CHI03LA216

NTSB accident investigation · Cessna 172H · Isle, MN · July 18, 2003

Accident · FatalLimited investigationFinal report
Date
July 18, 2003, 10:10 local (15:10 UTC)
Place
Isle, MN
Injuries
1 fatal, 3 minor
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N1606FCessna 172H
Weather
Visual (VMC) · Day
Status
Completed · report June 30, 2004
Report
Approved by Office Director
Parties
Federal Aviation Administration
FAA report
20030718017799A
Case key
57532

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

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Probable cause

The pilot's failure to maintain adequate airspeed which resulted in a stall. The trees, high density altitude, and the soft field were additional factors.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightTakeoff - initial climb
Airspeed - inadequatePilot in commandCause
Stall - inadvertentPilot in command
Aircraft control - not maintainedPilot in command
In flight collision with objectDescent - uncontrolled
Object - tree(s)
Weather condition - high density altitudeFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground
Airport facilities,runway/landing area condition - grassFactor

Analysis

The airplane was substantially damaged when it impacted trees and terrain during initial climb from a grass airstrip. The pilot attempted to depart with full fuel and three passengers on a local flight. A passenger aboard the airplane stated that the airplane banked to the right and then descended into the trees during the climb. Visual meteorological conditions prevailed at the time of the accident with an approximate density altitude of 2,339 feet mean sea level and 50 percent humidity. Damage to the airplane was consistent with a nose-down, low-speed impact. Examination of the wreckage revealed no anomalies with the flight control system and engine. The airplane was not equipped with shoulder harnesses, and the seat belts possessed stitching, which was not consistent with a manufactured product. The right rear passenger seat belt stitching separated at the lower attach point.

Factual narrative

History of flight

On July 18, 2003, at 1010 central daylight time, a Cessna 172H, N1606F, owned and piloted by a private pilot, was destroyed on impact with trees and terrain during initial climb from Isle Private Airport (MY72), Isle, Minnesota. The airplane struck trees at the departure end of the runway 16. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 personal flight was not operating on a flight plan. The pilot was fatally injured, and three passengers received minor injuries. The local flight was originating at the time of the accident.

According to the Sheriff Department Report of the accident, the passengers met the pilot at the airport about 1000. The pilot fueled the airplane, and the passengers then boarded the airplane. The passengers stated that the pilot checked the gauges on the airplane, taxied down the runway, turned, and took off. The airplane lifted off and started to climb above the trees. The airplane then tilted to the right and the pilot corrected the airplane's position. The airplane then started to descend and they could see the trees and leaves on the left side of the airplane and could see wires ahead. The airplane then crashed.

The Sheriff Department Report, a witness stated that she heard an airplane, which sounded like a "regular airplane." The witness did not hear any sputtering or the sound of an engine cutting out.

Personnel information

The pilot, age 69, was issued a private pilot certificate with a single-engine land rating on September 23, 1984, at a total flight time of 64 hours. In 1991, he logged a total flight time of 2.9 hours with no further entries until 2002. In 2002, he logged three flights with a total flight time of 3.1 hours, all of which were with a flight instructor. The next flight that was logged was dated February, 20, 2003, during which the pilot received a biennial flight review. The last flight logged was dated July 13, 2003 and was 4.9 hours in duration. In 2003, he logged a total flight time of 14.3 hours. He logged a total flight time of 264.0 hours since his first flight dated August 16, 1983.

The pilot was issued a third class medical certificate dated August 22, 2002, with the following limitation: "must have available glasses for near vision." His report weight was 164 lbs.

Aircraft information

The 1966 Cessna 172H, serial number 55001, was registered to the pilot as a co-owner on April 22, 2003. The airplane was powered by a Continental O-300-D, serial number 27647-D-2-D, engine rated at 145 horsepower and 2,700 rpm. The airplane received an annual inspection dated June 18, 2003, at a tachometer time of 5,397.2 hours.

An airplane weight and balance form dated February 11, 2003, stated the following: maximum gross weight 2,300 lbs, empty weight 1,405.5 lbs, empty center of gravity 37.11 inches; moment 52154.75 inch lbs; useful load 894.5 lbs.

Meteorological information

The Mora, Minnesota, surface weather observation recorded at 1016: wind 170 degrees at 6 knots; visibility 10 statute miles; sky conditions clear; temperature 24 degrees Celsius; dew point 13 degrees Celsius; altimeter setting 30.20 inches mercury. The relative humidity was 50 percent.

Airport information

MY72 was an uncontrolled airstrip with an elevation of 1,271 feet mean sea level. MY72 was served only by runway 16/34 (2,460 feet by 160 feet, turf). The obstructions listed for runway 16 were 25 foot trees 50 feet from the runway and 130 feet left of the runway centerline. There was a 2:1 slope to clear the obstructions. The obstructions listed for runway 34 were 65 foot trees 80 feet from the runway and 225 foot left of the centerline. There was a 10:1 slope to clear the obstructions.

Wreckage and impact information

Inspection of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the airplane was resting in a nose down attitude on a two-lane road. The empennage was bent about 10 degrees below the longitudinal axis of the airplane. The left wing was bent about 45 degrees downward from the wing strut attach point to the wing tip. The right wing was twisted upwards about the lateral axis from the wing strut attach point to the wing tip. All of the airplane's wing and control surfaces were intact. The flaps were extended to the 10-degree position.

Flight control continuity to the controls was confirmed and no anomalies were noted with the engine.

The throttle and mixture controls were in the forward position, the fuel selector was in the both position, and the ignition/starter switch was in the both position. The tachometer indicated 5,403.36 hours.

Medical and pathological information

An autopsy of the pilot was conducted by the Hennepin County Medical Examiner's Office on July 21, 2003.

The FAA Final Forensic Toxicology Fatal Accident Report of the pilot reported the following: no carbon monoxide detected in blood, no cyanide detected in blood, no ethanol detected in blood, ephedrine detected in blood, ephedrine detected in liver, pseudoephedrine detected in blood, pseudoephedrine detected in liver, 0.031 (ug/ml, ug/g) morphine detected in urine, opiates not detected in blood.

Ephedrine is sold (as a component of "ephedra" or "Ma-Huang") as a stimulant, weight loss product, or decongestant in many nutritional supplements and as an asthma medication (trade name Primatene) available over the counter in tablet form. It does not usually result in impairment and has stimulant effects. Pseudoephedrine is a common decongestant with a trade name Sudafed. It is also a component of "ephedra" and "Ma-Huang." Pseudoephedrine does not usually result in impairment, and has been shown to have stimulant effects.

Morphine is a prescription narcotic pain killer. Morphine may be produced by the metabolism of other narcotic pain relievers, including codeine (an ingredient in Tylenol-3, other painkillers, and certain cough suppressants available over-the-counter).

Survival aspects

FAA Advisory Circular 91-65, Use of Shoulder Harness in Passenger Seats, states: " ...the safety board found that 20 percent of the fatally injured occupants in these accidents could have survived with shoulder harnesses (assuming the seat belt was fastened) and 88 percent of the seriously injured could have had significantly less severe injuries with the use of shoulder harnesses..."

The airplane restraint system consisted of seat belts at each seat and was not equipped with shoulder harnesses.

A 100-hour/annual inspection checklist dated June 17, 2003, had the following cabin item checked: "14. Seats, seat rails, & safety restraint belts."

Inspection of the right rear passenger seat belt revealed it to be separated at the belt's lower attach point. The stitching in this area was separated and was not of a x-shape and box pattern. The stitch thread was not consistent with the remaining restraint system. There was also no manufacturer's data tag attached to the seat belt.

Aircraft

Registration
N1606F
Reported as
Cessna 172H
Category
Airplane
Serial number
55001
Airframe hours
5,397.2
Engine
Continental O-300-D, 145 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Carlin D. Cain
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 18, 2003 · 6.16 hours before
Departed
MY72 · Isle, MN
Destination
MY72
Airport
MY72 · Isle Private Airport, runway 16, 2,460 × 160 ft, grass/turf

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
69
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Last flight review
February 20, 2003
Seat
Left
Toxicology
Performed
Flight hours
264 total · 183 in this make and model · 212 as pilot in command · 13 in the last 90 days · 7 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 55 °F
Altimeter
30.20 inHg
Observed at
JMR, 18 nm away

Docket · 10

The files NTSB released with the investigation on May 14, 2004, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.4 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.

Other investigations on N1606F · 1

Matched to the same aircraft by N-number and date.