.

A surveillance camera partially captured the impact sequence. The surveillance camera's field of view was aligned to the southwest and focused primarily on an industrial yard located about 450 ft east of the initial impact point. At 1331:00.35, the airplane appeared in the upper right corner of the frame; however, the airplane was partially obscured by a tree that was positioned between the camera and the initial impact point. At 1331:00.54, a fire/explosion emerged and continued to grow as the impact sequence progressed from right to left over a period of about 2.6 seconds. At 1331:02.35, the left engine emerged from the central explosion, tumbling away from the main wreckage, and came to rest in an open field about 1331:07.35. There was a ground fire along the debris path and the associated smoke plumes appeared to drift toward the southeast. There was a power interruption to the surveillance camera between 1331:15.78 and 1337:35.72. When the footage resumed, a majority of the ground fire had subsided; however, the main wreckage remained on fire. There was a second power interruption between 1337:55.76 and 1342:44.66. After the footage resumed, the fire at the main wreckage had been extinguished by responding fire department personnel.



Pilot Information

Certificate: Commercial
Age: 30, 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: Yes
Instructor Rating(s): None
Toxicology Performed: No
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 11/25/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 950 hours (Total, all aircraft), 4 hours (Total, this make and model), 377 hours (Pilot In Command, all aircraft)

Check Pilot Information

Certificate: Airline Transport
Age: 56, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land; Single-engine Sea
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: 3-point
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Multi-engine; Airplane Single-engine; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 07/24/2015
Occupational Pilot: Yes
Last Flight Review or Equivalent: 04/17/2016
Flight Time:  (Estimated) 12214 hours (Total, all aircraft), 11967 hours (Pilot In Command, all aircraft), 57.2 hours (Last 90 days, all aircraft), 17.2 hours (Last 30 days, all aircraft), 0 hours (Last 24 hours, all aircraft)

--- Pilot ---

According to FAA records, the 30-year-old pilot held a commercial pilot certificate with single-engine land, multi-engine land, and instrument airplane ratings. He was type-rated for the Mitsubishi MU-300 and Hawker 400 twin-turbofan business jets. His most recent FAA first-class medical certificate was issued on November 25, 2015, with no restrictions or limitations. The pilot's application for the airline transport pilot certificate, dated May 4, 2016, listed a total flight time of 950 hours, of which 612 hours were accumulated in multi-engine airplanes. He reported 377 hours of flight experience as pilot-in-command, 194 hours at night, 162 hours in instrument conditions, and 4 hours in Cessna 310F airplanes. The pilot was a captain with the Air National Guard who typically flew four-engine turboprop Lockheed C-130 airplanes. According to available records, the pilot's most recent military flight was flown on April 9, 2016, in a Lockheed C-130H3 airplane.

--- Pilot Examiner ---

According to FAA records, the 56-year-old pilot examiner held an airline transport pilot certificate with a rating for airplane multi-engine land and commercial privileges for airplane single-engine land and sea. He was type-rated for the Cessna 500, Cessna 560XL, Cessna 650, Dassault Falcon 50, and Dassault Falcon 900 business jets. He also held a flight instructor certificate with airplane single- and multi-engine and instrument airplane ratings. His most recent FAA second-class medical certificate was issued on July 24, 2015, with a limitation for corrective lenses. His initial authorization as an FAA designated pilot examiner was on September 28, 1995, and his latest examiner renewal was approved by the FAA on January 21, 2016. He was designated an examiner for private, commercial, instrument airplane, air transport pilot, flight instructor, flight instructor renewals, sport pilot, and sport pilot instructor certificates. He was authorized to administer checkrides in single-engine land airplanes, single-engine sea airplanes, and small multi-engine airplanes.

The pilot examiner's flight history was established using his logbook. The final logbook entry was dated May 2, 2016, at which time he had accumulated 12,214 total hours of flight experience. He had logged 11,967.2 hours as pilot-in-command, 4,217.4 hours in single-engine airplanes, and 7,918.3 hours in multi-engine airplanes. He had accumulated 1,405.7 hours at night, 1,121.9 hours in actual instrument conditions, and 111.9 hours in simulated instrument conditions. He had flown 80.6 hours during the year before the accident, 74.4 hours during the 6 months before the accident, 57.2 hours during the 90 days before the accident, and 17.2 hours during the month before the accident. There was no record that he had flown during the 24 hours before the accident. The examiner had flown 20.2 hours in the accident airplane make/model during year before the accident. His most recent flight review, as required by 14 CFR 61.56, was completed on April 17, 2016. 



Aircraft and Owner/Operator Information

Aircraft Manufacturer: CESSNA
Registration: N6770X
Model/Series: 310F
Aircraft Category: Airplane
Year of Manufacture: 1961
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 310-0070
Landing Gear Type: Retractable - Tricycle
Seats: 5
Date/Type of Last Inspection: 05/01/2016, Annual
Certified Max Gross Wt.: 4830 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time: 6035.3 Hours as of last inspection
Engine Manufacturer: Continental
ELT: Installed, not activated
Engine Model/Series: IO-470-D
Registered Owner: Lashbrook, Inc.
Rated Power: 260 hp
Operator: Lashbrook, Inc.
Operating Certificate(s) Held: None 

The airplane, serial number 310-0070, was manufactured in 1961 and was a low-wing monoplane of conventional aluminum semimonocoque construction. The airplane was powered by two 260-horsepower, 6-cylinder, Continental IO-470-D reciprocating engines. The engines provided thrust through two constant-speed, full-feathering, two-blade, Hartzell HC-C2YF-2CUF propellers. The five-seat airplane was equipped with a retractable tricycle landing gear and wing flaps and had a maximum allowable takeoff weight of 4,830 pounds. The airplane had two fuel tanks, one located at each wingtip, and a total fuel capacity of 100 gallons. The FAA issued the airplane a standard airworthiness certificate on February 6, 1961. The owner/operator, Lashbrook Inc., purchased the airplane on May 3, 2015.

According to maintenance documentation, the most recent annual and 100-hour inspections were completed on May 1, 2016, at 6,035.3 total airframe hours. The recording hour meter was destroyed during the postimpact fire, which precluded a determination of the airplane's total service time at the time of the accident. The static system, altimeter system, automatic pressure altitude reporting system, and transponder were last tested on May 9, 2014.

As of the most recent annual inspection, the left engine, serial number 105176, had accumulated a total service time of 3,020.5 hours since new and 324.2 hours since being overhauled on August 1, 2003. The left propeller, serial number AN7313B, had accumulated a total service time of 720.1 hours since new and 273.4 hours since being overhauled on July 16, 2007.

As of the most recent annual inspection, the right engine, serial number 79315, had accumulated a total service time of 5,937.5 hours since new and 1,735.5 hours since being overhauled on April 16, 1990. The right propeller, serial number AN7312B, had accumulated a total service time of 720.1 hours since new and 273.4 hours since being overhauled on July 16, 2007.

A postaccident review of the available maintenance records found no history of unresolved airworthiness issues.

According to airplane manufacturer documentation, the minimum controllable airspeed (Vmc) for the airplane was 80 mph, the single-engine best angle-of-climb (Vxse) was 95 mph, and Vyse was 111 mph.



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: LIT, 266 ft msl
Observation Time: 1353 CDT
Distance from Accident Site: 8 Nautical Miles
Direction from Accident Site: 170°
Lowest Cloud Condition: Few / 4500 ft agl
Temperature/Dew Point: 25°C / 5°C
Lowest Ceiling: None
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 7 knots, 340°
Visibility (RVR):
Altimeter Setting: 29.99 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: North Little Rock, AR (ORK)
Type of Flight Plan Filed: None
Destination: North Little Rock, AR (ORK)
Type of Clearance: None
Departure Time: 1330 CDT
Type of Airspace: Class G 

A postaccident review of available meteorological data established that day visual meteorological conditions prevailed at the accident site. The nearest aviation weather reporting station was located at Bill and Hillary Clinton National Airport/Adams Field (LIT), Little Rock, Arkansas, about 7.7 miles south-southeast of the accident site.

At 1253, about 38 minutes before the accident, the LIT automated surface observing system reported wind from 320° at 13 knots with wind gusts of 19 knots, 10 miles surface visibility, few clouds at 25,000 ft agl, temperature 24°C, dew point 5°C, and an altimeter setting of 30.01 inches of mercury.

At 1353, about 22 minutes after the accident, LIT reported wind from 340° at 7 knots, surface visibility 10 miles, few clouds at 4,500 ft agl, temperature 25°C, dew point 5°C, and an altimeter setting of 29.99 inches of mercury.



Airport Information

Airport: North Little Rock Municipal (ORK)
Runway Surface Type: Concrete
Airport Elevation: 545 ft
Runway Surface Condition: Dry
Runway Used: 05
IFR Approach: None
Runway Length/Width: 5002 ft / 75 ft
VFR Approach/Landing: Forced Landing; Traffic Pattern 

ORK, a public airport located about 4 miles north of North Little Rock, was owned and operated by the City of North Little Rock, Arkansas. The airport field elevation was 545 ft msl. The airport was served by two runways, runway 5/23 (5,002 ft by 75 ft, concrete) and runway 17/35 (3,019 ft by 75 ft, asphalt). The airport was not equipped with an air traffic control tower. 



Wreckage and Impact Information

Crew Injuries: 1 Fatal, 1 Serious
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: On-Ground
Total Injuries: 1 Fatal, 1 Serious
Latitude, Longitude: 34.838333, -92.254444 

The initial impact point was in an industrial yard located about 0.17 miles east-northeast of the runway 17 displaced threshold and 0.13 miles south of West Maryland Avenue. Fragments of the left wingtip navigation light lens cover were found along a curb located about 27.5 ft past the initial impact point on a 170° magnetic heading. The wreckage debris path continued through an electrical service line and the airport perimeter fence. The main wreckage came to rest in an open grass field about 186 ft from the initial impact point. The left engine and its propeller, which separated from the left wing during impact, were located an additional 108 ft past the main wreckage.

The main wreckage consisted of the fuselage, both wings, empennage, and the right engine and its propeller. A majority of the fuselage, including the cockpit and instrument panel, was destroyed during the postimpact fire. Flight control cable continuity could not be established due to impact damage; however, all observed separations were consistent with overstress. Mechanical continuity from the engine components to their respective cockpit controls could not be established due to impact damage. The engine control quadrant was destroyed by postimpact fire, which precluded an accurate determination of the individual lever positions at the time of impact. Measurement of the flap actuator was consistent with the flaps being fully retracted at the time of impact. Measurements of the landing gear actuators were consistent with the landing gear being fully retracted at the time of impact. A majority of the fuel system was damaged during impact and the postimpact fire. Both fuel tanks were destroyed during impact and postimpact fire. The right fuel selector was found positioned to draw fuel from the right fuel tank. The left fuel selector separated from the airframe during impact, which precluded an accurate determination of its preimpact position. Both auxiliary fuel pump switches were destroyed during the postimpact fire. The postaccident airframe examination did not reveal any evidence of a mechanical malfunction that would have precluded normal operation during the flight.

The left engine separated from its mounts during impact. Internal engine and valve train continuity were confirmed as the engine crankshaft was rotated. Except for the No. 6 cylinder, compression and suction were noted in conjunction with crankshaft rotation. The push rod for the No. 6 cylinder exhaust valve exhibited impact damage that prevented the valve from seating properly during the compression test. Both magnetos provided spark from each ignition tower when the drive shaft was rotated on a test bench. The spark plugs exhibited normal wear features; however, they were dark in color, consistent with carbon fouling. The mechanical fuel pump rotated smoothly, and its drive pin was intact. Fuel was present in the hoses connected to the mechanical fuel pump. No anomalies were observed with the throttle body metering unit, fuel manifold valve, or fuel injectors. The throttle body metering unit's inlet fuel screen contained minor fiber contamination. The fuel manifold valve contained fuel and its filter screen did not exhibit any contamination. All fuel injectors were open and clear of debris. The oil pump discharged oil in conjunction with crankshaft rotation. The oil pickup screen was intact and covered in oil with no obstructions. The oil filter element was free of visible metal contaminants. The propeller governor separated from the engine during impact, and the observed damage precluded functional testing. There were no anomalies observed with the cylinders, pistons, valves, or valve seats. Additionally, there were no anomalies with the crankshaft, connecting rods, bearings, or counterbalance weights. There was no evidence of a preimpact mechanical malfunction that would have precluded normal operation of the left engine during the flight.

The right engine separated from its mounts and remained attached to the wing through control cables. Internal engine and valve train continuity were confirmed as the engine crankshaft was rotated. Compression and suction were noted on all cylinders in conjunction with crankshaft rotation. Both magnetos provided spark from each ignition tower when the drive shaft was rotated on a test bench. The spark plugs exhibited features consistent with normal engine operation. The mechanical fuel pump rotated smoothly, and its drive pin was intact. Fuel was present in the hoses connected to the mechanical fuel pump. No anomalies were observed with the throttle body metering unit, fuel manifold valve, or fuel injectors. The throttle body metering unit's inlet fuel screen was free of contamination. The fuel manifold valve contained fuel and its filter screen did not exhibit any contamination. All fuel injectors were open and clear of debris. The oil pump discharged oil in conjunction with crankshaft rotation. The oil pickup screen was intact and covered in oil with no obstructions. The oil filter element was free of visible metal contaminants. The propeller governor functioned normally when bench tested. There were no anomalies observed with the cylinders, pistons, valves, or valve seats. Additionally, there were no anomalies with the crankshaft, connecting rods, bearings, or counter-balance weights. There was no evidence of a preimpact mechanical malfunction that would have precluded normal operation of the right engine during the flight.

The left propeller remained attached to the engine crankshaft flange and exhibited limited leading-edge damage to one of the two blades. The other blade exhibited an aft bend. A teardown examination determined that the propeller was not in a feathered position at the time of impact and that both blades appeared to be at or near the start lock position. There was no evidence of a preimpact mechanical malfunction that would have precluded normal operation of the left propeller during the flight.

The right propeller remained attached to the engine crankshaft flange and exhibited prominent leading-edge gouging and chordwise scoring on the camber side of both blades. One blade displayed S-shape bending and the other blade was bent aft. A teardown examination determined that the propeller was forcibly rotated toward the low pitch stop during impact. There was no evidence of a preimpact mechanical malfunction that would have precluded normal operation of the right propeller during the flight.

Additional documentation for each engine and propeller examination is included in the docket materials associated with the investigation. 



Medical And Pathological Information

The Arkansas State Crime Laboratory, Little Rock, Arkansas, performed an autopsy on the pilot examiner. The cause of death was attributed to thermal injuries sustained during the accident.

The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology tests on specimens obtained during the autopsy. The pilot examiner's toxicology results were negative for carbon monoxide, ethanol, and all tested drugs and medications.



Additional Information

According to Hartzell Propeller Owner's Manual No. 115N, the constant-speed propellers were hydraulically operated with feathering capability. Oil pressure provided by the propeller governor was used to move the blades toward low pitch (blade angle). A feathering spring, counterweights, and an air charge moved the blades toward high pitch and into feather in the absence of governor oil pressure. The propellers were also equipped with spring-energized latches (start locks) to keep the propeller blade angle low to minimize torque during engine start. The start locks engage the feathering high pitch stops when engine speed decreases below about 800 rpm. According to the propeller manufacturer, for a propeller to be found on the start locks after an accident, the propeller blade angle at impact was either at or below the start lock angle when engine speed decreased below 700-900 rpm, or the blade forces during impact moved the blade angle into a start lock position after engine speed decreased below 700-900 rpm.

FAA Special Airworthiness Information Bulletin No. CE-05-51 describes a scenario in which the propeller of an inoperative engine did not feather because the windmilling speed had decreased below the propeller's start lock engagement speed. The bulletin states that a windmilling propeller produces a large amount of parasitic drag in a twin-engine airplane with one engine inoperative, which can result in the airplane's total drag exceeding the power available and an inability to maintain level flight.

The Cessna 310F Owner's Manual states that, in an event of a loss of engine power shortly after liftoff, a pilot should maintain the Vyse speed of 111 mph unless there are obstructions which require a steep climb to avoid. The manual further stipulates that allowing the airspeed to fall below the Vxse speed of 95 mph would reduce or eliminate the airplane's ability to climb with one engine inoperative.

The Cessna Pilot Safety and Warning Supplements states that, in event of a loss of engine power during takeoff, "prompt retraction of the landing gear, identification of the inoperative engine, and feathering of the propeller is of utmost importance if the takeoff is to be continued." The supplement further states that a windmilling propeller will severely degrade climb performance with one engine inoperative. Additionally, the supplement states that if an immediate climb is not necessary for obstacle clearance, a pilot should maintain Vyse, because it will provide the best chance of climb or least altitude loss during single-engine flight. 



NTSB Identification: CEN16FA172
14 CFR Part 91: General Aviation
Accident occurred Thursday, May 05, 2016 in North Little Rock, AR
Aircraft: CESSNA 310F, registration: N6770X
Injuries: 1 Fatal, 1 Serious.

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 May 5, 2016, about 1331 central daylight time, a Cessna model 310F twin-engine airplane, N6770X, was destroyed when it impacted terrain following a loss of control near the North Little Rock Municipal Airport (ORK), North Little Rock, Arkansas. A postimpact fire ensued. The airline transport pilot (ATP) applicant sustained serious injuries. The pilot examiner was fatally injured. The airplane was registered to and operated by Lashbrook Inc. under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Day visual meteorological conditions (VMC) prevailed for the local area flight that was originating at the time of the accident.

The accident occurred during an ATP checkride that was being administered by a Federal Aviation Administration (FAA) designated pilot examiner. According to available radar track data, at 1329:43 (hhmm:ss), the accident airplane appeared on radar shortly after departing from runway 5 and did not subsequently climb above 800 feet msl. The airplane continued on a northeast heading of 050 degrees for approximately 24 seconds before it entered a left turn to a southwest heading of 225 degrees. The 175 degree left turn took about 29 seconds to complete and had a turn radius of about 1/3 mile. The turn rate averaged about 6 degrees per second during the left turn. After completing the left turn, the airplane continued to the southwest, on a ground track toward runway 17, while maintaining 800 feet msl, until the final recorded radar point at 1330:56. The final radar data point was located about 1/3 mile northeast of the runway 17 displaced threshold.

Preliminary performance calculations, based on available radar data, indicated that the airplane initially maintained a calculated true airspeed of 85-96 knots during the upwind leg from runway 5; however, the calculated true airspeed decreased from 96 knots to 84 knots during the left turn to the southwest. During the final 20 seconds of recorded radar data, the calculated true airspeed further decreased from 84 knots to 79 knots. According to airplane manufacturer documentation, the minimum controllable airspeed (Vmc) for the accident airplane was 70 knots (80 mph), the single-engine best angle-of-climb (Vxse) was 83 knots (95 mph), and the single-engine best rate-of-climb (Vyse) was 97 knots (111 mph).

A witness photographed the airplane shortly before it impacted the ground. According to the associated file metadata, the photo was captured at 1330:59. At that time, the airplane was observed in a left wing low, 45-degree bank, in a slightly nose low attitude. Additional review of the photograph established the airplane was on a southerly heading and was at or below treetop level.

A surveillance camera partially captured the accident impact sequence. The surveillance camera's field-of-view was aligned to the southwest and primarily focused on an industrial yard that was located about 450 feet east of the initial impact point. At 1331:00.35 (hhmm:ss.ss), the accident airplane appeared in the upper right corner of the field-of-view; however, the airplane was partially obscured by a tree that was positioned between the camera and the initial impact point. At 1331:00.54, a fire/explosion emerged and continued to grow, over a period of about 2.6 seconds, as the impact sequence progressed from right-to-left in the field-of-view. At 1331:02.35, the left engine emerged from the central explosion, tumbling away from the main wreckage, and came to rest in an open field about 1331:07.35. A ground fire was observed along the debris path and the associated smoke plumes appeared to drift toward the southeast. There was a power interruption to the surveillance camera, between 1331:15.78 and 1337:35.72. When the footage resumed, a majority of the ground fire had subsided; however, the main wreckage remained on fire. There was a second power interruption, between 1337:55.76 and 1342:44.66. After the footage resumed, the fire at the main wreckage had been extinguished by responding fire department personnel.

Following the accident, several fire department personnel spoke with the ATP applicant concerning the accident flight. When asked what had occurred during the flight, the ATP applicant told the fire department personnel that the left engine had experienced a loss of engine power shortly after takeoff. The ATP applicant further stated that, following the loss of left engine power, the examiner took over airplane control and was attempting to fly the airplane back to the airport when the accident occurred.

The ATP applicant was not interviewed by the NTSB or the FAA before the release of this preliminary report. Although attempts were made to interview the ATP applicant at the hospital, his on-going medical treatment precluded an interview or his providing a written statement.

The ATP applicant was a captain with the Air National Guard and typically flew four-engine turboprop Lockheed C-130 airplanes. The ATP applicant also held a FAA commercial pilot certificate with single-engine land, multiengine land, and instrument airplane ratings. His application for the ATP certificate, dated May 4, 2016, listed a total flight time of 950 hours, of which 612 hours were accumulated in multiengine airplanes. The pilot examiner held a FAA ATP certificate with single-engine land, single-engine sea, multiengine land, and instrument airplane ratings. The pilot examiner also held a flight instructor certificate with single-engine, multiengine, and instrument airplane ratings. According to a FAA medical application, dated July 24, 2015, the pilot examiner had accumulated 12,257 hours of flight time.

At 1253, about 38 minutes before the accident, an automated surface observing system located at Bill and Hillary Clinton National Airport/Adams Field (LIT), about 7.5 miles south of the accident site, reported the following weather conditions: wind 320 degrees true at 13 knots, gusting 19 knots; surface visibility 10 miles; few clouds at 25,000 feet agl; temperature 24 degrees Celsius, dew point 5 degrees Celsius, and an altimeter setting of 30.01 inches of mercury.

At 1353, about 22 minutes after the accident, the LIT automated surface observing system reported the wind 340 degrees true at 7 knots, surface visibility 10 miles, few clouds at 4,500 feet agl, temperature 25 degrees Celsius, dew point 5 degrees Celsius, and an altimeter setting of 29.99 inches of mercury.