# NTSB ERA14FA377: Cessna 150, N7968Z, Senoia, GA, August 9, 2014 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 9, 2014, 05:55 local (09:55 UTC) - Place: Senoia, GA - Coordinates: 33.317222, -84.528892 - Nearby events: https://openairdocs.org/map.md?lat=33.3172&lon=-84.5289&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 23, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA, Textron Aviation, Continental Motors, Inc. - NTSB case key (mKey): 89831 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA14FA377 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89831/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89831 - Page: https://openairdocs.org/ntsb/ERA14FA377 ## Probable cause The noninstrument-rated pilot’s inadequate preflight weather planning and his improper decision to attempt a visual flight rules flight in night instrument metrological conditions, which resulted in subsequent collision with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: weather planning](https://openairdocs.org/ntsb-findings/02061020): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 150C, 1 case](https://openairdocs.org/ntsb-findings/02061020/cases.md?model=2071808), [All aircraft, 156 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 150C, 4 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2071808), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Ceiling/visibility/precip: clouds](https://openairdocs.org/ntsb-findings/03035025): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Cessna 150C, 1 case](https://openairdocs.org/ntsb-findings/03035025/cases.md?model=2071808), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/03035025/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Cessna 150C, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=2071808), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 150C, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=2071808), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Cessna 150C, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=2071808), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Initial climb: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Cessna 150C, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=2071808), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 150C, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2071808), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The noninstrument-rated private pilot departed for a cross-country flight in night instrument meteorological conditions (IMC). No record was found indicating that the pilot obtained an official weather briefing before the flight. GPS data indicated that, about 5 minutes after takeoff, the airplane turned back toward the departure airport. About 2 minutes later, as the airplane was flying at an altitude just above the height of the surrounding terrain (about 823 ft), it made a slight descending left turn. The airplane continued to descend, impacted a berm on the side of a gravel road and then trees, and came to rest nose down. Postaccident examination of the wreckage did not reveal any preimpact mechanical malfunctions that would have precluded normal operation. A weather observation taken at the departure airport about the time of the accident included visibility of 6 statute miles with mist and an overcast ceiling at 600 ft above ground level (agl). A witness reported that visibility was restricted due to patchy areas of fog or mist and that the ceiling was about 300 to 400 ft agl. He added that "the sky was very dark" with little ambient light. Based on the GPS data, it is likely that the pilot was attempting to return to the airport and subsequently chose to attempt an off-airport landing due to the poor weather conditions. Toxicological testing detected ibuprofen, lidocaine, oxycodone, oxymorphone, and salicylate in the pilot's urine. However, none of these medications were present in the pilot's blood at the time of the accident; therefore, impairment by the medications did not contribute to the accident. In addition, the testing revealed that the pilot had diabetes, which had not been previously diagnosed; however, it is unlikely that the pilot's diabetes contributed to the accident. Review of the pilot's medical records revealed that he had received a spinal injection to treat ongoing low back pain radiating to his arms and legs the day before the accident. Although painful symptoms and these injections can cause complications, they do not affect decision-making. In this case, the noninstrument-rated pilot improperly decided to fly in IMC, which led to the accident. Therefore, neither the back pain nor the injection contributed to the accident. ## Factual narrative Global Positioning System Receiver Data were successfully downloaded from the GPS. The data that were associated with the accident flight began about 0540, with the airplane on the ramp area at FFC. At 0548:24, the airplane was on the takeoff roll departing from runway 31. After takeoff, the airplane made a left turn and climbed to a GPS recorded altitude of 1,191 feet. The airplane turned toward the southeast and continued on a southeasterly heading, where its altitude varied between approximately 1,100 and 1,800 feet. Around 0553, the airplane began a right turn from an altitude of 1,368 feet toward a westerly heading, which was back toward the departure airport. At 0554:26, at an altitude of 1,227 feet, and a derived groundspeed of 99 knots, the airplane began a slight left descending left turn toward the accident site location. During this time, the data showed the airplane reached a maximum groundspeed of 123 knots. At 0554:40, the airplane was at an altitude of 823 feet and a groundspeed of 116 knots, approximately 3.25 nautical miles southeast of FFC. At 0554:51, the airplane had descended to an altitude that roughly matched the surrounding terrain. The last recorded data point was taken at 0555:12, in the immediate vicinity of the wreckage location. The single-engine, fixed-gear airplane, serial number 15060068, was manufactured in 1963. It was powered by a Continental Motors O-200-A, 100-horsepower engine equipped with a McCauley two-blade propeller. According to the engine and propeller logbooks, the most recent annual inspection was performed on October 9, 2013. At that time, the engine had been operated for about 915 hours since overhaul and about 3,000 total hours since new. The airframe logbook was not located. A fuel receipt from FFC indicated that the airplane was refueled with 9.8 gallons of aviation gasoline on August 8, 2014. On August 9, 2014, about 0555 eastern daylight time, a Cessna 150C, N7968Z, owned and operated by a private individual, was destroyed when it impacted terrain while maneuvering in Senoia, Georgia. The private pilot and a passenger were fatally injured. Night instrument meteorological conditions prevailed and no flight plan had been filed for the flight that departed Atlanta Regional Airport-Falcon Field (FFC), Peachtree City, Georgia, at 0548, destined for Eagle Neck Airport (1GA0), Shellman Bluff, Georgia. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The airplane was owned by the pilot and his wife, and based at FFC. The pilot and his wife also owned a home in a residential community at 1GA0. According to pilot's wife, the pilot and the passenger, who was her brother, intended to fly to 1GA0 to attend a homeowner's association meeting that was scheduled to begin at 0800. A witness, who lived about 3 miles from the airport stated that he observed a very low flying airplane about 0600. The airplane was flying about 30 to 40 feet above the tree line andthe engine noise sounded normal. He lost sight of the airplane and recalled hearing a "thud," shortly thereafter. At the time, he did not consider that the airplane may have crashed and was not aware of the accident until hearing a news report. He described the weather conditions at the time he observed the airplane as "humid and rather foggy." The airplane was subsequently found in a wooded area about 3.5 miles southeast of FFC, adjacent to a gravel road. An autopsy was performed on the pilot by the Georgia Bureau of Investigation, Division of Forensic Sciences. The autopsy report listed the cause of death as "generalized blunt force injuries." Toxicological testing performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, identified ibuprofen, lidocaine, oxycodone, oxymorphone, and salicylate in urine. However, neither these nor any other tested-for substances were identified in blood. The vitreous was negative for glucose; but, the glucose level in urine was 135mg/dl, and the hemoglobin A1C was measured at 7.4 percent. According to the pilot's wife, the pilot was not known to be diabetic. Records obtained from his treating orthopedist confirm that he did not carry a diagnosis of diabetes. In addition, pharmacy records did not include any medications used to treat diabetes. Review of medical records revealed that the pilot received a spinal injection to treat ongoing low back pain radiating to his arms and legs, on the day prior to the accident. A weather observation taken at FFC, at 0553, reported: calm winds, 6 statute miles visibility with mist, overcast ceiling at 600 feet above ground level, temperature 21 degrees Celsius (C), dew point temperature 21 degrees C, and an altimeter setting of 30.05 in-Hg. Review of infrared satellite imagery around the time of the accident depicted low clouds in and around the departure airport. There was no record of the pilot obtaining an official weather briefing for the flight. The pilot's wife stated that the pilot checked weather conditions for the flight the night prior to, and the morning of the accident using his iPad. A witness, who was an FAA air traffic controller and active commercial pilot, described the weather at the time of the accident as "not good." He further stated that visibility was restricted due to some patchy areas of fog or mist and that the ceiling was about 300 to 400 feet above ground level. He further added that "the sky was very dark with no ambient light except for the parking lot lights." Astronomical data obtained from the United States Naval Observatory revealed that for the date of the accident, the beginning of civil twilight was 0627, with Sunrise at 0654. The pilot, age 57, held a private pilot certificate with a rating for airplane single-engine land, which was issued on May 16, 2014. The pilot did not possess an instrument rating. His most recent Federal Aviation Administration (FAA) second-class medical certificate wasissued on July 31, 2014. The pilot was employed as an FAA air traffic controller and also held a control tower operator certificate. According to the pilot's logbook, at the time of the accident, the pilot had accumulated about 230 hours of total flight experience, which included about 190 hours in the accident airplane. In addition, he had accumulated about 50 and 20 total hours in the accident airplane, during the 90 and 30 days prior to the accident; respectively. The airplane's initial impact point was a berm on the side of a gravel road that was adjacent to east-west high tension power lines, at an elevation about 800 feet. The impact with the berm was consistent with the airplane in a level attitude. Debris was strewn for about 80 feet, on a heading about 240 degrees, and the airplane came to rest nose down, in trees facing the opposite direction of the debris path. All major components of the airplane were accounted for at the accident site. The cockpit was crushed and the instrument panel was fragmented. The left wing was separated from the fuselage and contained leading edge compression damage approximately mid-span and was crushed in a tapering fashion toward the left wing tip. The right wing remained attached to the center wing section at the aft attachment bolt and was fractured into two pieces at approximately mid-span. The empennage was separated and remained attached via control cables. The vertical stabilizer, rudder, left horizontal stabilizer and left elevator remained attached. The leading edge of the right horizontal stabilizer, an approximate 2-foot section of the outboard right horizontal stabilizer, and the right elevator and trim tab were separated. The separated leading edge of the right horizontal stabilizer and the outboard section of the right horizontal stabilizer exhibited a semi-circular deformation consistent with tree impact. Control cable continuity was established for all flight control surfaces. The flap actuator handle was observed in the down (flaps retracted) position. The engine remained partially attached to the airframe firewall via engine mounts and various lines, cables and hoses. The propeller, both magnetos, starter, vacuum pump, and carburetor separated from the engine and exhibited impact damage. The propeller was located about 65 feet from the initial impact point and remained attached to the crankshaft flange, which separated from the crankshaft. The propeller blades displayed chord-wise scratches, leading edge gouges, and "S-bending." The engine crankshaft was rotated by hand with a pipe wrench. Continuity to the accessory gears and valve train was established. Thumb compression was attained, and valve movement was observed on all cylinders. The cylinders were also inspected with a lighted borescope with no anomalies noted. One magneto produced spark from all towers. The second magneto was impact fractured and could not be rotated completely. The carburetor was disassembled with no anomaliesnoted. The carburetor fuel bowl contained a small amount of fuel that was consistent with 100 low-lead aviation gasoline. The vacuum pump was disassembled and exhibited normal operating signatures. The vacuum pump drive gear was not located. A handheld gps receiver was recovered from the cockpit and forwarded to the NTSB Vehicle Recorder Laboratory, Washington, D.C., for data download. ## Aircraft - Registration: [N7968Z](https://openairdocs.org/deregistered/N7968Z-2015-12-12), registration cancelled 2015-12-12, S/N 15060068, built 1963 (OpenAirDocs) - Reported make and model: CESSNA 150 (C) - Registry model: [Cessna 150C](https://openairdocs.org/model/cessna-150c) (registry code 2071808) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 15060068 - Year built: 1963 - Airframe hours: 4925 - Engines: CONT MOTOR O-200-A 100 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 9, 2013 - Departed: FFC, Peachtree City, GA - Destination: 1GA0, Shellman Bluff, GA - Airport: FFC, Atlanta Rgnl Falcon Field, runway 31, 5,768 × 100 ft, asphalt - Equipment: Handheld GPS, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; private; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; last flight review May 16, 2014; seat: left; restraint: lap only; toxicology performed; flight hours: 230 total, 230 in this make and model, 130 as pilot in command, 46 in the last 90 days, 18 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Night - Wind: calm - Visibility: 6 statute miles - Lowest ceiling: 600 ft overcast - Temperature: 70 °F, dew point 70 °F - Altimeter: 30.35 inHg - Observed at: FFC, 3 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 20140809018589A](https://openairdocs.org/incident/20140809018589A), Aug 9, 2014: Cessna 150C, Senoia, GA, Destroyed, 2 fatal. On August 9, 2014, about 0600 eastern daylight time, a Cessna 150C, N7968Z, owned and operated by a private individual, was destroyed when it impacted the… ## Docket (13 files) The files NTSB released with the investigation on May 3, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89831. 9.5 MB in all. - Aircraft Bill of Sale (item 1, .PDF, 161 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439636&FileExtension=.PDF&FileName=Aircraft%20Bill%20of%20Sale-Master.PDF - Memorandums and Witness Statements (item 2, .PDF, 612 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439637&FileExtension=.PDF&FileName=Memorandums%20and%20Witness%20Statements-Master.PDF - NTSB GPS Device - Specialist's Factual Report (item 3, .PDF, 6 photos, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439638&FileExtension=.PDF&FileName=NTSB%20GPS%20Device%20-%20Specialist%27s%20Factual%20Report-Master.PDF - NTSB GPS Device - Specialist's Factual Report (Attachment 1) (item 4, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439639&FileExtension=.PDF&FileName=NTSB%20GPS%20Device%20-%20Specialist%27s%20Factual%20Report%20(Attachment%201)-Master.PDF - Weather Information (item 5, .PDF, 693 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439640&FileExtension=.PDF&FileName=Weather%20Information-Master.PDF - Pilot's Logbook (excerpts) (item 6, .PDF, 945 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439641&FileExtension=.PDF&FileName=Pilot%27s%20Logbook%20(excerpts)-Master.PDF - Maintenance Records (excerpts) (item 7, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439642&FileExtension=.PDF&FileName=Maintenance%20Records%20(excerpts)-Master.PDF - Refueling Receipt (item 8, .PDF, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439643&FileExtension=.PDF&FileName=Refueling%20Receipt-Master.PDF - NTSB Party Guidance and Form (item 9, .PDF, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439644&FileExtension=.PDF&FileName=NTSB%20Party%20Guidance%20and%20Form-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439645&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Toxicological Report (item 11, .PDF, 452 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439647&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Evidence Control Form (item 12, .PDF, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439646&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF - Photo Array (item 13, .PDF, 10 photos, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439648&FileExtension=.PDF&FileName=Photo%20Array-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.