# NTSB ERA15FA351: Cessna 172, N52445, Riegelwood, NC, September 11, 2015 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 11, 2015, 15:10 local (19:10 UTC) - Place: Riegelwood, NC - Coordinates: 34.343055, -78.303054 - Nearby events: https://openairdocs.org/map.md?lat=34.3431&lon=-78.3031&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 23, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Lycoming, Cessna/Texton Aviation, FAA - NTSB case key (mKey): 91961 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15FA351 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91961/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91961 - Page: https://openairdocs.org/ntsb/ERA15FA351 ## Probable cause The noncertificated pilot’s failure to maintain adequate clearance from terrain for reasons that could not be determined based on the available evidence. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 172P, 4 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2072436), [All aircraft, 1,311 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Cessna 172P, 8 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=2072436), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Pilot; cases with it: [Cessna 172P, 1 case](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=2072436), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md) - [Health/Fitness: physical fitness](https://openairdocs.org/ntsb-findings/02013010): Personnel issues › Physical · Pilot; cases with it: [Cessna 172P, 1 case](https://openairdocs.org/ntsb-findings/02013010/cases.md?model=2072436), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/02013010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) (defining event); cases with it: [Cessna 172P, 5 cases](https://openairdocs.org/ntsb-events/000/sequence.md?model=2072436), [All aircraft, 1,706 cases](https://openairdocs.org/ntsb-events/000/sequence.md) ## Analysis A witness reported observing the noncertificated pilot depart from a private airstrip. When the pilot did not arrive at his destination as expected, a search and rescue effort was initiated. Subsequently, the wreckage was found 3 miles from the departure airport on a northeast heading, consistent with the flight route toward the intended destination. The wreckage and wreckage path exhibited evidence of a high-speed, low-angle, left-wing-low impact. Day visual meteorological conditions were reported near the accident site around the time of the accident. The pilot was not certificated. Further, his flight experience could not be determined because the most recent records found indicating his flight time were 36 years old. Although the airplane's maintenance records indicated that a recent annual inspection had not been conducted, examination of the wreckage revealed no evidence of any preexisting mechanical deficiencies that would have precluded normal operation. The pilot's autopsy findings included significant cardiomegaly; progressive but not occlusive coronary atherosclerosis in identified grafted vessels; and extensive, concentric myocardial scarring. Additionally, the presence of some hyperemia in the posterior medial left ventricle suggested the possibility of ongoing ischemia at the time of the accident, but the microscopic evaluation only identified scarring from more remote cardiac events. Although it is possible that the pilot experienced a cardiac event in flight, because the autopsy did not show evidence of a recent event, the investigation could not determine whether the pilot became impaired or incapacitated by his cardiac disease during the flight. The lack of radar data and witness information and lack of information about the pilot's flight experience precluded a determination of what caused the accident. ## Factual narrative The four-seat, high-wing, fixed landing gear airplane, was manufactured in 1981. It was powered by a Lycoming O-320-D2J engine and equipped with a McCauley model DES1C160 fixed-pitch propeller. Review of maintenance logbook records showed an annual inspection was completed on March 26, 2008, at a recorded tachometer reading of 5,005 hours, airframe total time of 10,527 hours, and engine time since major overhaul of 1,407 hours. The tachometer time observed at the accident site was 5,031.98. According to FAA records, the airplane was issued a "Special Flight Permit" for maintenance due to the airplane not having a current annual inspection. The ferry permit was issued on December 5, 2012. A review of a maintenance invoice revealed that the airplane was flown from Wilmington International Airport Wilmington, North Carolina, (ILM) to ACZ in April 2015. On September 11, 2015, about 1510 eastern daylight time, a Cessna 172P, N52445, collided with terrain near Riegelwood, North Carolina. The non-certificated pilot was fatally injured, and the airplane sustained substantial damage. The airplane was privately owned and operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions existed along the route of flight around the time of the accident, and no flight plan was filed. The flight departed from a private grass airstrip in Bolton, North Carolina, at 1500 with a destination of Henderson Field Airport (ACZ), Wallace, North Carolina. According to the owner of the departure airstrip, a mechanic/pilot and the accident pilot arrived from ACZ to pick up his airplane for repairs. After they landed, he recalled that his mechanic exited the accident airplane from the right seat. The mechanic/pilot then entered his airplane and prepared it for departure. The owner of the private airstrip then watched as the mechanic/pilot departed in his airplane first, followed by the accident airplane. He also noted that the accident airplane sounded "fine" as it departed, and noted that after takeoff it turned to the left and did not follow his airplane. About 45 minutes later, after the mechanic/pilot landed at ACZ, he called the private airstrip owner and asked if the accident pilot had departed. The airstrip owner said that he departed "right after you." The owner of the airstrip went on to say that the mechanic/pilot told him he was "going back up" in an attempt to find his friend. An hour had passed and the mechanic/pilot called the airstrip owner to see if the accident airplane had returned, as he had been unable to locate him. The airstrip owner told him that the airplane had not returned. The mechanic/pilot contacted the Air Force Rescue Coordination Center (AFRCC) and reported the missing airplane. According to AFRCC, an active emergency locator transmitter signal was received at 1815. A search ensued and the wreckage was found in a field about three nautical miles northeast of the departure airstrip at 0030 thefollowing day. The North Carolina Department of Health and Human Services, Office of the Chief Medical Examiner, Raleigh, North Carolina, performed an autopsy on the pilot. The cause of death was recorded as multiple blunt force trauma. The autopsy was limited by the degree of damage to the body, but evidence of previous 3-vessel coronary artery bypass grafting, ongoing coronary artery disease, and extensive scarring in a very enlarged heart were identified. The FAA Civil Aerospace Medical Institute performed forensic toxicology testing on specimens from the pilot, with negative results for carbon monoxide, drugs, and alcohol. The recorded weather at ILM, located 20 nautical miles from the accident site, at 1453, included winds from 100 degrees at 10 knots; 10 statute miles visibility, few clouds at 6,000 feet, and 8,000 feet scattered. A temperature of 28 degrees Celsius (C), dew point temperature 22 degrees C, and an altimeter setting of 29.82 inches of mercury. The pilot, age 76, did not hold a pilot certificate. According to the Federal Aviation Administration (FAA) records, the pilot had first applied for a medical certificate in 1973. At that time, he reported 3 hours of flight experience. On his next and last application, dated 01/18/1979, he reported 6,800 total hours of flight experience. He reported no medical conditions and no medications to the FAA. In 1979, he received a second-class medical certificate with a requirement to have available glasses for near vision. That certificate expired for all classes in 1981. No flight records or flight logbooks were located for the pilot after the expiration of his last medical certificate. Wreckage debris and broken tree limbs were scattered for about 600 feet along an approximate 150-degree magnetic heading, emanating from a cluster of scraped and broken trees. A separated section of the outboard left wing and an outboard section of the left aileron were along the beginning of the debris path. A ground scar about 30 feet-long and 4 feet-wide was observed on the ground, about 50 feet southeast of the initial cluster of broken trees. The fuselage and empennage were located about 550 feet southeast of the ground scar. Examination of the left wing revealed it remained attached to the main wing spar. Approximately 5 feet of the outboard wing was fragmented, and the remainder of the wing was buckled forward. The flap was in the up positon and the inboard section of the aileron remained attached to the wing. The aileron control cable was traced from the aileron to the cockpit controls, and continuity was confirmed. The fuel tank was breached and the fuel cap was locked and secure. Examination of the right wing revealed that it remained attached to the main wing spar. The entire span of the wing was buckled. The flap was in the up position and aileron remained attached to the wing. The aileron control cable was traced from the aileron to the cockpit controls and continuity was confirmed. The fueltank was breached and the fuel cap was secure. The empennage was attached to the fuselage with the vertical stabilizer attached. The rudder was attached to the vertical stabilizer at all attach points, and the rudder control cables were attached to the rudder horn. Rudder control continuity was established from the rudder to the cockpit. The horizontal stabilizer structure and elevators were still attached to the empennage. Elevator control continuity was confirmed from the control surface to the cockpit. The elevator trim tab was observed in the 5-degree nose up position. The fuselage came to rest flat on the belly of the airplane. The cabin, cabin roof, and cabin floor showed crush damage, and the cabin door was separated. The instrument panel was crushed with most instruments and avionics separated from their mounts. The control yoke and rudder pedals were crushed within the cockpit. The engine power controls were damaged and the positions could not be determined. The engine start and magneto switch was found separated with the key absent and the orientation of the switch in the "both" position. The attitude indicator and the directional gyro were found crushed and separated. The readings were unreliable. The engine was separated from the firewall with sections of the engine mount bent and attached. The propeller, oil filter, exhaust muffler and portions of the intake and exhaust tubing were separated from the engine. The engine was partially disassembled to facilitate the examination. The engine crankshaft was rotated using a tool inserted in the vacuum pump drive pad, and continuity of the crankshaft to the rear gears and to the valve train was confirmed. Compression and suction were observed on all four cylinders. Oil was observed in the engine. The oil cooler and associated hoses were impact-damaged. Both magnetos were impact-damaged and remained attached to the engine. The left magneto case was fractured and could not be operated. The right magneto was rotated by hand and produced spark from all four electrode towers. The carburetor was impact-damaged and partially separated from the engine. The float bowl was separated and empty. The brass floats were crushed, and the carburetor fuel inlet screen was not located. The propeller was separated from the crankshaft and one blade was bent aft about 5 degrees, exhibited blade twisting, and leading edge abrasions on the span of the blade. The other blade was curved forward about 5 degrees at about 2/3 span, and exhibited leading edge abrasions. ## Aircraft - Registration: [N52445](https://openairdocs.org/deregistered/N52445-2018-03-30), registration cancelled 2018-03-30, S/N 17274526, built 1980 (OpenAirDocs) - Reported make and model: CESSNA 172 (P) - Registry model: [Cessna 172P](https://openairdocs.org/model/cessna-172p) (registry code 2072436) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17274526 - Year built: 1980 - Airframe hours: 10527 - Engines: LYCOMING O-320-D2J 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, March 26, 2008, 27 hours before - Departed: PVT, Bolton, NC - Destination: ACZ, Wallace, NC - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 76; injuries: fatal; medical: class 2, with waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 3 total, 3 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 72 °F - Altimeter: 29.81 inHg - Observed at: ILM, 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 20150911016489A](https://openairdocs.org/incident/20150911016489A), Sep 11, 2015: Cessna 172P, Riegelwood, NC, Destroyed, 1 fatal. The accident aircraft took off from a privately owned grass airstrip flown by a uncertificated pilot. The takeoff appeared to be normal. The aircraft climbed… ## Docket (7 files) The files NTSB released with the investigation on March 6, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91961. 5.3 MB in all. - Memorandum for Record - Airplane Owner and Mechanic Statement (item 1, .PDF, 361 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449682&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Airplane%20Owner%20and%20Mechanic%20Statement-Master.PDF - Maintenance Records (item 2, .PDF, 839 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449683&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Maintenance Records - Invoice (item 3, .PDF, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449684&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Invoice-Master.PDF - Photo Array (item 4, .PDF, 6 photos, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449685&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Toxicological Report (item 5, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449688&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 692 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449687&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 327 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40449689&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.