CEN20FA010

NTSB accident investigation · Cessna 172 · Aberdeen, SD · October 10, 2019

Accident · FatalClass 3 · FieldFinal report
Date
October 9, 2019, 22:35 local (Oct 10, 2019, 03:35 UTC)
Place
Aberdeen, SD
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N6483BCessna 172
Defining event
Maneuvering-low-alt flying: Loss of visual reference
Weather
Instrument (IMC) · Night/dark
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Continental Aerospace Technologies, FAA, Textron Aviation
FAA report
20191009019649A
Case key
100465

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The noncertificated pilot’s decision to fly in dark night instrument conditions, resulting in impact with terrain.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCessna 172: 2 casesAll aircraft: 448 casesProbable cause
Ceiling/visibility/precip: low ceilingEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCessna 172: 2 casesAll aircraft: 190 casesProbable cause
Ceiling/visibility/precip: fogEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeCessna 172: 1 caseAll aircraft: 78 casesProbable cause
Experience/qualifications: total experiencePersonnel issues › Experience/knowledge · PilotCessna 172: 3 casesAll aircraft: 126 casesProbable cause
Action: unnecessary actionPersonnel issues › Action/decision · PilotCessna 172: 1 caseAll aircraft: 52 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

About 10 days prior to the accident flight, the noncertificated pilot had flown his airplane to the airport for an annual inspection. Several mechanical issues were identified, but the pilot chose to not have them addressed. The airplane was tagged as not airworthy and sat on the ramp for several days until the pilot decided to fly the airplane on the night of the accident. The pilot, who held only a student pilot certificate, had low flight time, and was not instrument-rated, departed the airport in dark night instrument meteorological conditions (IMC). There were no records of the pilot contacting any services for weather reports. No communication with the pilot was heard, and no radar of the flight was recorded. The airplane impacted terrain about 7 miles from the airport. The debris distribution on site was consistent with a high speed, low-angle impact with terrain. The airplane was operating within the range of serious carburetor icing at any power setting. Although the carburetor heat control in the cockpit was found in the OFF position, the carburetor and air box were severely damaged and detached from the engine and could not be examined for functionality. The propeller blade damage was consistent with rotation at the time of impact. Toxicological testing results were consistent with the pilot taking disqualifying and potentially impairing medications for depression. However, whether the pilot was impaired or incapacitated by his presumed medical condition or use of multiple potentially impairing medications and whether impairment contributed to this accident could not be determined. Even though several mechanical issues were identified during the inspection before the accident, no obvious mechanical anomalies were found with the engine or airframe during postaccident examinations that could have contributed to the accident. The pilot likely did not have a visible horizon after takeoff due to the instrument meteorological conditions and dark night and the wreckage debris was consistent with a high speed, low angle impact. It is likely that the pilot impacted terrain due to a lack of visibility.

Factual narrative

Maintenance logbooks for the airframe and engine were not found. The only records that were available were work orders that were generated by Aberdeen Flying Service FBO, while assessing the airplane for an annual inspection on October 1, 2019. The inspection was not performed at the pilot’s request. There were no records of any radio communications from the pilot. There was no radar information on the accident flight. The airplane was not equipped with automatic dependent surveillance-broadcast. On October 9, 2019, about 2235 central daylight time, a Cessna 172 airplane, N6483B, was destroyed when it was involved in an accident near Aberdeen, South Dakota. The pilot sustained fatal injuries. The personal flight was conducted under the provisions of Title 14 Federal Code of Regulations Part 91. According to records provided by the airport and a local fixed base operator (FBO), the airplane was flown by the pilot to Aberdeen Regional Airport (ABR) on September 30, 2019, to be assessed for an annual inspection at a local FBO. The pilot was informed by the FBO of what work needed to be accomplished to complete an annual inspection. The pilot decided not to have the work completed and parked the airplane on a ramp at ABR. After the assessment was made, the FBO issued an Aircraft Condition Notice FAA Form 8620-1 and tagged the airplane. The notice stated, “Aircraft deemed un-airworthy due to numerous un-airworthy findings to include broken or cracked landing gear saddles. Other items as described on work order 1083 at ABR Flying Service.” According to a family member, the pilot was dropped off at the airport after normal operating hours and intended to fly the airplane to an airport in North Dakota where the airplane was normally hangered. Airport video surveillance records showed the airplane taking off from runway 31 about 2231 on October 9, 2019. The family member reported the airplane missing when it did not arrive at the destination airport. After an extensive search, the airplane wreckage was located about 7 miles from ABR on October 21, 2019. First responders identified the airplane and notified the FAA and NTSB. The NTSB arrived on scene on October 22, 2019. The pilot had not reported any chronic medical conditions or use of any medications to the FAA. The pilot had previously (2017) had his student pilot license and medical certificate revoked by the FAA for performing unauthorized cross-country flights and falsifying a reviewer’s signature. However, he had reapplied in 2019 and been granted a student pilot and third-class medical certificate. A hotline report had been made to the FAA 6 days before the accident indicating the pilot may have had cognitive problems and unreported medical issues as well as unsafe piloting behaviors. According to the autopsy performed by the University of North Dakota Forensic Pathology, the cause of death was multiple blunt force injuries, and the manner of death was accident. During the autopsy, an implantablemedical device was identified in the left anterior chest wall with leads extending into the neck towards the head. Toxicology testing identified cetirizine (151 ng/ml); citalopram (573 ng/ml) and its metabolite N-desmethylcitalopram; bupropion (549 ng/ml) and its metabolite hydroxybuproprion; and trazodone (110 ng/ml) in heart blood. All of these substances were also identified in liver tissue. Dark night instrument meteorological conditions (IMC) prevailed in the area There were no records of the pilot contacting any services for weather reports. According to residents who loved nearby the accident site, the weather was cold, windy, low clouds, fog, and mist on the night of October 9, 2019. An NTSB Weather Study (included in the docket) confirmed that IMC existed in the area. The nearest weather reporting facility (ABR), located about 7 miles from the accident site, issued a METAR at 2253 CDT. METAR KABR 100353Z AUTO 35019G27KT 7SM -RA BKN007 OVC014 05/03 A2994 RMK AO2 PK WND 34027/0352 SLP144 P0001 T00500033. According to the carburetor icing probability chart, with a temperature of 5ºC and a dew point of 3ºC (+2 dewpoint depression), the airplane was operating within the range of serious carburetor icing at any power setting. According to FAA records, the pilot did not hold a valid pilot certificate, had no instrument training or rating, and had no medical certificate. The pilot’s flight logbooks were not found, and his total flight time could not be determined. A family member reported that the pilot had about 100 hours of flight time in the accident airplane. The airplane's wreckage was not found until 12 days after the accident. The wreckage was in a farmer's field, about 7 miles north of ABR. On scene observations showed evidence that the airplane initially impacted a 60-foot-tall tree with its left wing. Debris was scattered beyond the initial impact of the tree on a heading of 148º. The fuselage skidded along the ground for about 500 feet, coming to rest on the edge of standing water. The engine was separated from the fuselage and submerged in the standing water. Both wings remained attached to the fuselage. The fuselage and empennage were severely crushed and fragmented. The empennage was separated about flight station (FS) 90 and was partially attached by control cables. The vertical fin and rudder separated during the impact sequence and were found about 15 feet in front of the main wreckage. Both fuel tanks were compromised and impact damaged. Fuel quantity and quality at takeoff are unknown. The airframe fuel system could not be examined due to impact damage. The carburetor heat control in the cockpit was found in the OFF position. The carburetor and air box were detached from the engine and could not be examined for functionality due to impact damage. Flight control cable continuity was established from all control surface to the cockpit controls. All flight controls remained attached to their respective surfaces. The flap handle(bar) was observed in the third notch (30º of flaps). The firewall and engine separated and was found about 20 feet in front of the main wreckage submerged in standing water. The propeller assembly was found fractured at the engine crank flange. Both propeller blades were twisted, polished, and exhibited “S” bending. Engine drive continuity and thumb compression were established. No mechanical anomalies were found. The damage to the propeller blades was consistent with rotation at the time of impact.

Aircraft

Registration
N6483B
Reported as
Cessna 172 (Undesignat)
Category
Airplane
Serial number
29683
Built
1956
Engine
Continental O-300 SER, 145 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
ABR · Aberdeen, SD
Destination
2D5 · Oaks, SD
Airport
ABR · Aberdeen Regional Airport
Equipment
None

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
70
Injuries
Fatal
Certificate
Student
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
100 total · 100 in this make and model

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
350° at 19 knots, gusting 27
Visibility
7 statute miles
Lowest ceiling
700 ft broken
Temperature
41 °F, dew point 37 °F
Altimeter
29.94 inHg
Observed at
KABR, 7 nm away
METAR
METAR KABR 100353Z AUTO 35019G27KT 7SM -RA BKN007 OVC014 05/03 A2994 RMK AO2 PK WND 34027/0352 SLP144 P0001 T00500033.

Docket · 15

The files NTSB released with the investigation on January 27, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 22.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.