Sunday, July 14, 2019

Loss of Engine Power (Total): Cessna 172L Skyhawk, N2893Q; fatal accident occurred August 16, 2018 near Rhome Meadows Airport (T76), Wise County, Texas

Curtis Scott Moore
December 11th, 1954 – August 16th, 2018
~

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Irving, Texas
Lycoming Engines; Texas
Textron Aviation; Wichita, Kansas

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


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

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


http://registry.faa.gov/N2893Q


Location: Rhome, TX
Accident Number: CEN18FA336
Date & Time: 08/16/2018, 1935 CDT
Registration: N2893Q
Aircraft: Cessna 172
Aircraft Damage: Substantial
Defining Event: Loss of engine power (total)
Injuries: 1 Fatal, 3 Serious
Flight Conducted Under: Part 91: General Aviation - Personal 

Analysis 

The commercial pilot was taking family members for rides in his airplane; the accident flight was the third flight of the evening. After the second flight, the pilot landed and taxied the airplane back to his property, where three family members boarded the airplane while the engine continued to run. The pilot taxied back to the runway and departed. A pilot-rated witness stated that the takeoff roll was longer than expected, and, once airborne, the airplane pitched "very high" nose-up to about 50 ft above ground level (agl), then the nose came back down. The airplane appeared to accelerate down the runway until it climbed to about 300 ft agl, then made a left turn and descended out of view. The airplane impacted several trees and continued into a field, where it came to rest inverted. Damage to the propeller was consistent with a lack of engine power at the time of impact.

Examination of the airplane revealed evidence of a longstanding pattern of inadequate maintenance, including a rodent's nest in the leading edge of the left wing, a large mud dauber nest on the oil cooler, and cobwebs in the engine compartment. An automotive hydraulic hose was used in place of the main fuel line from the gascolator to the carburetor. The gascolator fuel strainer contained 3 large pieces of organic debris similar to insect cocoons, which were the same size as the hydraulic hose and associated fuel fitting. It is likely that the fuel line was removed for an extended period of time and eventually replaced with the automotive hydraulic hose, during which time the fuel system was exposed, which allowed insects to nest inside; because there were no maintenance records associated with the airplane, it could not be determined when the hose was replaced. During the accident flight, it is likely that the organic material became dislodged and restricted fuel to the carburetor, which subsequently starved the engine of available fuel and resulted in a total loss of engine power.

The autopsy of the pilot revealed evidence of hypertension and coronary artery disease; however, it is unlikely that these conditions contributed to the accident. Toxicological testing indicated that the pilot had been using alcohol before the accident and had levels considered impairing; it is likely that alcohol impaired the pilot's decision making and his ability to operate the airplane. Toxicological testing also revealed evidence that the pilot had used marijuana before the accident; however, it could not be determined if the concentrations would have been impairing or would have affected his performance.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's inadequate maintenance of the airplane, which resulted in a total loss of engine power due to fuel starvation when organic debris restricted available fuel to the carburetor, and the pilot's impairment due to the ingestion of alcohol, which affected his ability to safely operate the airplane following the loss of engine power. 

Findings

Aircraft
Fuel distribution - Not serviced/maintained (Cause)
Fuel distribution - Damaged/degraded (Cause)
Hoses and tubes - Inadequate inspection
Hoses and tubes - Incorrect service/maintenance
Hoses and tubes - Incorrect use/operation
Fuel filter-strainer - Not serviced/maintained

Personnel issues
Maintenance - Pilot (Cause)
Decision making/judgment - Pilot (Cause)
Alcohol - Pilot (Cause)

Factual Information

History of Flight

Prior to flight
Preflight or dispatch event
Aircraft inspection event

Initial climb
Fuel starvation
Loss of engine power (total) (Defining event)

Emergency descent
Off-field or emergency landing

On August 16, 2018, about 1935 central daylight time, a Cessna 172L airplane, N2893Q, impacted trees and terrain shortly after departure from Rhome Meadows Airport (T76), Rhome, Texas. The commercial pilot was fatally injured and the three passengers sustained serious injuries. The airplane sustained substantial damage. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident and no flight plan had been filed. The local flight was departing T76 at the time of the accident.

A family member stated that the pilot retrieved the airplane from under the open-air shelter for "family fun night" and was giving rides to several family members. The family members stated that the pilot had flown the airplane about one week before the accident, then again two times immediately preceding the accident flight. The two preceding flights lasted about 20 minutes and 10 minutes respectively and the family members reported no anomalies with the airplane. They also stated that during the accident flight the airplane departed from the grass runway and did not gain much altitude before it banked hard to the left and then descended behind a tree line. Figure 1 represents a satellite map view of T76 and the accident location.

Figure 1. Overhead map view of airport and accident area

A pilot-rated witness reported that he saw the airplane depart T76 and then land soon after. The airplane taxied back and three passengers boarded with the engine still running. He stated that the airplane taxied back to the runway and started the takeoff roll, during which the engine did not sound like it was developing full power. The takeoff roll was longer than he expected, and once the airplane was airborne, the nose pitched up "very high" to about 50 ft above ground level (agl), then the nose came back down. The airplane flew low over the runway and appeared to accelerate until it pitched up and climbed to about 300 ft agl. The airplane then made a left turn and descended out of view.


Curtis Scott Moore

Pilot Information

Certificate: Commercial
Age: 63, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Right
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 2 With Waivers/Limitations
Last FAA Medical Exam: 10/13/2017
Occupational Pilot: Yes
Last Flight Review or Equivalent:
Flight Time:  (Estimated) 8000 hours (Total, all aircraft) 

On his most recent second-class medical certificate application, dated October 13, 2017, the pilot reported 8,000 total hours of flight experience and 125 hours in the preceding 6 months. The pilot's wife stated that he did not log his recent flight time and had not recorded flights in his pilot logbook since the 1990s.

During the flight, the pilot was seated in the front right seat with a minor in the front left seat; an adult and minor were seated on the rear bench seat. 



Aircraft and Owner/Operator Information

Aircraft Make: Cessna
Registration: N2893Q
Model/Series: 172 L
Aircraft Category: Airplane
Year of Manufacture: 1971
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 17259893
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection:  Unknown
Certified Max Gross Wt.: 2299 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: Lycoming
ELT: C91A installed, not activated
Engine Model/Series: O-320-E2D
Registered Owner: On file
Rated Power: 150 hp
Operator: On file
Operating Certificate(s) Held: None 

The pilot's wife stated that the airplane's maintenance logbooks were never received from the previous owner after the airplane was purchased in 2013. There was no documentation of maintenance performed since that time and no evidence that the airplane had received an annual inspection. A representative for the previous owner could not find the logbooks.

Family members stated that fuel cans, which were filled at another airport, were typically used to refill the airplane; those fuel cans were used to fuel the airplane on the night of the accident. The fuel cans were filled at an unknown time the week before the accident. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Dusk
Observation Facility, Elevation: KLUD, 1047 ft msl
Distance from Accident Site: 8 Nautical Miles
Observation Time: 1735 CDT
Direction from Accident Site: 324°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 3 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 150°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 29.97 inches Hg
Temperature/Dew Point: 34°C / 19°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Rhome, TX (T76)
Type of Flight Plan Filed: None
Destination: Rhome, TX (T76)
Type of Clearance: None
Departure Time: 1935 CDT
Type of Airspace: Class E 

Airport Information

Airport: Rhome Meadows (T76)
Runway Surface Type: Grass/turf
Airport Elevation: 900 ft
Runway Surface Condition: Dry
Runway Used: 13
IFR Approach: None
Runway Length/Width: 3700 ft / 60 ft
VFR Approach/Landing: None 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 3 Serious
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal, 3 Serious
Latitude, Longitude: 33.148056, -97.490000

The airplane came to rest inverted on a southeast heading about 350 yards north of the departure end of runway 13 (see figure 2).

Figure 2. Airplane inverted in a field

A postaccident examination of the accident site and wreckage revealed that the left wing leading edge was crushed aft and sustained impact damage, including evidence of tree strikes; the wing was partially separated from the fuselage and distorted aft. The right wing leading edge was crushed aft. All flight control cables were traced from their respective control surfaces to the cockpit controls with no separations or anomalies noted. The elevator trim tab was slightly nose-down but near neutral. The flaps were retracted. The right control yoke was separated at the control column, consistent with impact damage. The left control yoke was damaged consistent with impact.

There were no shoulder harnesses installed. The adult passenger reported that all occupants wore lap belts during the flight, and all four lap belts appeared to exhibit stretching in the webbing, indicative of the belts being worn during impact. The right rear lap belt was found separated from the eyelet at the floorboard. The left front seat was improperly safety-wired.

The fuel selector handle and valve were found in the OFF position; first responders reported that they moved the handle to OFF after the accident. A small amount of fuel was found in the firewall fuel strainer. The fuel was tested for water using water-detecting paste; the test was negative. The left and right wing fuel tanks were impact damaged, but about 2 gallons of fuel were drained from the tanks during the recovery process.

Two empty beer cans were found in the front left floorboard area near the rudder pedals. A rodent's nest was found inside the left wing near an area that had been impact damaged. A significant amount of cobwebs were observed in the engine compartment. The airbox was clear of obstructions. A large mud dauber nest was found on the fins of the oil cooler. The ELT was found in place with battery acid residue on the outside of the case. An automotive battery was installed in the airplane.

The tip of the propeller spinner was bent but the rest of the spinner was mostly undamaged. The 2 propeller blades were straight and undamaged with no chordwise scratches or leading edge damage.

The gascolator fuel strainer was disassembled and organic debris similar to insect cocoons was found inside the strainer screen (see figure 3). The strainer bowl was mostly full of blue-colored fuel consistent with 100LL aviation gasoline.

Figure 3. Fuel fitting with organic contaminants

The main fuel line from the gascolator to the carburetor was a hydraulic hose manufactured in July 2013 and featured a Department of Transportation marking consistent with an automotive hydraulic hose.

Engine crankshaft and camshaft continuity was confirmed by manually rotating the propeller. Thumb suction and compression was obtained for each cylinder. Normal rocker and valve movement was observed and all accessory gears rotated at the back of the engine. The exhaust system sustained damage to the heat exchanger, which was breached as a result of the accident. All of the flame cones were deteriorated and missing.

The carburetor was removed and disassembled; the float chamber contained about 5 mL of fuel. The fuel was tested for water using water-detecting paste; the test was negative. Both magnetos were secure on their respective mounts. The ignition timing was verified at 25° before top dead center on the left magneto. The left magneto was actuated by rotating the propeller by hand, it produced spark at all outlet points. The right magneto was secure on its mount. The ignition timing was verified about 30° before top dead center. The right magneto was removed from its mount and rotated using an electric drill, it produced spark at all outlet points. The top spark plugs were removed and exhibited a color consistent with normal combustion. The oil filter did not display any information regarding the last time it was changed. 




Medical And Pathological Information

Southwestern Institute of Forensic Sciences, Dallas, Texas, completed an autopsy on the pilot and determined the cause of death was "blunt force injuries." The autopsy discovered evidence of hypertensive and atherosclerotic cardiovascular disease, including cardiomegaly, left ventricular hypertrophy, a fusiform aneurysm in the right coronary artery, and moderate atherosclerosis of two other coronary arteries.

Toxicology testing performed by the FAA Forensic Sciences Laboratory identified ethanol in subclavian blood, vitreous fluid, and urine (0.154 gm/dL, 0.177 gm/dL, and 0.194 gm/dL respectively); and 0.0033 µg/mL of delta-9-tetrahydrocannabinol (THC) in the blood. THC's active metabolite, 11-hydroxy-delta-9-THC, was not detected, but the inactive metabolite, carboxy-delta-9-THC, was detected at 0.0139 µg/mL. Both THC metabolites were detected in urine; 11-hydroxy-delta-9-THC at 0.0094 µg/mL and carboxy-delta-9-THC at 0.0346 µg/mL.

Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. Ethanol acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Effects of ethanol on aviators are generally well understood; it significantly impairs pilots' performance, even at very low levels. Title 14 CFR Section 91.17 (a) prohibits any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dL or more ethanol in the blood. Ethanol is water soluble, and after absorption it quickly and uniformly distributes throughout the body's tissues and fluids. The distribution pattern parallels water content and blood supply of the tissue. A small amount of ethanol can be produced after death by microbial activity, usually in conjunction with other alcohols such as methanol; vitreous humor and urine do not suffer from such production. Postabsorption, vitreous humor has about 12% more ethanol than blood and urine about 25% more ethanol than blood.

THC is the primary psychoactive substance in marijuana, which is listed as a schedule I controlled substance. THC's mood-altering effects include euphoria, relaxed inhibitions, disorientation, image distortion, and psychosis. THC is stored in fatty tissues and can be released back into the blood long after consumption. While the psychoactive effects may last for a few hours, THC may be detected in the blood for days or weeks. Low THC levels of a few nanograms per milliliter in blood can result from relatively recent use (e.g., smoking within 1 to 3 hours) when some slight or even moderate impairment is likely to be present, or it can result from chronic use where no recent ingestion has occurred and no impairment is present. Thus, the level of THC in the blood and level of impairment do not appear to be closely related. See the NTSB Medical Factual Report in the public docket for additional information and references.

30 comments:

  1. RIP, such unfortunate unsuspecting passengers joy riding...

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  2. I can't tell what was in worse condition before the crash, the pilot or the plane. Yikes!

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  3. The plane could not have climbed 300 feet with only partial power. The pilot in right seat was likely giving unregulated "instruction" to the minor in the left seat who was likely manipulating the controls.

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  4. What the hell did I just read?

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  5. Ok, pilot was "teaching" child in left seat how to do a takeoff. Child did not apply full power in a timely manner, leading witness on the ground to say engine was not developing normal takeoff power. Then child over rotates and pilot tells child to push nose down to accelerate. Then child pulls back on elevator to climb. Airspeed drops, planes stalls and drops behind trees.

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  6. Everything compromised here.

    No safety, no longevity.

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  7. Only the pilot was killed .....hopefully the 3 recover from their injury’s completely.
    Sounds to me it was just a matter of time .... very poor maintenance using unapproved parts ,alcohol and drugs involved etc etc etc He won’t be risking others lives anymore .....

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  8. I'm sorry he died, but I'm really glad he won't be flying anywhere near me. This guy was an accident waiting to happen and it finally happened.

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  9. All aeroplanes bite fools,that placard was seen in the cockpit many times reminding us of impending accidents.
    There is no room in flying for things like this and so sad that innocent parties have been injured,reading the report is like an horror story.

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  10. Crazy. This has accident waiting to happen written all over it.

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  11. It is a Libertarian view to be free from government influence/interference.

    I respect that point of view and it works for some. However, that viewpoint does not fit when critical standards of maintenance and performance of individuals are involved.

    Some people who fly say it is only their business how they conduct themselves.

    I do not agree. The air highway is paved right over the top of everyone. People who sit in the seats around us and dwell on the ground below us have expectations of our best decision-making and airworthiness.

    I am convinced that Pilot in Command is a continuous state. You earn it and then have to own it. More of a lifestyle as it extends to all phases of flight and ownership.

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  12. Jim. B… exactly! As PIC we have ultimate responsibility for the safety of our passengers, and the people that dwell below our flight paths. I am astonished at how many people detailed in this blog totally ignore this sacred obligation and plunge blindly into the blue abyss in unairworthy airplanes, in an inebriated or impaired state, and/or making rash impulsive decisions that ultimately cost them and others their lives and futures.

    Looks like this guy had been on the edge for a while... it was inevitable that he'd have a problem sooner or later. In his picture he's wearing a parachute rig...maybe he'd have been better sticking to skydiving, more supervision...and if he wrecks he only hurts himself.

    In aviation, you need to pay attention to the rules people, they are written in blood...

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  13. well said, Jim B. In my opinion, Libertarian is not a license to do what you want as if you're the only person on the planet. It requires an incredibly high standard of personal accountability in that you conduct yourself in a manner so as not to impinge upon the rights of others.

    When you buy a plane without logbooks, cobble it together with whatever materials come to hand in whatever manner you can, then launch that plane into the sky with others on board where you may collide with other aircraft or completely innocent people who happen to be on the ground where you crash the damn thing, all the while it whatever state of inebriation you choose, you are not a Libertarian. You are an idiot and a criminal.

    I cannot imagine people at his airfield knew nothing about his behavior. A word to the FAA and a ramp check could've at least delayed his injury of those three kids.

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  14. A Coveted crook crashes and almost killed 3 kids.. I bet the coward pilots on that field knew all those violations he was doing for years and the cowards didnt report this potential killer..

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    1. Come one man, why would you say that? Do you know if any of the pilot sin your field are violating any rule? How can anyone possibly know that?

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  15. Plane was not airworthy, and neither was the pilot. He’d had a hard time getting it to run, hence the test flights. Afraid to cut off the engine, hence boarding the passengers and kid pilot with the prop spinning. Obviously had never annualed the aircraft. Good ‘ole dead guy. Thankfully, the others weren’t killed, and hopefully have recovered. Could have flown it to the ground except for being impaired. Sad event, he certainly knew better than to take the risk and endanger his passengers.

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  16. Impressive read...!
    I liked the empty beer cans best!

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  17. Access your own plane, a strip, do your own maintenance, carry your own jerry cans, fly beyond controlled airspace and you are under the radar of any and all oversight; no feds are searching for illegal rec pilots, and sheriff deputies in good old boy are likely looking for a flight then question the pilot's qualifications!

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  18. I hate to say this but I'm glad that guy is dead he probably would have killed more then himself in the future.

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  19. You can't stand between a man and his destiny ;)

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  20. You had me at "two beer cans".

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  21. I hope the children are recovering. That was a very hard impact. Not good.

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  22. Usually in a case like this the pilot is the only one to survive.
    Too bad about the passengers, but I bet that guy could tell stories that would curl your toes. How did he make it into his sixties?
    Wow, this report was a real eye-opener!

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  23. God must have known this idiot.
    He was sitting in the right seat.

    BTW, Sunset for Rhome Texas that night was 2014L.

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  24. You can smell the beer and cigs just looking at his picture on this report! love the wife beater shirt.

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  25. It's a wonder it didn't happen before now, especially if this is one of the aircraft he was using in his business affairs.
    https://dfw.cbslocal.com/2018/08/17/man-died-plane-crash-experienced-pilot-ran-skydiving-business/

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  26. I experienced fuel starvation issues due to the same sort of "cocoons" in the fuel system. It was mud from mud daubers that entered via the C-150's vent tube on the left wing. The aircraft must have sat for a very long time as they built an epic nest in there. I had to remove the tank and clean it extensively and replaced the vent tube with the upgraded "no drip" style. What a mess.

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  27. I read about his skydiving business and looks like it was a huge ripoff. Lotsa complaints about lack of professionalism and botched skydive cancelled at the last minute while he would keep the deposits or inability to get any video from the jumps etc....

    This guy should have never been flying and instead of experienced was just lucky. If he displayed the same ethics in operating the skydive plane the dissatisfied customers should consider themselves happy they kept their lives.

    So it also happens I saw an ad for a quick estate sale for it coinciding with the NTSB report so I suspect the legal ramification of his crash are coming to roost.

    And the NTSB is right to push for part 135 requirements for skydive operators as the crash in Hawaii and a few others show the carelessness of some operators.

    Just like that balloon crash that killed 19 revealed glaring lack of oversight for "mom and pop" operations the FAA is unable to monitor.

    And someone must have known about the terrible shape of that plane and it being illegal and nor airworthy due to lack of annual to begin with, and his drug/alcohol use especially with the beer cans in that bird, and not reported it to the FSDO?

    Lives are at stake here folks!

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  28. The final report was published a couple of days ago. Nothing new though lack of maintenance and alcohol impairment were confirmed as contributing factors.
    I personally knew the pilot and we had a mutual agreement that I would never get into one of his aircraft.

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