Accident Probe: Every Rule In The Book

What appears to have been total refusal to follow basic standards has an inevitable conclusion.

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Every now and then, I come across an NTSB accident report that leaves me shaking my head. After absorbing the facts and the outcome, I want to reach out to grab the pilot and shake him—it’s always a “him”—into some more enlightened state of awareness regarding the possible consequences of his actions. So it is with this month’s Accident Probe entry, which pretty much represents the gold standard of what not to do when it comes to aircraft ownership and operation. Rather than attempt to explain the inexplicable as an introduction, let’s just dive right in.

Background

On August 16, 2018, at about 1935 Central time, a Cessna 172L Skyhawk impacted trees and terrain shortly after takeoff from the turf runway at the Rhome Meadows Airport (T76), Rhome, Texas. The commercial pilot was fatally injured; the three passengers sustained serious injuries. The airplane was substantially damaged. Visual conditions prevailed.

A family member later stated the pilot retrieved the airplane from under the open-air shelter for “family fun night” and was giving rides to family members. The pilot had flown the airplane about a week before, then twice again immediately preceding the accident flight. There were no reported anomalies with the airplane.

A pilot-rated witness saw the airplane land and taxi back. Three passengers boarded while the engine remained running. The airplane began its takeoff roll but did not sound like it was developing full power, and the takeoff roll was longer than expected. Becoming airborne, the airplane’s nose pitched up “very high” as it climbed to about 50 feet AGL, and then the nose came back down. The airplane flew down the runway, appearing to accelerate, and then pitched up and climbed to about 300 feet AGL. It then made a left turn and descended out of view, coming to rest inverted about 350 yards north of the departure end of Runway 13.

Investigation

Post-accident examination revealed all flight control cables were continuous from their respective control surfaces to the cockpit controls. The flaps were retracted. The fuel selector handle and valve had been moved to the OFF position by first responders. A small amount of fuel was found in the firewall fuel strainer. Both wing-mounted fuel tanks were impact-damaged, but about two gallons of fuel were drained from them during the recovery process.

According to the NTSB, “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…. 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 propeller blades were straight and relatively undamaged, indicating the engine was not producing power at the time of impact. Organic debris similar to insect cocoons was found in the fuel strainer, which was mostly full of a liquid consistent with 100LL. The fuel tested negative for water.

“The main fuel line from the gascolator to the carburetor was a hydraulic hose manufactured in July 2013,” the NTSB noted. The exhaust system’s flame cones were either deteriorated or missing altogether. The left magneto’s ignition timing was verified at 25 degrees before top dead center; the right magneto’s timing was about 30 degrees BTDC. Both magnetos generated spark when turned. There was no information on the oil filter about the date or engine time when it was changed.

The pilot’s wife told investigators that the airplane’s maintenance logbooks were never received from the previous owner after the airplane was purchased in 2013. According to the NTSB, “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.”

On October 13, 2017, the date of his most recent medical certificate application, the pilot reported 8000 hours of flight experience and 125 hours in the preceding six 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,” the NTSB said.

Toxicology testing identified ethanol in the pilot’s tissue samples at levels greater than can be explained by postmortem microbial activity and in excess of FAA regulations. Active and inactive metabolites of tetrahydrocannabinol (THC), the psychoactive substance in marijuana, were detected in the pilot’s urine. It’s important to note that there is no established relationship between THC levels and impairment, according to a 2017 Report to Congress by the National Highway Traffic Safety Administration, an FAA sister agency.

During the accident 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.

Probable Cause

The NTSB determined the probable cause(s) of this accident to include: “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.”

According to the NTSB, “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.”

We all know at least one pilot who occasionally displays one or two of the hazardous attitudes the FAA identifies (see the chart below), but it’s difficult to find one who checks almost all the boxes. Now you have.


Accident Profile: Cessna 172L Skyhawk

OEM Engine: Lycoming O-320-E2D

Empty Weight: 1315 lbs.

Maximum Gross Takeoff Weight: 2300 lbs.

Typical Cruise Speed: 115 KTAS

Standard Fuel Capacity: 42 gallons

Service Ceiling: 13,100 feet

Range: 417 NM

VS0: 43 KCAS


Jeb Burnside is the editor-in-chief of Aviation Safety magazine. He’s an airline transport pilot who owns a Beechcraft Debonair, plus the expensive half of an Aeronca 7CCM Champ.


This article originally appeared in the August 2021 issue of Aviation Safety magazine.

For more great content like this, subscribe to Aviation Safety!

Jeb Burnside is the editor-in-chief of Aviation Safety magazine. He’s an airline transport pilot who owns a Beechcraft Debonair, plus the expensive half of an Aeronca 7CCM Champ.

8 COMMENTS

  1. People are reluctant, if not afraid, to report irresponsible behavior to any authority. Misbehavior as egregious as this could not have gone unknown for so long to others in the local area. Certainly, the WingNut behind the wheel was primarily responsible for the crash and injury to others, but do the other party goers and onlookers who were aware of the misbehavior escape responsibility? I think not. Just another opinion.

  2. Another absolute Darwin Candidate, out of control.

    Like the intoxicated baseball player who dover his icon or whatever amphibian into the water.

    I was tempted to hope that his wife had a good insurance policy on him – but it seems she may have tolerated his DC behaviour.

    BTW, automotive police have criteria for evaluating intoxication from marijuana, and thresholds of impairment. He seems like a substance-abusing personality.

    And as I hope many of you know, different materials are sensitive to different fluids. A classic example is Skydrol and mineral hydraulic fluid, putting Skydrol into a B737 gear strut may cost you a gear-up landing. Chrysler automotive fuel manifolds of the early 90s had leaks because engineers cleverly changed materials of seals to something that sounded good but was more affected by ethanol and other things added to gasoline.

    • While I agree with you on almost everything you said, and also on the point that this pilot was totally irresponsible I do have to make a rebuttal.

      On the fact automotive police which I assume you mean police in general as there is no sky cops or land cops for that matter but that’s not the point, police do have means of evaluating impairment but not in the manner that you are thinking.
      A standard test if impairment for substances other then alcohol requires a series of tests that are pass fail and determine if the suspect has a deminished mental capacity to the point in which tasks such as driving could no longer be preformed safely how ever this test does not work across the board as tolerance is different for each person and there is no test for THC in the sense of metabolic chemistry levels in which a certain number is deemed to be a limit as with alcohol, also THC lasts in the body much longer then alcohol so there is no exact science to prove when the substance was ingested we only get a general idea and even then so we again fall back to every one tolerates different so you’d have to prove at the time the suspect was physically and mentally impaired by the THC.

      This isn’t to say I approve of THC use or think by any means this pilot made sound judgements just that the argument regarding means of testing this like we do alcohol isn’t a strong one because land cops still lose over 95 precent of the cases in which they issued summons regarding impairment by use of THC.

      Lastly the accused pilots substance abusing personality.. look I’ll leave at this there is no way from the brief article we could know he loved abusing substances. Everyone has a beer or two every now and then and now with marijuana becoming legal in most places their is going to be plenty more use then in the past but that doesn’t mean that someone who is found to have used either substance is abusing or has an abusive personality just that they had either bad judgement prior to using the substance or gained bad judgment after using the substance..

      Now if we said the man had two bottle before noon and a handle for dinner and was found with a needle in his arm and a pipe in his mouth I would say that pilot has more then a substance abusing personality lol.

      .

      • Thankyou for pointing out that marijuana is not benign.

        Police in BC and WA had to develop procedures for evaluating level of impairment with marijuana. I doubt they lose most of their cases, though beware that statistics may vary depending on whether or not police can lay charges – Alberta, or just provide evidence to prosecutors – BC, which is cautious about losing.

        People are idiots in many ways. Saanich BC police caught a fem speeding in a school zone, smelled marijuana. She and some other mothers had smoked marijuana to celebrate their children returning to school. (Poor children do not have parents. :-o) By the time police got a marijuana specialist on scene she tested just under the legal limit. I believe Saanich police are now more capable of deciding more quickly.

        Meanwhile boozers are still about, some driving despite their license having been yanked.

  3. The investigators are wrong to say there have been no studies of THC and performance.
    A French, extensive, government study of road accident drivers who died in the crash, published around 5 years ago, found drivers who had THC in their system were at double the risk compared to drivers without performance affecting substances.
    Drivers just over the first of the drink drive limits in France 0.5 mg alcohol per 100 ml of blood, were five times more at risk, those just over the second limit , 0.8 mg alcohol per 100 ml blood (the one with automatic bans) were eight times more at risk.