# NTSB ATL07FA029: Cessna 340A, N808RA, Charleston, SC, December 22, 2006 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 22, 2006, 13:35 local (18:35 UTC) - Place: Charleston, SC - Coordinates: 32.718055, -79.987777 - Nearby events: https://openairdocs.org/map.md?lat=32.7181&lon=-79.9878&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report April 30, 2008 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, McCauley Propeller Systems, Columbia FSDO-13, Cessna Aircraft Company - NTSB case key (mKey): 65066 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL07FA029 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/65066/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=65066 - Page: https://openairdocs.org/ntsb/ATL07FA029 ## Probable cause The pilot's failure to maintain airspeed during a turn from base to final, resulting in an inadvertent stall/spin. Contributing to the accident was the impairment of the pilot due to the combination of drugs found in his toxicological report. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - vfr pattern - base leg/base to final - impairment(drugs), pilot in command (cause) - stall/spin - inadvertent, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - water ## Analysis According to an airport employee at the Charleston Executive Airport (JZI), Charleston, South Carolina, the pilot contacted the JZI UNICOM radio frequency to request an airport advisory. The airport employee informed the pilot that the "winds were from 180 at 12 knots gusting to 17." The pilot then responded that he would be landing on runway 18, and was advised by the employee that there was no "runway 18." The pilot then stated that he would land on runway 27, and shortly thereafter said that he would land on runway 22. The employee said that out of curiosity he stepped outside to witness the approach of the airplane. He said that the airplane was southwest of the airport moving northeast perpendicular to runway 22, at an altitude of approximately 500 feet. He watched as the airplane was on a left base for runway 22. He said that the airplane overshot the runway and began a "tight, low right turn" away from the airport. Shortly thereafter, the airplane stalled and completed two revolutions before it was lost from his sight. Examination of the airframe, flight controls, engine assemblies and accessories revealed no evidence of a pre-crash mechanical failure or malfunction. A forensic toxicology test was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens contained, Tramadol (also known by the trade name Ultram), which is used for the management of moderate to severe pain. The level of Tramadol found in the pilot's blood on post-mortem toxicology testing was at least twice that of maximal regular doses of the substance. Single doses have been shown to cause mild impairment of psychomotor abilities in healthy volunteers. Diphenhydramine was also found in the blood of the pilot. The pilot may have been impaired, at that time, due to the use of Tramadol or Diphenhydramine or both. ## Factual narrative HISTORY OF FLIGHT On December 22, 2006, at 1335 eastern standard time, a Cessna 340A, N808RA, registered to and operated by a private pilot, as a 14 Code of Federal Regulations Part 91 personal flight, collided with the Stono River during a visual approach into Charleston Executive Airport (JZI), Charleston, South Carolina. Instrument meteorological conditions prevailed at the time of the accident, and an instrument flight rules flight plan was filed. The private pilot and three passengers were fatally injured, and the airplane sustained substantial damage. The flight departed Rock Hill Airport-Bryant Field, Rock Hill, South Carolina on December 22, 2006, at 1130. According to Charleston Approach Control personnel, at 1330, the pilot was cleared for the ILS 09-approach into Charleston Executive Airport. The pilot elected to cancel his IFR handling and maintain 2,000 feet. Approach control notified the pilot to squawk 1200, and radar services were terminated. No further radio or radar contact was made with the flight. According to an airport employee at JZI, the pilot contacted the JZI UNICOM radio frequency to request an airport advisory. The airport employee informed the pilot that the "winds were from 180 at 12 knots gusting to 17." The pilot then reported that he would be landing on runway 18. The airport employee advised the pilot that there was no "runway 18." The pilot then stated that he would land on runway 27, and then said that he would land on runway 22. The employee stepped outside to witness the approach of the airplane. He reported that the airplane was southwest of the airport moving northeast, perpendicular to runway 22, at an altitude of approximately 500 feet. He witnessed the airplane on a left base for runway 22. He said that the airplane overshot the runway and began a "tight, low right turn" away from the airport. He then witnessed the airplane stall and completed two revolutions before it was lost from his sight. PERSONNEL INFORMATION The pilot, age 58 held a private pilot certificate with ratings for airplane single engine land, and multi-engine land issued on November 27, 2005,and a third-class medical certificate issued December 22, 2005 with limitations for corrective lenses. Review of the pilot's logbook revealed he had accumulated 1504 total flight hours, of which 129.6 hours were in the Cessna 340A. The pilot had logged 19.7-flight hour's, which were flown in the last 90 days. AIRCRAFT INFORMATION The six-seat, low-wing, fixed-gear airplane, serial number (S/N) 340A0796, was manufactured in 1979. It was powered by two Continental TSIO-520-NB 300-hp engines and equipped with McCauley 3AF32C93-NR constant speed propellers. Review of the maintenance logbook records showed an annual inspection was completed October 20, 2006, at a recorded tachometer reading of 3494.9 hours, airframe total time of 3828.9 hours, and engine time since major overhaul of 1173.8 hours. The tachometer and Hobbs hour-meter were integrated in the Chelton Electronic Flight Information System, however, damage to the system precluded determining the current readings. METEOROLOGICAL INFORMATION A review of recorded data from the Charleston Air Force Base/International Airport automated weather observation station, elevation 46 feet, revealed at 1318, conditions were winds 170 degrees at 14 knots, with gust to 24 knots, visibility 2.5 statute miles with light rain and fog; cloud conditions broken at 2,800 feet, overcast at 4,800 feet. WRECKAGE AND IMPACT INFORMATION Examination of the wreckage revealed that the airplane crash into the Stono River and came to rest 15 feet below the surface of the river. The airplane was recovered to the bank of the river for examination. Examination of the recovered airframe and flight control system components revealed no evidence of preimpact mechanical malfunction. Examination of the airplane revealed the nose section was partially separated from the fuselage and crushed. The nose wheel assembly remained attached to the nose section and was in the extended position. Examination of the cockpit revealed both engine controls in the cockpit were in the full forward position and both fuel selectors were in the main tank positions. The underside of the cockpit and cabin section of the fuselage was buckled upwards. The empennage aft of the pressure bulkhead was separated from the fuselage and remained attached by the elevator and rudder control cables. The main landing gear assemblies were in the down and locked position. Flight control cable continuity was established throughout the aircraft to all flight control surfaces. Both engines were partially attached to the wing by the engine mounts and the oil supply lines. Examination of the recovered engines and system components revealed no evidence of preimpact mechanical malfunction. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on December 23, 2006, by Medical University of South Carolina, Department of Pathology and Lab Medicine, Charleston, South Carolina, as authorized by the deputy coroner of Charleston, South Carolina. The autopsy findings included "multiple blunt force injuries," and the report listed the specific injuries. The cause of death was reported as two of the listed injuries. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol was detected in the liver or muscle, and Atenolol, Tramadol, Diphenhydramine, and Bupropion were detected in the blood. Atenolol, Tramadol, Diphehydramine, Hydrocodone, Dihydrocodeine, and Bupropion were detected in the urine. An autopsy was performed on the three passengers on December 23, 2006, by Medical University of South Carolina, Department of Pathology and Lab Medicine, Charleston, South Carolina, as authorized by the deputy coroner of Charleston, South Carolina. The autopsy findings reported cause of death was due to blunt force trauma. Forensic toxicology was performed on specimens from the passengers, and the toxicology report stated negative for drugs and alcohol. TEST AND RESEARCH The airplane was equipped with an Insight Instrument Gemini 610 1200 Series Twin Engine system displays. An internal inspection revealed moderate signs of corrosion due to fluid exposure. The internal backup-battery was intact but showed signs of corrosion. Due to extensive corrosion damage, the unit could not be powered-up successfully. A non-volatile memory chip was identified on the main PC board, and sent to the manufacturer for data recovery. The memory chip was returned to the NTSB, and the manufacturer reported that the memory chip was corrupted, and that no flights were recoverable from the memory device. ## Aircraft - Registration: [N808RA](https://openairdocs.org/deregistered/N808RA-2007-10-31), registration cancelled 2007-10-31, S/N 340A0796, built 1979 (OpenAirDocs) - Reported make and model: Cessna 340A - Registry model: [Cessna 340A](https://openairdocs.org/model/cessna-340a) (registry code 2076405) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 340A0796 - Airframe hours: 3828.9 - Engines: Continental TSIO-520-NB 310 horsepower reciprocating; Continental TSIO-520-NB 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Ray Baxter Armistead - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 1, 2006 - Departed: KUZA, Rock Hill, SC - Destination: KJZI, Charleston, SC - Flight plan: IFR - Airport: JZI, Charleston Executive, runway 22, 4,313 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review February 1, 2006; seat: left; toxicology performed; flight hours: 1,504 total, 129 in this make and model, 19 in the last 90 days, 12 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 170° at 14 knots, gusting 24 - Visibility: 2.5 statute miles - Lowest ceiling: 2,800 ft broken - Temperature: 63 °F, dew point 61 °F - Altimeter: 30.04 inHg - Observed at: KCHS, 12 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20061222026039A](https://openairdocs.org/incident/20061222026039A), Dec 22, 2006: Cessna 340A, Charleston, SC, Destroyed, 4 fatal. (-23) Charleston SC ATC reported downed aircraft in the stono river near Charleston SC. The aircraft had been cleared ILS approach to runway 09, johns island,… ## Docket (26 files) The files NTSB released with the investigation on April 28, 2008, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=65066. 43.7 MB in all. - Medical Records Information (item 1, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293521&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF - NVM 17 - Graphic Engine Monitor Study (item 2, .PDF, 995 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40287727&FileExtension=.PDF&FileName=NVM%2017%20-%20Graphic%20Engine%20Monitor%20Study-Master.PDF - Reports from Federal Agencies-ATC TRANSRIPT (item 3, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291731&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies-ATC%20TRANSRIPT%20-Redacted.PDF - Reports from State Agencies-JZI INSPECTION REPORT (item 4, .PDF, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291733&FileExtension=.PDF&FileName=Reports%20from%20State%20Agencies-JZI%20INSPECTION%20REPORT-Master.PDF - Reports from Federal Agencies-US COAST GUARD R#PORT (item 5, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291734&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies-US%20COAST%20GUARD%20R%23PORT-Redacted.PDF - Other Pertinent Forms and Reports-AIRCRAFT LOGBOOK (item 6, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291735&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-AIRCRAFT%20LOGBOOK-Redacted.PDF - Other Pertinent Forms and Reports-LF ENGINE LOGBOOK (item 7, .PDF, 565 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291737&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-LF%20ENGINE%20LOGBOOK%20-Redacted.PDF - Other Pertinent Forms and Reports-LF PROPELLER LOGBOOK pages (item 8, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291739&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-LF%20PROPELLER%20LOGBOOK%20pages-Redacted.PDF - Other Pertinent Forms and Reports-RT ENGINE LOGBOOK pages (item 9, .PDF, 502 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291742&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-RT%20ENGINE%20LOGBOOK%20pages-Redacted.PDF - Other Pertinent Forms and Reports-RT PROPELLER LOGBOOK pages (item 10, .PDF, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291744&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-RT%20PROPELLER%20LOGBOOK%20pages-Redacted.PDF - Reports from Parties to the Investigation-McCAULEY PROPELLER REPORT (item 11, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291820&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation-McCAULEY%20PROPELLER%20REPORT-Redacted.PDF - Other Pertinent Forms and Reports-Pilots logbook pages (item 12, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40356162&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Pilots%20logbook%20pages-Redacted.PDF - Other Pertinent Forms and Reports-Pilots logbook pages (item 13, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291821&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Pilots%20logbook%20pages-Redacted.PDF - Other Pertinent Forms and Reports-Summary of On-scene examination (item 14, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291826&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Summary%20of%20On-scene%20examination-Master.PDF - Toxicological Report (item 15, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291829&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo-1- Recovery NTSB digital photo (item 16, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291852&FileExtension=.PDF&FileName=Photo-1-%20Recovery%20NTSB%20digital%20photo-Master.PDF - Photo 2- NTSB digital photo (item 17, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291855&FileExtension=.PDF&FileName=Photo%202-%20NTSB%20digital%20photo-Master.PDF - Photo 3-On scene NTSB digital photo (item 18, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291858&FileExtension=.PDF&FileName=Photo%203-On%20scene%20NTSB%20digital%20photo-Master.PDF - Photo 4-Aerial view NTSB digital photo (item 19, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291861&FileExtension=.PDF&FileName=Photo%204-Aerial%20view%20NTSB%20digital%20photo%0D%0A-Master.PDF - Photo 5-Front view NTSB digital photo (item 20, .PDF, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291862&FileExtension=.PDF&FileName=Photo%205-Front%20view%20NTSB%20digital%20photo-Master.PDF - Photo 6-Leftside main fuselage NTSB digital photo (item 21, .PDF, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291863&FileExtension=.PDF&FileName=Photo%206-Leftside%20main%20fuselage%20NTSB%20digital%20photo-Master.PDF - Photo 7- Aft view digital NTSB photo (item 22, .PDF, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291865&FileExtension=.PDF&FileName=Photo%207-%20Aft%20view%20digital%20NTSB%20photo-Master.PDF - Photo 8-Rightside fuselage NTSB digital photo (item 23, .PDF, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40291866&FileExtension=.PDF&FileName=Photo%208-Rightside%20fuselage%20NTSB%20digital%20photo-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 24, .PDF, 863 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40292358&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 25, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40292474&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Reports from Local Agencies-CHARLSTON POLICE DEPARTMENT WITNESS STATMENT (item 26, .PDF, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40293109&FileExtension=.PDF&FileName=Reports%20from%20Local%20Agencies-CHARLSTON%20POLICE%20DEPARTMENT%20WITNESS%20STATMENT%20-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.