The National Transportation Safety Board did not travel to the scene of this accident.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Grand Rapids, Michigan
Investigation Docket - National Transportation Safety Board:
Location: Whitehall, Michigan
Accident Number: CEN19LA308
Date and Time: September 9, 2019, 11:40 Local
Registration: N9492U
Aircraft: Cessna 150
Aircraft Damage: Destroyed
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Personal
Analysis
The pilot was conducting a personal flight in visual meteorological conditions below the minimum safe altitudes and over congested areas when the airplane impacted the center of a water tower. Witnesses observed the airplane in straight and level flight before impact and reported the engine was running at that time. Examination of the wreckage revealed no anomalies that would have prevented the pilot from maneuvering to avoid the tower.
The pilot’s toxicology results were positive for an antidepressant and a sedating antihistamine. The pilot was operating the airplane with an expired medical certificate, and his medical records indicated that he had been prescribed an antidepressant to treat anxiety/depression. This medication required the pilot to obtain a special issuance medical certificate before operating the airplane. It could not be determined if the pilot was impaired by his use of these medications or by the underlying conditions that warranted the medication.
The reasons that the pilot operated the airplane over a congested area at a low altitude and failed to avoid the water tower could not be determined based on the available evidence for this investigation.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s flight into a water tower while operating below minimum safe altitudes for reasons that could not be determined based on the available evidence for this investigation.
Findings
Aircraft Altitude - Incorrect use/operation
Aircraft Directional control - Incorrect use/operation
Environmental issues Tower/antenna (incl guy wires) - Contributed to outcome
Factual Information
History of Flight
Enroute-cruise Controlled flight into terr/obj (CFIT) (Defining event)
On September 9, 2019, about 1140 eastern daylight time, a Cessna 150 airplane, N9492U, was involved in an accident when it impacted a water tower in Whitehall, Michigan. The pilot was fatally injured, and the airplane was destroyed. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight.
The flight originated from Fremont Municipal Airport (FFX), Fremont, Michigan, about 1115. The pilot’s intended destination could not be determined from the available evidence for this investigation. Witnesses reported observing the airplane flying from the north-northeast at a low altitude and in straight and level flight before the airplane impacted the 180-ft-tall municipal water tower, which was located in a densely populated area about 17 miles west of the departure airport. The witnesses also reported hearing the engine operating at a high-power setting when the impact occurred.
Pilot Information
Certificate: Private
Age: 79, Male
Airplane Rating(s): Single-engine land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: None
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 None
Last FAA Medical Exam: November 1, 1998
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:
No pilot logbooks were found during the investigation. The pilot reported a total flight experience of 2,000 hours at the time of his last medical exam, which occurred more than 20 years before the accident. The FAA had no records indicating that the pilot had renewed his third-class medical certificate after it expired.
Aircraft and Owner/Operator Information
Aircraft Make: Cessna
Registration: N9492U
Model/Series: 150M
Aircraft Category: Airplane
Year of Manufacture: 1976
Amateur Built:
Airworthiness Certificate: Utility
Serial Number: 15078440
Landing Gear Type: Tricycle
Seats:
Date/Type of Last Inspection: Unknown
Certified Max Gross Wt.: 1601 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: Continental
ELT:
Engine Model/Series: O-200 SERIES
Registered Owner:
Rated Power: 100 Horsepower
Operator: On file
Operating Certificate(s) Held: None
No maintenance logbooks were located during the investigation.
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC)
Condition of Light: Day
Observation Facility, Elevation: KMKG,633 ft msl
Distance from Accident Site: 17 Nautical Miles
Observation Time: 11:55 Local
Direction from Accident Site: 142°
Lowest Cloud Condition: Scattered / 3500 ft AGL
Visibility: 10 miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 90°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.56 inches Hg
Temperature/Dew Point: 17.8°C / 11.1°C
Precipitation and Obscuration:
Departure Point: Fremont, MI (FFX)
Type of Flight Plan Filed: None
Destination:
Type of Clearance: None
Departure Time: 11:15 Local
Type of Airspace:
Airport Information
Airport: Fremont Municipal Airport KFFX
Runway Surface Type:
Airport Elevation: 771 ft msl
Runway Surface Condition: Unknown
Runway Used:
IFR Approach: None
Runway Length/Width:
VFR Approach/Landing: None
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries:
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 43.405555,-86.335556(est)
The water tower showed impact damage near the center of the tank that was consistent with the damage noted on the leading edge of the wings and the propeller. The damage to the airplane and the water tower was consistent with the airplane impacting the water tower perpendicular to the tank. The impact was on an approximate heading of 225°. The airplane wreckage was aligned on an approximate heading of 260°. The wreckage was mostly contained to an area that was 15 ft in diameter in the northeast corner of a fenced lot containing the water tower. Miscellaneous debris consisting of a nose and main landing gear tire and small pieces of metal, plastic, and windshield were located within a 130-ft radius of the main wreckage.
Most of the cockpit area and fuselage were consumed by postimpact fire. Flight control continuity was established from the elevators, rudder, and ailerons to the cockpit area, but the impact and fire damage prevented control continuity from being established within the cockpit. The flaps were attached to the wings in the retracted position, the flap cables were intact, and continuity was established between the flaps.
The engine was located under fire-damaged fuselage debris. The engine sustained impact and fire damage and was found fragmented. The engine crankcase was fractured, and cylinders were expelled from the crankcase. The crankshaft was fractured with a part still attached to the propeller.
The propeller had separated from the engine and came to rest under the horizontal and vertical stabilizers. The propeller was damaged from its impact with the water tower. The spinner assembly was flattened and deformed into the propeller hub, and a circular flattening was observed. The propeller mounting bolts were sheared and exhibited rotational bending. One blade was bent aft at the tip, bent midspan, and had chordwise scratching. The other blade was bent aft near the blade root and had chordwise scratching. No airframe or engine anomalies consistent with a preimpact failure or malfunction were noted.
Additional Information
Title 14 Code of Federal Regulations 91.119, Minimum Safe Altitudes, states in part the following:
Except when necessary for takeoff or landing, no person may operate an aircraft below the following altitudes…Over any congested area of a city, town, or settlement, or over any open air assembly of persons, an altitude of 1,000 feet above the highest obstacle within a horizontal radius of 2,000 feet of the aircraft.
Medical and Pathological Information
The Western Michigan University School of Medicine, Medical Examiner and Forensic Services, performed an autopsy of the pilot. His cause of death was multiple injuries. Toxicology testing performed at the Federal Aviation Administration’s Forensic Sciences Laboratory detected citalopram, N-desmethylcitalopram, and diphenhydramine in the pilot’s specimens.
Citalopram is a prescription medication used to treat various conditions, including depression, obsessive-compulsive disorder, panic disorder, anxiety disorder and post-traumatic stress disorder. N-desmethylcitalopram is a metabolite of citalopram. Diphenhydramine is a sedating antihistamine used to treat allergic conditions and facilitate sleep.
The patient instructions for citalopram state the following:
Because psychoactive drugs may impair judgment, thinking, or motor skills, patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that [citalopram] therapy does not affect their ability to engage in such activities.
The effects of long-term use of citalopram on performance is not known. The FAA requires pilots using antidepressants, including citalopram, to have a special issuance medical certificate.
The pilot’s personal medical records for the 3 years before the accident were reviewed. The records revealed that the pilot had a longstanding history of high blood pressure, high cholesterol, and an anxiety disorder. He used lisinopril to treat his high blood pressure, atorvastatin to treat his high cholesterol, and escitalopram to treat anxiety/depression. These records did not mention of the extent or seriousness of the pilot’s anxiety/depression.
Major depression is associated with significant cognitive degradation, particularly in executive functioning skills. The cognitive degradation may not improve even with remission of a depressed episode, and patients with severe depression are more significantly affected than those with fewer symptoms or episodes.
They can't say it for liability purposes, but the odds that this wasn't intentional are pretty slim.
ReplyDeleteExactly what I was thinking!
DeleteAgreed.
Delete