CHI05FA194

NTSB accident investigation · Cessna 172P · Jackson, WI · July 20, 2005

Accident · FatalField investigationFinal report
Date
July 20, 2005, 07:40 local (12:40 UTC)
Place
Jackson, WI
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N65875Cessna 172P
Weather
Visual (VMC) · Day
Status
Completed · report May 30, 2006
Report
Approved by Office Director
Parties
Cessna Aircraft Company, Federal Aviation Administration, Lycoming
FAA report
20050720024649A
Case key
62099

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 not maintaining aircraft control for undetermined reasons while maneuvering.

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 flightManeuvering
Aircraft control - not maintainedPilot in commandCause
Psychological conditionPilot in command
Reason for occurrence undeterminedCause
Communications/information/atc - delayedAtc personnel(fss)
In flight collision with terrain/waterDescent - uncontrolled
Object - tree(s)
Terrain condition - ground

Analysis

The airplane was destroyed on impact with trees and terrain while maneuvering. The student's solo flight departed about 0725 with Hobbs meter reading of 29.1 for a proposed hour flight. The Air Traffic Control Tower was contacted by the flight school about 1010, in reference to that flight. The Automated Flight Service Station (AFSS) was contacted about 1100 by the flight school, and was informed that the flight was overdue. Air Force Rescue Coordination Center first detected an emergency locator transmitter signal at 1041. At 1401, the center was aware of the overdue airplane. At 1410, the Civil Air Patrol was contacted in reference to the overdue airplane. At 1431, the center received notification that the Civil Air Patrol would have a search airplane up in 20 minutes. At 1449, the center received an Alert Notice (ALNOT) from AFSS on the overdue airplane. At 1549, the center received notification that the ALNOT was cancelled and that the wreckage was found. An on-scene examination revealed that no pre-impact anomalies were found with the airframe or engine. The Hobbs meter read 29.5 hours. The pilot had a history of chronic depression, at times accompanied by suicidal thoughts or intent, particularly when off of antidepressant medications. He did not indicate his use of antidepressant medications or his history of depression on his only application for FAA Airman Medical Certificate. No antidepressants were detected on toxicological evaluation following the accident. Diphenhydramine, an over-the-counter antihistamine with impairing and sedative effects, was detected in the pilot's blood consistent with recent ingestion. The pilot reportedly suffered from seasonal allergies. A plot of airplane radar track data showed the flight's path and altitudes that represented the received airplane's pressure altitude reading. The plotted data showed that the airplane was climbing in a northwest direction after its departure. The plot showed the airplane reached a maximum altitude of 2,700 feet at about 0732:35. The airplane was at 2,700 feet until 0734:05 when the plotted data showed it in a descent and turn to the northeast. The plot showed the airplane at 1,900 feet at 0736:55 and the returns showed the airplane in a turn to the west. The airplane's returns showed it in a descent on the west bound direction. The last plotted return showed the airplane at 1,400 feet at 0740:36. The accident site was plotted on that chart and the site was below that last return.

Factual narrative

History of flight

On July 20, 2005, about 0740 central daylight time, a Cessna 172P, N65875, operated by Gran Aire as a rental airplane and piloted by a student pilot, was destroyed on impact with trees and terrain while maneuvering near Jackson, Wisconsin. The solo instructional flight was operating under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident. No flight plan was on file. The pilot sustained fatal injuries. The local flight originated from the Lawrence J. Timmerman Airport (MWC), near Milwaukee, Wisconsin, about 0725.

According to the student's flight instructor, the purpose of the flight was for the student to perform ground reference maneuvers in a practice area north of MWC for an hour. The instructor and student were scheduled to fly together after the morning solo flight.

The instructor and flight school started to inquire about the student's flight and contacted the Federal Aviation Administration Air Traffic Control Tower at MWC about 1010, in reference to the student pilot's flight not returning. Flight school employees called and drove to local airports inquiring in reference to the student pilot's flight. About 1100, a representative of the school contacted the Green Bay Automated Flight Service Station (AFSS) and informed the flight service station representative that the flight was overdue. The flight school had also sent airplanes to search for the overdue flight.

Air Force Rescue Coordination Center records showed that an emergency locator transmitter signal was first picked up at 1041. At 1201, the center contacted Green Bay AFSS to confirm no missing or overdue aircraft. At 1401, the center was aware of the overdue airplane. At 1410, the center started to contact the Civil Air Patrol in reference to the overdue airplane. At 1431, the center received notification that the Civil Air Patrol would have a search airplane up in 20 minutes. At 1449, the center received an Alert Notice (ALNOT) from Green Bay AFSS on the overdue airplane. At 1549, the center received notification that the ALNOT was cancelled and that the wreckage was found. The Washington County Sheriff's department had located the wreckage about five miles south of the West Bend Airport.

The sheriff's department took a statement from a witness. The statement, in part, said:

I was driving to work South on [Washington County Highway G and] turned onto

Pleasant Valley Rd. I saw a small plane nose down just above the tree line on the

south/west corner. ... I continued slowly along Pleasant Valley looking for smoke

and saw nothing. I never heard a crash. ... I noticed [a] corn field South of the marsh

North of Hwy 60 and assumed it was a crop dusting plane I saw. This all occurred

around 7:45 AM.

Personnel information

The pilot held a Federal Aviation Administration (FAA) third-class medical certificate and student pilot certificate. That medical certificate was issued on March 16, 2005, with a limitation that he "shall wear corrective lenses." An instructor certifying that the pilot met the requirements and was competent for solo flight in a Cessna 172 endorsed that certificate.

He had accumulated about 61 hours of total flight time. His first solo flight occurred on June 26, 2005 and his second solo was on July 19, 2004.

Aircraft information

N65875, a 1983 Cessna 172P, serial number 17275910, was a high wing, propeller-driven, fixed landing gear, semi-monocoque design, four-seat airplane. A 160-horsepower, four-cylinder, air cooled, horizontally opposed, carbureted, Lycoming O-320-D2J, serial number RL 18353-39A, engine, powered the airplane. The propeller was a two-bladed, all-metal, fixed pitch, McCauley model.

The airplane's logbooks showed that an annual inspection was completed on May 8, 2005, and a 100-hour inspection was completed on July 6, 2005. The airplane had accumulated 3696.4 hours of total time at the date of the 100-hour inspection. The airplane departed with Hobbs meter reading of 29.1.

Meteorological information

At 0745, the recorded MWC weather was: Wind 180 degrees at 8 knots; visibility 10 statute miles; sky condition scattered 5,000 feet, broken 6,000 feet; temperature 24 degrees C; dew point missing; altimeter 30.04 inches of mercury.

Wreckage and impact information

The airplane came to rest at latitude 42 degrees 20.620 minutes N and longitude 88 degrees 07.572 minutes W, in a wooded area of the Jackson Marsh Wildlife Area west of Washington County Highway G. Tree branches were found broken in the area of the wreckage. The leading edges of the wings exhibited rearward crush angles that indicated the airplane impacted terrain nearly vertically.. The fuselage, engine, and propeller were found below grade. The propeller was about 4 feet below grade. The smell of fuel was present on-scene. The flaps were extended. The pilot's seatbelt and shoulder harness were reported to have been cut by first responders.

An on-scene examination of the wreckage was conducted. Flight control cable continuity was established. Engine control continuity was established. The extension of the flap's jackscrew indicated that the flaps were extended about 25 degrees. A liquid consistent with aviation gasoline was observed exiting from the carburetor when the engine was being removed.

The wreckage was removed to a sheltered area for detailed examination. The propeller exhibited leading edge polishing. The engine produced a thumb compression at all cylinders. Both magnetos produced spark. Removed spark plugs were gray in color. The tachometer read 3727.1 hours. The Hobbs meter read 29.5 hours. No pre-impact anomalies were found with the airframe or engine.

Medical and pathological information

The Washington County Medical Examiner's office arranged for the autopsy that was performed on the pilot.

The FAA Civil Aeromedical Institute prepared a Final Forensic Toxicology Accident Report. The report stated:

0.074 (ug/ml, ug/g) DIPHENHYDRAMINE detected in Blood

DIPHENHYDRAMINE detected in Liver

The NTSB's Medical Officer, from the pilot's medical records maintained by the FAA Aerospace Medical Certification Division, extracted the following information:

3/16/05 - The pilot's only recent application for 3rd class Airman Medical and

Student Pilot Certificate indicates "no" for item 17.a. "Do you currently use any

medication" and for all items under "18. Medical History," including specifically

item 18.m. "Mental disorders of any sort: depression, anxiety, etc."

The NTSB's Medical Officer, from the medical records maintained on the pilot by his psychiatrist, extracted the following information:

3/27/98 - "Psychiatric Intake Assessment" notes "... onset depression 1993. ...

severe depression, being overwhelmed by stress, and suicidal ideation. ... It

appears that patient has had problems prior to that with mild depression. He has

been on Paxil [paroxetine] for at least the last two and a half years with

significant, dramatic improvements in overall symptomatology. ... notes that he

has gone without his medications several times for brief periods, such as 36 to 48

hours, with resulting severe withdrawal symptomatology, including onset of mild

suicidal ideation. ... Provisional Diagnosis: ... Major Depression, single episode,

in remission ..."

4/23/01 - "Psychiatric Follow-up" notes that the pilot reports "Slight increase in

symptoms of depression for last 4 weeks since decreasing Paxil ... suicidal

intention, ... anhedonia ... safe for outpatient treatment for now ... increase Paxil

... refer to psychotherapist ..."

1/28/03 - "Psychiatric Follow-up" notes that the pilot "... continues to report

chronic depression - but slightly better on Celexa [citalopram] ... no suicidal

ideations ... will try Lexapro [escitalopram] ..."

T

Aircraft

Registration
N65875
Reported as
Cessna 172P
Category
Airplane
Serial number
17275910
Airframe hours
3,727.1
Engine
Lycoming O-320-D2J, 160 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Registered owner
Grand-Aire Inc.
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · July 1, 2005 · 30.7 hours before
Departed
MWC · Milwaukee, WI

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
44
Injuries
Fatal
Certificate
Student
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
61 total · 61 in this make and model · 1 as pilot in command · 12 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 8 knots
Visibility
10 statute miles
Lowest ceiling
6,000 ft broken
Temperature
75 °F
Altimeter
30.04 inHg
Observed at
MWC, 15 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.