# NTSB CEN19FA259: Air Tractor AT502, N6113C, Sumner, IA, August 8, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: August 8, 2019, 07:21 local (12:21 UTC) - Place: Sumner, IA - Coordinates: 42.847778, -92.116943 - Nearby events: https://openairdocs.org/map.md?lat=42.8478&lon=-92.1169&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Pratt & Whitney Canada, Air Tractor Inc., FAA Flight Standards - NTSB case key (mKey): 100022 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA259 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100022/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100022 - Page: https://openairdocs.org/ntsb/CEN19FA259 ## Probable cause The pilot’s impairment by medical conditions and/or medications, which resulted in the airplane’s impact with power lines and terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Impairment/incapacitation](https://openairdocs.org/ntsb-findings/02012000): Personnel issues › Physical · Pilot (probable cause); cases with it: [Air Tractor AT-502B, 1 case](https://openairdocs.org/ntsb-findings/02012000/cases.md?model=0390307), [All aircraft, 40 cases](https://openairdocs.org/ntsb-findings/02012000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Medical event](https://openairdocs.org/ntsb-events/850); cases with it: [Air Tractor AT-502B, 1 case](https://openairdocs.org/ntsb-events/850/sequence.md?model=0390307), [All aircraft, 63 cases](https://openairdocs.org/ntsb-events/850/sequence.md) - [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) (defining event); cases with it: [Air Tractor AT-502B, 22 cases](https://openairdocs.org/ntsb-events/220/sequence.md?model=0390307), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md) - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Air Tractor AT-502B, 18 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=0390307), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Air Tractor AT-502B, 46 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0390307), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot overflew the intended destination airport and continued about 14 miles north before turning to the south. Witnesses located about 2-1/2 miles north of the accident site reported observing the airplane overfly their homes at a low altitude. One witness noted that the airplane appeared to be in level flight, and the engine seemed to be operating normally. A witness near the accident site observed the airplane approach from the west-northwest. The airplane struck power lines; however, the airplane's flightpath was not affected. The airplane then nearly struck a building before it struck a second set of power lines. It then veered left, and the nose dropped. The airplane subsequently impacted a road, skidded across the road, and impacted the ground near a large tree. A postimpact fire ensued. According to witnesses, there was nothing unusual about the airplane before the initial wire strike. The airplane seemed to be intact, and the engine sounded normal. The airplane remained in a shallow left turn as it struck the power lines and did not appear to be climbing or descending. A postaccident airframe examination did not reveal any evidence of an in-flight structural failure or flight control system anomaly. An engine examination revealed circumferential contact marks throughout the engine consistent with rotation at impact. No anomalies consistent with a preimpact failure or malfunction were observed. Review of the pilot’s medical records, toxicology testing, and autopsy results revealed that he was at significant risk of impairment from multiple serious medical conditions and the use of multiple potentially impairing medications. The pilot had heart disease, a subarachnoid hemorrhage that appeared to be several days old, chronic kidney disease treated with dialysis, poorly controlled diabetes, hypertension, chronic pain, and anxiety. In addition, the pilot was taking hydrocodone, fentanyl, trazodone, and yohimbine, any of which had the potential to be impairing. Further, the investigation revealed that the pilot was involved in another wire strike event 8 days before the accident. Witnesses noted that after that wire strike, the pilot seemed shaken, and he was heard coughing and vomiting several days later. The timing of the pilot’s subarachnoid hemorrhage suggests that it may have resulted from this previous wire strike event. Although additional details about the events surrounding the wire strike are not known, the wire strike event itself suggests a possibility of some manifestation of pilot impairment that began before the accident flight. While it could not be determined which specific medical factor or factors played a role in this accident, it is likely that one or more of the pilot's multiple medical conditions, medications, or the previous wire strike impaired his performance during the accident flight, as evidenced by his overflight of the intended destination airport and his continued low altitude flight in the vicinity ofpower lines and buildings without a change in flightpath or any apparent effort to avoid them. ## Factual narrative The owner of an agriculture operation based at OLZ noticed damage to the propeller, windshield, and spray boom following the pilot’s previous wire strike. The airplane remained at OLZ until repairs were completed; the engine and propeller were removed, and the airplane was returned to service 3 days before the accident. A maintenance entry dated August 5, 2019, indicated that the engine power section was removed for an unscheduled inspection due to a propeller strike. It was repaired, reinstalled, and approved for return to service. On August 8, 2019, about 0721 central daylight time, an Air Tractor AT-502B, N6113C, was destroyed when it was involved in an accident near Sumner, Iowa. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 positioning flight. The flight originated from the Mt. Pleasant Municipal Airport, Mt. Pleasant, Iowa, about 0615 and was destined for Oelwein Municipal Airport (OLZ), Oelwein, Iowa. A witness at OLZ reported that the pilot overflew the runway but then continued north. The airplane appeared to be intact, and the engine seemed to be running normally at that time. Based on multiple witness statements, the airplane continued about 14 miles north of OLZ before it turned south. Witnesses located about 2-1/2 miles north of the accident site reported observing the airplane overfly their homes at a low altitude. One witness noted that the airplane appeared to be in level flight, and the engine seemed to be operating normally. A witness near the accident site observed the airplane approach from the west-northwest in a constant 20° left turn. The airplane struck the power lines; however, the airplane's flightpath was not affected. The airplane then nearly struck a building before it struck a second set of power lines. It then veered left, and the nose dropped. The airplane subsequently impacted a road, skidded across the road, and impacted the ground near a large tree. A postimpact fire ensued. The witness added that nothing seemed to be unusual about the airplane before the initial wire strike except that it was at a “very low altitude.” The airplane seemed to be intact, and the engine sounded normal. He also stated that the airplane remained in the shallow left turn as it struck the power lines and did not appear to be climbing or descending. An autopsy conducted by the Iowa Office of the State Medical Examiner, Ankeny, Iowa, attributed the pilot's death to multiple blunt force injuries with thermal injuries. The autopsy identified evidence of heart disease, a subarachnoid hemorrhage that appeared to be several days old, pulmonary hypertension, and chronic kidney disease. Medical records revealed the pilot received dialysis for kidney disease and was being treated for diabetes, which his primary care doctor described as "not well controlled." In addition, the pilot had a history of coronary artery disease treated with stent placement and high blood pressure treatedwith medication. Toxicology testing was performed by the Federal Aviation Administration Forensic Sciences Laboratory. The testing detected hydrocodone and dihydrocodeine, fentanyl and norfentanyl, trazodone, and yohimbine in heart blood and liver tissue. Hydrocodone and fentanyl were prescribed to the pilot for chronic pain due to spinal stenosis. Both are in a class of medications referred to as opioid analgesics and have the potential to be impairing. Dihydrocodeine and norfentanyl are metabolites of hydrocodone and fentanyl, respectively. Trazodone was prescribed for anxiety. It is in a class of medications referred to as serotonin modulators and may impair the mental and/or physical ability required for the performance of potentially hazardous tasks. Yohimbine is used as a dietary supplement for multiple reasons including impotence, diabetic neuropathy, high blood pressure, and chest pain. It has stimulant effects and may impair mental and physical ability to perform hazardous tasks. Sunrise occurred at 0608. At the time of the accident, the sun was positioned about 12° above the horizon at an azimuth of 079° (relative to true north). The pilot's logbook was not available to the National Transportation Safety Board during the investigation. On his most recent medical certificate application, the pilot reported taking no medications and having diet-controlled diabetes. He was involved in a wire strike event in the accident airplane 8 days before the accident. Witnesses noted that after that wire strike, the pilot seemed shaken, and he was heard coughing and vomiting several days later. Damage to two sets of power lines, a small roof-mounted antenna on a single-story building, and a power line support pole was consistent with the airplane striking them before impacting a two-lane road and coming to rest against a large tree. The accident site was in the yard of a mixed-use commercial/residential building. The main wreckage consisted of the fuselage, right wing, inboard portion of the left wing, and empennage. The outboard portion of the left wing and the left aileron had separated and were located near the power line support pole. The engine, with the propeller attached, had separated from the airframe and was located at the accident site. A postimpact fire consumed most of the fuselage. A postaccident airframe examination did not reveal any evidence of an in-flight structural failure or flight control system anomaly. An engine examination revealed circumferential contact marks throughout the engine consistent with rotation at impact. No anomalies consistent with a preimpact failure or malfunction were observed. ## Aircraft - Registration: [N6113C](https://openairdocs.org/deregistered/N6113C-2022-11-05), registration cancelled 2022-11-05, S/N 502B-0275, built 1994 (OpenAirDocs) - Reported make and model: Air Tractor AT502 (B) - Registry model: [Air Tractor AT-502B](https://openairdocs.org/model/air-tractor-at-502b) (registry code 0390307) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52034, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 502B-0275 - Year built: 1994 - Airframe hours: 10605 - Engines: Pratt & Whitney PT6A-34AG 750 horsepower turbo prop - Damage: Destroyed - Fire: On-Ground - Flight: Positioning, Part 91 - Operator: Air Advantage Inc - Registered owner: Air Advantage Inc - Airworthiness certificate: Special, Restricted (Special) - Last inspection: 100 hour, July 9, 2019 - Departed: MPZ, Mt. Pleasant, IA - Destination: OLZ, Oelwein, IA - Equipment: Stall warning system, Satellite tracking device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: fatal; commercial; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; seat: single; restraint: 4-point; toxicology performed; flight hours: 21,000 total ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 63 °F - Altimeter: 29.93 inHg - Observed at: OLZ, 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 20190808015739A](https://openairdocs.org/incident/20190808015739A), Aug 8, 2019: Air Tractor Inc AT-502B, Sumner, IA, Destroyed, 1 fatal. 06:10, 8/8/2019 ? Pilot departed mount pleasant municipal airport (mpz) direct to oelwein municipal airport (orc). Pilot was instructed to load fungicide at… ## Other investigations on N6113C (1) 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. - [NTSB CEN13LA473](https://openairdocs.org/ntsb/CEN13LA473), Jul 15, 2013: Air Tractor AT-502B (N6113C), Nauvoo, IL, substantial damage. Probable cause: A fatigue failure of an engine compressor turbine blade, which resulted in extensive secondary engine damage and a complete loss of engine power. ## Docket (14 files) The files NTSB released with the investigation on April 29, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100022. 25.7 MB in all. - Accident site diagram (item 1, PDF, 1 page, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9182584&FileExtension=pdf&FileName=(01)%20Accd%20Site%20Diagram-Rel.pdf - Witness statements (item 2, PDF, 20 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9181824&FileExtension=pdf&FileName=(02)%20Witness%20Stmts_redacted-Rel.pdf - Airplane examination summary (item 3, PDF, 7 pages, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9182570&FileExtension=pdf&FileName=(03)%20Examination%20Summary%20--%20CEN19FA259-Rel.pdf - Accident report photos (item 4, PDF, 7 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9181660&FileExtension=pdf&FileName=(04)%20Docket%20Photos%20--%20CEN19FA259-Rel.pdf - Maintenance records -- airframe (item 5, PDF, 21 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9182593&FileExtension=pdf&FileName=(05)%20Maintenance%20Records%20--%20Airframe_redacted-Rel.pdf - Maintenance records -- engine (item 6, PDF, 13 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9181833&FileExtension=pdf&FileName=(06)%20Maintenance%20Records%20--%20Engine_redacted-Rel.pdf - Maintenance records -- propeller (item 7, PDF, 4 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9182579&FileExtension=pdf&FileName=(07)%20Maintenance%20Records%20--%20Propeller_redacted-Rel.pdf - Maintenance records -- AD compliance (item 8, PDF, 3 pages, 510 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9181669&FileExtension=pdf&FileName=(08)%20Maintenance%20Records%20--%20AD%20Compliance_redacted-Rel.pdf - Maintenance records -- engine repair invoice (wire stike event) (item 9, PDF, 8 pages, 7.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9182602&FileExtension=pdf&FileName=(09)%20Maintenance%20Records%20--%20Engine%20Repair%20Invoice%20(Wire%20Strike%20Event)_redacted-Rel.pdf - Email correspondence -- insurance adjuster (item 10, PDF, 2 pages, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9551182&FileExtension=pdf&FileName=(10)%20Email%20--%20Old%20Republic%20Aerospace%20(Russell%20Day)%20--%2012Aug2019_redacted-Rel.pdf - Toxicological report (item 11, PDF, 2 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9182910&FileExtension=pdf&FileName=(11)%20Toxicology%20Rpt%20--%20David%20Baker_redacted-Rel.pdf - Medical officer's factual report (item 12, PDF, 5 pages, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9545380&FileExtension=pdf&FileName=CEN19FA259_Sumner_IA_Medical_Factual_FINAL_042720-Rel.pdf - Statement of party representatives to NTSB investigation (item 13, PDF, 1 page, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9181678&FileExtension=pdf&FileName=(12)%20Party%20Form%20--%20Air%20Tractor%20(CEN19FA259)_redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 14, PDF, 2 pages, 456 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9623859&FileExtension=pdf&FileName=Release%20of%20Wreckage%20--%20CEN19FA259_redacted-Rel.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.