CHI95IA030

NTSB incident investigation · Cessna 150 · Chesterfield, MO · October 26, 1994

Incident · Minor injuriesIncident investigationFinal report
Date
October 26, 1994, 18:00 local (23:00 UTC)
Place
Chesterfield, MO
Injuries
1 minor
Damage
No damage
Phase of flight
Enroute
Aircraft
N7XCCessna 150
Weather
Visual (VMC) · Day
Status
Completed · report March 27, 1995
Report
Approved by Office Director
FAA report
19941026040109I
Case key
9754

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

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Probable cause

the cracked heater exhaust muffler which resulted from an improper repair. Factors were the physical impairment of the solo flight student as a result of her inadequate training concerning carbon monoxide hazards.

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.

Airframe/component/system failure/malfunctionCruise - normal
Exhaust system,muffler - crackedCause
Maintenance,rebuild/remanufacture - improperOther maintenance personnelCause
Physical impairment(carbon monoxide)Pilot in commandFactor
Inadequate initial trainingFlight instructor(on ground)Factor

Analysis

The student solo pilot returned from a cross country flight complaining of headache, nausea, and difficulty walking. The pilot stated that she had smelled exhaust fumes, was not taught of a potential connection between exhaust smells and carbon monoxide poisoning, and continued the flight. Medical tests revealed elevated carbon monoxide, which required 5 1/2 hours of 100% oxygen to reduce to normal levels. Post-flight inspection revealed a crack in the repaired muffler which had been installed 18 hours earlier. The private pilot practical test standards require that an applicant exhibit knowledge of symptoms, effects, and corrective actions for carbon monoxide poisoning.

Factual narrative

On October 26, 1994, at 1800 central daylight time, a student pilot returned from a solo cross country in a Cessna 150, N7XC, operated as a 14 CFR Part 91 training flight by Weiss Aviation of Chesterfield, Missouri. The student complained she was nauseous, about to pass out, and had difficulty walking, but drove herself home. Four hours later, after discovering an exhaust muffler crack (the repaired muffler had accumulated 18 hours in service since installation), the operator contacted the student and recommended she obtain medical attention. Medical testing revealed an elevated blood level of Carbon Monoxide (17.5%). After 5 1/2 hours of 100% Oxygen treatment, the CO concentration had reduced to 1.5% and the pilot was released.

The pilot stated that she had smelled fumes during the flight, was not taught of a potential hazard or connection between the smell and Carbon Monoxide poisoning, and continued the flight.

AC-61-21A, the Federal Aviation Administration Flight Training Handbook, discusses the hazards of Carbon Monoxide poisoning and faulty heater systems as a cause. FAA-S-8081, the Private Pilot Practical Test Standards, requires under "Aeromedical Factors" that an applicant exhibits knowledge of symtoms, effects, and corrective action of carbon monoxide poisoning.

Aircraft

Registration
N7XC
Reported as
Cessna 150
Category
Airplane
Serial number
15078099
Airframe hours
3,822
Engine
Continental O-200-A, 100 horsepower, reciprocating
Damage
No damage
Flight
Instructional · Part 91
Operator
Midwest Air Service, Inc., doing business as Weiss Aviation
Registered owner
Midwest Air Service, Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Unknown · October 11, 1994 · 18 hours before
Departed
SUS
Destination
SUS
Flight plan
VFR
Airport
SUS · Spirit Of St. Louis

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
17
Certificate
Student
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
43 total · 43 in this make and model · 20 in the last 90 days

Weather

Conditions
Visual (VMC) · Day

FAA reports on this event · 1

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