# NTSB ERA09LA258: Cessna A188B, N4789Q, Pinehurst, GA, April 23, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: April 23, 2009, 10:00 local (14:00 UTC) - Place: Pinehurst, GA - Coordinates: 32.20639, -83.786392 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.2064&lon=-83.7864&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 22, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Cessna Aircraft Company - NTSB case key (mKey): 73712 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA258 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73712/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73712 - Page: https://openairdocs.org/ntsb/ERA09LA258 ## Probable cause The pilot's failure to maintain aircraft control for undetermined reasons. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Cessna A188B, 7 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=2073005), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Cessna A188B, 9 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2073005), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Cessna A188B, 7 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2073005), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis After spraying for mosquitoes for approximately 2 hours, the pilot returned for landing. The airplane approached the north runway, a 2,600-foot-long, 100-foot-wide, turf runway. During the approach, the airplane banked left onto final approach and the engine revved to high rpm. The airplane touched down long, toward the left side of the runway. The airplane traveled off the left side of the runway, impacted bushes, and came to rest inverted. Examination of the wreckage did not reveal any preimpact mechanical malfunctions and fuel was noted throughout the fuel system. The wreckage was righted, the engine was started, and it ran continuously to 2,500 rpm. The pilot had accumulated about 15,000 hours of total flight experience. Although the autopsy report noted the cause of deal as blunt force trauma, the report also indicated that examination of the pilot’s heart revealed a markedly enlarged (but not thickened) heart, consistent with dilated cardiomyopathy, a condition frequently associated with sudden cardiac death. There was no indication that the pilot was aware of the condition, and a relationship between the condition and the accident could not be conclusively established. Another pilot reported that the wind was from the west at 5 to 7 mph at the time of the accident. ## Factual narrative On April 23, 2009, about 1000 eastern daylight time, a Cessna A188B, N4789Q, operated by A & C Ag Aviation Inc., was substantially damaged while landing at a private airstrip near Pinehurst, Georgia. The certificated commercial pilot was killed. Visual meteorological conditions prevailed and no flight plan was filed for the aerial application flight conducted under the provisions of 14 Code of Federal Regulations Part 137. The flight originated from the private airstrip about 0800. A Federal Aviation Administration (FAA) inspector stated that after spraying for mosquitoes, the pilot returned for landing. The airplane approached the north runway, a 2,600-foot-long, 100-foot-wide, turf runway. The airplane touched down long, toward the left side of the runway. The airplane traveled off the left side of the runway, impacted bushes, and came to rest inverted. The pilot was wearing harnesses and a helmet, but was found deceased at the scene. A witness, who was flying in the area, knew the accident pilot. The witness stated that the accident pilot was on a left downwind leg for the north runway, and "waved his wings" at the witness's airplane. About 1 minute later, the witness heard the accident airplane engine rev to high rpm and the accident airplane made a "hard" left turn onto final approach. The witness thought that the engine rev and hard turn were uncharacteristic of the accident pilot, as he usually approached very "steady." The witness lost sight of the accident airplane on final approach, but thought that the pilot must have been experiencing some sort of difficultly to be flying in the manner that he was. The witness further stated that the wind was from the west at 5 to 7 mph at the time of the accident. The single-seat, low-wing, fixed-gear airplane, serial number 18802531T, was manufactured in 1976. It was powered by a Continental Motors IO-520, 300-horsepower engine. Review of the airplane's engine logbook revealed that an annual inspection was completed on March 28, 2009, at a total airframe time of 10,477 hours. At the time of the inspection, the engine had accumulated 1,402 hours of operation since major overhaul. Examination of the wreckage by the FAA inspector did not reveal any preimpact mechanical malfunctions. Fuel was present in both fuel tanks and some had leaked out while the airplane was inverted. The wreckage was righted, and 5 gallons of fuel was added to the left wing fuel tank. The engine was then started and ran continuously to 2,500 rpm. The pilot, age 73, held a commercial pilot certificate with ratings for airplane single-engine land and airplane multiengine land. His most recent second-class medical certificate was issued on January 19, 2009. At that time, the pilot reported a total flight experience of 15,000 hours. The pilot also indicated “No” to all items under “Medical History,” including specifically “Heart or vascular trouble.” The pilot’s spouse indicated she was not aware of any personal or family historyof heart disease for the pilot. An autopsy was performed on the pilot by the State of Georgia Bureau of Investigation, Forensic Sciences Division, on April 29, 2009. The autopsy report noted the cause of death as "blunt force trauma to the neck." The report also noted, “The heart weighs 570 grams…The left ventricular wall and the muscular interventricular septum are each 1.3 cm thick. The right ventricular wall thickness is 0.4 cm. …” Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. The results were negative for drugs and alcohol. The reported weather at an airport located about 30 miles southwest of the accident site, at 0953, included few clouds at 1,300 feet, visibility 7 miles, and wind from 170 degrees at 6 knots. ## Aircraft - Registration: [N4789Q](https://openairdocs.org/deregistered/N4789Q-2015-09-21), registration cancelled 2015-09-21, S/N 18802531T, built 1976 (OpenAirDocs) - Reported make and model: CESSNA A188B - Registry model: [Cessna A188B](https://openairdocs.org/model/cessna-a188b) (registry code 2073005) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18802531T - Airframe hours: 10477 - Engines: CONT MOTOR IO-520-D 300 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial application, Part 137 - Operator: A & C Ag Aviation Inc. - Registered owner: A & C Ag Aviation Inc. - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, March 28, 2009 - Departed: NONE, Pinehurst, GA - Destination: NONE, Pinehurst, GA - Airport: NONE, Private Airstrip, runway 36, 2,600 × 100 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; medical: class 2, with waivers/limitations; seat: single; toxicology performed; flight hours: 20,000 total, 5,000 in this make and model, 75 in the last 90 days, 50 in the last 30 days, 6 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 6 knots - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 63 °F - Altimeter: 30.00 inHg - Observed at: ABY, 30 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 20090423007879A](https://openairdocs.org/incident/20090423007879A), Apr 23, 2009: Cessna A188B, Pinehurst, GA, Substantial damage, 1 fatal. (-23) The agricultural aircraft on a commercial flight was substantially damaged while landing at a private turf airstrip near Pinehurst, Georgia. The airplane… ## Docket (9 files) The files NTSB released with the investigation on November 4, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73712. 2.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 249 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317657&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - FAA Inspector Statement (item 2, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40320884&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Redacted.PDF - Interview Summaries (item 3, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317658&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Bill of Sale (item 4, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318689&FileExtension=.PDF&FileName=Bill%20of%20Sale-Redacted.PDF - Excerpt From Engine Logbook (item 5, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318690&FileExtension=.PDF&FileName=Excerpt%20From%20Engine%20Logbook-Redacted.PDF - Weather Report (item 6, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317659&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Toxicological Report (item 7, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317660&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Medical Records Information (item 8, .PDF, 12 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40318559&FileExtension=.PDF&FileName=Medical%20Records%20Information-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317661&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.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.