January 16, 2000 NTSB Incident Report on the Cessna 150 at Chesterfield, MO (CHI95IA030)

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by	The Editors of AVweb
	Documents Provided by the NTSB

NTSB Identification: CHI95IA030.
The docket is stored in the (offline) NTSB Imaging System.

Incident occurred OCT-26-94 at CHESTERFIELD, MO
Aircraft: CESSNA 150, registration: N7XC
Injuries: 1 Minor.

THE STUDENT SOLO PILOT RETURNED FROM A CROSS COUNTRY FLIGHT COMPLAINING OF HEADACHE, NAUSEA, AND DIFFICULTY WALKING. THE PILOT STATED THAT SHE HAD SMELLED EXHAUST FUMES, WAS NOT TAUGHT OF A POTENTIAL CONNECTION BETWEEN EXHAUST SMELLS AND CARBON MONOXIDE POISONING, AND CONTINUED THE FLIGHT. MEDICAL TESTS REVEALED ELEVATED CARBON MONOXIDE, WHICH REQUIRED 5 1/2 HOURS OF 100% OXYGEN TO REDUCE TO NORMAL LEVELS. POST-FLIGHT INSPECTION REVEALED A CRACK IN THE REPAIRED MUFFLER WHICH HAD BEEN INSTALLED 18 HOURS EARLIER. THE PRIVATE PILOT PRACTICAL TEST STANDARDS REQUIRE THAT AN APPLICANT EXHIBIT KNOWLEDGE OF SYMPTOMS, EFFECTS, AND CORRECTIVE ACTIONS FOR CARBON MONOXIDE POISONING.

Probable Cause
the cracked heater exhaust muffler which resulted from an improper repair. Factors were the physical impairment of the solo flight student as a result of her inadequate training concerning carbon monoxide hazards.

On October 26, 1994, at 1800 central daylight time, a student pilot returned from a solo cross country in a Cessna 150, N7XC, operated as a 14 CFR Part 91 training flight by Weiss Aviation of Chesterfield, Missouri. The student complained she was nauseous, about to pass out, and had difficulty walking, but drove herself home. Four hours later, after discovering an exhaust muffler crack (the repaired muffler had accumulated 18 hours in service since installation), the operator contacted the student and recommended she obtain medical attention. Medical testing revealed an elevated blood level of Carbon Monoxide (17.5%). After 5 1/2 hours of 100% Oxygen treatment, the CO concentration had reduced to 1.5% and the pilot was released.

The pilot stated that she had smelled fumes during the flight, was not taught of a potential hazard or connection between the smell and Carbon Monoxide poisoning, and continued the flight.

AC-61-21A, the Federal Aviation Administration Flight Training Handbook, discusses the hazards of Carbon Monoxide poisoning and faulty heater systems as a cause. FAA-S-8081, the Private Pilot Practical Test Standards, requires under "Aeromedical Factors" that an applicant exhibits knowledge of symtoms, effects, and corrective action of carbon monoxide poisoning.