# NTSB CHI95FA200: Cocchi Lancair 320, N3118J, Marengo, IL, June 24, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 24, 1995, 12:30 local (17:30 UTC) - Place: Marengo, IL - Coordinates: 41.8694, -87.890029 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.8694&lon=-87.8900&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 18, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 9738 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI95FA200 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/9738/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=9738 - Page: https://openairdocs.org/ntsb/CHI95FA200 ## Probable cause pilot incapacitation due to cardiac arrhythmia (heart attack). ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - aircraft control - not possible, pilot in command - incapacitation(cardiovascular), pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled ## Analysis A WITNESS REPORTED THAT HE OBSERVED THE AIRPLANE DEPART THE AIRSTRIP ABOUT 2 HOURS BEFORE THE WRECKAGE WAS DISCOVERED. HE SAID THE AIRPLANE TOOK OFF ON RUNWAY 27 AND TURNED ABRUPTLY TO THE SOUTH, BEHIND A TREE LINE, BEFORE IT REACHED THE END OF THE RUNWAY. HE DID NOT, HOWEVER, OBSERVE THE ACCIDENT. EXAMINATION OF THE WRECKAGE REVEALED NO EVIDENCE OF PREIMPACT MECHANICAL MALFUNCTION. ANATOMICAL FINDINGS OF A FORENSIC PATHOLOGIST WERE THAT 'THE PILOT DIED OF CARDIAC ARRHYTHMIA DUE TO ISCHEMIC HEART DISEASE AS EVIDENCED BY SEVERE CORONARY ARTERY ATHEROSCLEROSIS AND ENLARGEMENT OF THE HEART. THERE WAS NO SIGNIFICANT INJURY FROM THE AIRCRAFT ACCIDENT. THE AMOUNT OF BLOOD IN THE AIRWAY WAS NOT SUFFICIENT TO HAVE CAUSED ASPHYXIATION AND THERE WAS NO EVIDENCE THAT BLOOD HAD BEEN INHALED INTO THE PARENCHYMA.' ## Factual narrative HISTORY OF FLIGHT On June 24, 1995, about 1230 central daylight time, a Cocchi Lancair 320, N3118J, was destroyed when it impacted the terrain near Marengo, Illinois. The private pilate sustained fatal injuries. The personal flight, conducted under 14 CFR Part 91, originated in Marengo, Illinois, about 1230. No flight plan was filed and visual meteorological conditions prevailed. In a personal interview with a Federal Aviation Administration (FAA) Inspector, a witness reported that he observed the airplane depart the airstrip at approximately 1230. He described the airplane takeoff on runway 27 and turn abruptly to the south, behind a tree line, before it reached the end of the runway. He did not, however, observe the accident. No witnesses to the accident were discovered. The wreckage was discovered about 1430 by the pilot of another airplane. WRECKAGE AND IMPACT INFORMATION The NTSB on-scene investigation began about 1630 on June 24, 1995. The wreckage was located south of the William Rose Airstrip, in a stagnant tributary of a flowing stream. A barbed wire fence, which extended over the water in an east-west orientation, located approximately 20 feet north of the main wreckage, was broken and hanging into the water. The main wreckage was located on a magnetic heading of 030 degrees, submerged, with the tail and upper fuselage above the surface. A fragment of the canopy frame was located on the east bank and a fragment of the right inboard wing skin was submerged approximately 20 feet south of the main wreckage. All primary airframe components were located in the water near the main wreckage. The fuselage was fractured near the center of the wing chord and the forward portion was fragmented. The aft fuselage and empennage were intact. The wing spar was separated from the fuselage. The spar was fractured at the midspan of the left wing and the inboard portion of the wing was fragmented. Two slashes were located 10 and 38 inches, respectively inboard of the left wing tip, in the leading edge. The slashes matched the geometry of the barbed wire fence. The angles of the slashes corresponded to a pitch of approximately 30 to 40 degrees nose down and 45 to 50 degrees of left bank. The flap actuator was extended 9 3/8 inches. According to the kit manufacturer, in a typical installation, this position corresponds to the flaps full up, seven degrees reflexed position. Inspection of flight control continuity revealed no evidence of preimpact mechanical malfunction. Both of the composite fuel tanks were ruptured. The left seat belt buckle was fastened and shoulder harness fittings were not installed in the buckle. The hard points of the belt ends were separated from the structure. The mounts exhibited traces of structural adhesive bonded to the aluminum fittings. No composite fiber material was present on the fittings. All three blades of the composite carbon fiber propeller were fractured, but still attached to the hub. The engine remained attached to the mounts, firewall, and instrument panel. The engine turned freely. Engine compression and engine control continuity were verified and all four leads from the left magneto sparked when the impulse coupling was turned. Magneto timing was checked for both magnetos with no discrepancy noted. Approximately 1/2 pint of clear blue fuel and 1/4 pint of brown sediment and water was drained from the carburetor bowl. The metal float and one piece venturi were normal. Examination of the single axis autopilot revealed one of the gyroscope centering springs was missing. The remaining spring pulled the gyroscope to the extreme right position. The autopilot servo was not recovered. The autopilot switch was in the "off" position. MEDICAL AND PATHOLOGICAL INFORMATION Autopsy of the pilot was conducted by the McHenry County Coroner, Woodstock, Illinois, on June 26, 1995. Anatomical findings of the Forensic Pathologist were that "the pilot died of cardiac arrhythmia due to ischemic heart disease as evidenced by severe coronary artery atherosclerosis and enlargement of the heart. There was no significant injury from the aircraft accident. The amount of blood in the airway was not sufficient to have caused asphyxiation and there was no evidence that blood had been inhaled into the parenchyma." Toxicological testing was negative for all tests conducted. TESTS AND RESEARCH The electronic instrumentation digital processing unit (DPU) was interrogated by the manufacturer for fault codes and other pertinent data. All data was corrupt. According to a representative of the manufacturer, this was due to submersion of the unit upon impact. "There was evidence that the microprocessor was attempting to restart itself" but could not due to water contamination. ADDITIONAL INFORMATION Parties to the investigation were the Federal Aviation Administration Flight Standards District Office, West Chicago, Illinois, Neico Aviation, Inc., and Textron Lycoming. Following the on-scene portion of the investigation, the wreckage was released to Mr. Allen Penticoff of Loss Management Services, Inc. ## Aircraft - Registration: [N3118J](https://openairdocs.org/deregistered/N3118J-2013-05-14), registration cancelled 2013-05-14, S/N 729, built 1994 (OpenAirDocs) - Reported make and model: COCCHI LANCAIR 320 (LANCAIR 32) - Registry model: [Cocchi Armand A LANCAIR 320](https://openairdocs.org/model/cocchi-armand-a-lancair-320) (registry code 05620RH) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 729 - Airframe hours: 39 - Engines: LYCOMING O-360-C2E 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Armand A. Cocchi - Airworthiness certificate: Special, Experimental (Special) - Destination: UNKNOWN - Airport: William Rose Airstrip, runway 27, 2,200 × 200 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,040 total, 39 in this make and model, 802 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 6 knots - Visibility: 7 statute miles - Lowest ceiling: none - Altimeter: 29.00 inHg - Observed at: DPA, 20 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 19950624020569A](https://openairdocs.org/incident/19950624020569A), Jun 24, 1995: Amtr LANCAIR, Marengo, IL, Destroyed, 1 fatal. Suffered heart attack on climbout. Impacted into a creek. Severe coronary obstruction and enlarged heart. (-23) on June 24, 1995 at 1230 CDT Lancair 320,… ## Docket (11 files) The files NTSB released with the investigation on February 27, 1996, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=9738. 702 KB in all. - DPU Inspection Report (item 1, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384780&FileExtension=.PDF&FileName=DPU%20Inspection%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 2, .PDF, 272 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384781&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 3, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384782&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 4, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384783&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1. Main Wreckage of N3118J (item 5, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40041739&FileExtension=.PDF&FileName=Photo%201.%20%20Main%20Wreckage%20of%20N3118J-Master.PDF - Photo 2. Front View of N3118J. (item 6, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40041733&FileExtension=.PDF&FileName=Photo%202.%20%20Front%20View%20of%20N3118J.-Master.PDF - Photo 3. Propeller. (item 7, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40041734&FileExtension=.PDF&FileName=Photo%203.%20%20Propeller.-Master.PDF - Photo 4. Left Wingtip. (item 8, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40041735&FileExtension=.PDF&FileName=Photo%204.%20%20Left%20Wingtip.-Master.PDF - Photo 5. Left Wing Leading Edge. (item 9, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40041737&FileExtension=.PDF&FileName=Photo%205.%20%20Left%20Wing%20Leading%20Edge.-Master.PDF - Photo 6. Pilot Seatbelt Attach Point (item 10, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40041736&FileExtension=.PDF&FileName=Photo%206.%20%20Pilot%20Seatbelt%20Attach%20Point-Master.PDF - Photo 7. Autopilot Gyro (item 11, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40041738&FileExtension=.PDF&FileName=Photo%207.%20%20Autopilot%20Gyro-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.