# NTSB CEN17FA170: Air Tractor AT 602, N604RH, Hollis, OK, April 28, 2017 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 28, 2017, 13:00 local (18:00 UTC) - Place: Hollis, OK - Coordinates: 34.700279, -99.908607 - Nearby events: https://openairdocs.org/map.md?lat=34.7003&lon=-99.9086&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 8, 2019 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Hartzell Propeller Inc., Air Tractor Inc., Pratt & Whitney Canada, FAA Flight Standards - NTSB case key (mKey): 95078 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17FA170 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95078/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95078 - Page: https://openairdocs.org/ntsb/CEN17FA170 ## Probable cause An impact with terrain during final approach for reasons that could not be determined because no evidence of an in-flight failure or malfunction was observed. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Air Tractor AT-602, 13 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=0390309), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Health/Fitness: use of medication/drugs](https://openairdocs.org/ntsb-findings/02013020): Personnel issues › Physical · Pilot; cases with it: [Air Tractor AT-602, 2 cases](https://openairdocs.org/ntsb-findings/02013020/cases.md?model=0390309), [All aircraft, 73 cases](https://openairdocs.org/ntsb-findings/02013020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) (defining event); cases with it: [Air Tractor AT-602, 5 cases](https://openairdocs.org/ntsb-events/000/sequence.md?model=0390309), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Air Tractor AT-602, 37 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0390309), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was returning from an application flight at the time of the accident. A witness observed the airplane approaching the airport. He noted that an unusual noise came from the airplane but was unsure of the exact nature. Shortly afterward, he heard a loud explosion. Ground-based video footage depicted the airplane entering a rapid descent while on final approach until it went behind an intervening tree line. A plume of smoke rose from that location few seconds later. A postaccident examination of the airframe, engine and propeller did not reveal any anomalies consistent with a preimpact failure or malfunction. However, an examination of some components was limited due to the extent of the impact damage. Toxicology testing revealed that the pilot had used three sedating drugs: cetirizine, oxycodone, and oxazepam. However, only oxycodone was still present at a level that could have been impairing. Because patients using opioids may develop significant tolerance to the sedating side effects, there is no accepted relationship between blood levels and impairment from these medications. Therefore, the extent of impairment, if any, could not be determined. The reason for the abrupt descent and impact with terrain while on final approach could not be determined because the postaccident examination did not reveal any preimpact anomalies. ## Factual narrative The airplane flight manual "Glide and Approach (Before Landing)" procedure instructed pilots to adjust the engine power to provide the required rate of descent. It noted: "Do not move power lever below idle stop position. Check Beta light – OUT." It noted that, after landing, "reverse thrust may be selected as necessary." In order to prevent an inadvertent application of reverse thrust, the pilot must press the reverse trigger on the power lever and move the lever aft to enter beta mode. On November 29, 2017, Air Tractor issued a service letter regarding the use of propeller beta mode in flight. The letter informed operators that the use of beta in flight is prohibited and that doing so may result in a loss of control due to disrupted airflow over the empennage. On April 28, 2017, about 1300 central daylight time, an Air Tractor AT-602 airplane, N604RH, impacted terrain while on final approach for runway 35 at the Hollis Municipal Airport (O35), Hollis, Oklahoma. The pilot was fatally injured. The airplane was substantially damaged. The airplane was registered to the pilot and operated by Gray Ag Air as a Title 14 Code of Federal Regulations Part 137 aerial application flight. Visual meteorological conditions prevailed at the time of the accident. The flight was not operated on a flight plan. The local flight originated from O35 about 1200. According to a colleague, the pilot was returning from his third or fourth application flight of the day when the accident occurred. The pilot had treated a field about 4 miles northwest of the airport. A witness working near the airport reported hearing the airplane. He subsequently looked up and observed the airplane approaching the airport. Nothing looked unusual about the flight path, attitude, or appearance of the airplane at that time. However, he noted that an unusual noise came from the airplane. He was unsure of the exact nature of the noise but thought that it was either associated with the engine or with the propeller changing pitch. Shortly afterward he heard a loud explosion. Ground-based video footage was recovered from a surveillance camera located about 1.65 miles southwest of the accident site. Due to the location and resolution of the camera, specific details of the airplane were not visible. The airplane appeared as a black dot as it approached runway 35 from the south. About 8 seconds after coming into view, the airplane entered a rapid descent and went out of sight behind an intervening tree line. A plume of smoke was visible rising from behind the tree line a few seconds later. (A copy of the video footage is included in the docket associated with the investigation.) An analysis of the video footage estimated the airplane altitude as about 140 ft above ground level (agl) as it entered the field of view. Shortly before it entered the rapid descent, the altitude was estimated to be 92 ft agl and the rate of descent was about 6 ft/sec (360 ft/min). The airplane groundspeed was estimated at121 +/- 18 knots during that timeframe. Once the airplane entered the final descent, the rate of descent was about 80 ft/sec (4,800 ft/min). The airplane stall speeds ranged from 61 knots to 71 knots with the wing flaps extended depending on the gross weight. The Oklahoma Board of Medical Investigations, Office of the Chief Medical Examiner, Oklahoma City, Oklahoma, performed an autopsy of the pilot and attributed his death to multiple blunt force injuries sustained in the accident. Toxicology testing preformed by the Federal Aviation Administration Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, identified cetirizine at levels too low to quantify, oxycodone at 0.116 ug/ml, and oxymetazoline in cavity blood. Cetirizine, oxycodone, oxymetazoline, acetaminophen, oxazepam, and oxymorphone were identified in urine. Cetirizine is an antihistamine available over-the-counter and commonly used to treat allergies. Oxycodone is an opioid medication available by prescription and commonly used for pain management. Oxymetazoline is a vasoconstrictor available in over-the-counter nasal sprays commonly used to control congestion. Acetaminophen is an analgesic available over-the-counter and commonly used for pain management. Oxazepam is a benzodiazepine available by prescription and commonly used to treat anxiety. Oxymorphone is a metabolite of oxycodone. Cetirizine, oxycodone and oxazepam are known to be sedating. The airplane impacted a wheat field about 101 yards south of the runway 35 threshold. The fuselage came to rest about 26 yards north of the point of initial impact. A postaccident examination was conducted by the NTSB investigator-in-charge with the assistance of technical representatives from the airframe, engine, and propeller manufacturers. The examination did not reveal any anomalies consistent with a preimpact failure or malfunction. Evidence indicated that the propeller blade angles were in the normal operating range at the time of impact. Damage to the propeller governor precluded functional testing. The wing flap actuator extension was consistent with the flaps being down. A detailed summary of the examination is included in the docket associated with the investigation. ## Aircraft - Registration: [N604RH](https://openairdocs.org/deregistered/N604RH-2019-02-01), registration cancelled 2019-02-01, S/N 602-1202, built 2011 (OpenAirDocs) - Reported make and model: AIR TRACTOR INC AT 602 (NO SERIES) - Registry model: [Air Tractor AT-602](https://openairdocs.org/model/air-tractor-at-602) (registry code 0390309) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-65AG](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-65ag) (registry code 52109, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 602-1202 - Year built: 2011 - Airframe hours: 2183.9 - Engines: Pratt & Whitney Canada PT6A-65AG 1300 horsepower turbo prop - Damage: Substantial damage - Fire: On-Ground - Flight: Aerial application, Part 137 - Operator: Gray Ag Air - Registered owner: Pilot - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, April 12, 2017 - Departed: O35, Hollis, OK - Destination: O35, Hollis, OK - Airport: O35, Hollis Municipal, runway 35, 3,008 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: fatal; commercial; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; last flight review February 21, 2017; seat: single; restraint: 5-point; toxicology performed; flight hours: 14,617 total ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 48 °F - Altimeter: 29.63 inHg - Observed at: CDS, 25 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 20170428006579A](https://openairdocs.org/incident/20170428006579A), Apr 28, 2017: Air Tractor Inc AT-602, Hollis, OK, Destroyed, 1 fatal. Aircraft appeared to have struck the ground with the RH wing short of rnwy 35. Next impact was propeller stuck in the ground with blades broken off from hub… ## Docket (12 files) The files NTSB released with the investigation on March 12, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95078. 171 MB in all. - Witness Statements (item 1, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471003&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Ground-Based Surveillance Video Footage (item 2, AVI, 47.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471004&FileExtension=avi&FileName=Ground-Based%20Surveillance%20Video%20Footage-Master - Video Study (item 3, .PDF, 3 photos, 574 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471005&FileExtension=.PDF&FileName=Video%20Study-Master.PDF - Airplane Examination Summary (item 4, .PDF, 134 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471006&FileExtension=.PDF&FileName=Airplane%20Examination%20Summary-Master.PDF - Maintenance Records - Airframe (item 5, .PDF, 44.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471007&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Airframe-Master.PDF - Maintenance Records - Engine (item 6, .PDF, 47.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471008&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Engine-Master.PDF - Maintenance Records - Propeller (item 7, .PDF, 29.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471009&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Propeller-Master.PDF - Airplane Flight Manual - Excerpts (item 8, .PDF, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471010&FileExtension=.PDF&FileName=Airplane%20Flight%20Manual%20-%20Excerpts-Master.PDF - Air Tractor Service Letter (item 9, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471011&FileExtension=.PDF&FileName=Air%20Tractor%20Service%20Letter-Master.PDF - Weather Documentation (item 10, .PDF, 59 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471012&FileExtension=.PDF&FileName=Weather%20Documentation-Master.PDF - Toxicological Report (item 11, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471013&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 399 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471014&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.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.