# NTSB ERA17FA232: Morrisey 2150A, N917JL, Honesdale, PA, July 6, 2017 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 6, 2017, 16:45 local (20:45 UTC) - Place: Honesdale, PA - Coordinates: 41.515556, -75.251663 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.5156&lon=-75.2517&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 16, 2018 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, FAA/FSDO - NTSB case key (mKey): 95506 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17FA232 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95506/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95506 - Page: https://openairdocs.org/ntsb/ERA17FA232 ## Probable cause A total loss of engine power due to fuel exhaustion. Contributing to the accident was the pilot's use of two psychoactive substances, which led to his impaired decision to attempt to takeoff after engine issues became evident. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid level (probable cause); cases with it: [Morrisey 2150A, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=5940204), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Impairment/incapacitation: illicit drug](https://openairdocs.org/ntsb-findings/02012020): Personnel issues › Physical · Pilot (probable cause); cases with it: [Morrisey 2150A, 1 case](https://openairdocs.org/ntsb-findings/02012020/cases.md?model=5940204), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/02012020/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Morrisey 2150A, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=5940204), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot; cases with it: [Morrisey 2150A, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=5940204), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel exhaustion](https://openairdocs.org/ntsb-events/192) (defining event); cases with it: [Morrisey 2150A, 1 case](https://openairdocs.org/ntsb-events/192/sequence.md?model=5940204), [All aircraft, 804 cases](https://openairdocs.org/ntsb-events/192/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Morrisey 2150A, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=5940204), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Morrisey 2150A, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=5940204), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Morrisey 2150A, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=5940204), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot was taking off in day, visual meteorological conditions. According to a witness who was both a pilot and a mechanic, the airplane took off and sounded "normal" and returned for landing. After touchdown, the airplane continued for a touch-and-go landing but the engine, "fumbled… faltered drastically for 3 or 4 seconds" before the pilot aborted the takeoff, taxied back to the beginning of the runway, and took off again. During that takeoff, the witness heard the engine "miss" and heard further power interruptions before his attention was diverted from the airplane. The witness did not see the accident. Airport surveillance video depicted the airplane on its takeoff roll, followed by an initial climb and a left turn in the vicinity of the crosswind leg of the airport traffic pattern. The airplane then entered a shallow descent and a shallow bank angle as it descended from view behind trees. Examination of the airplane at the accident site revealed no fuel odor and no evidence of fuel spillage at the scene. Three ounces of fuel were recovered from the airplane. Detailed examination of the airframe and engine revealed no preimpact mechanical anomalies that would have precluded normal operation; however, locking pliers were substituted for the trim actuator handle, and a bird's nest was found in the engine. In addition, the lap belt and shoulder harnesses were not buckled, and the shoulder harnesses were stowed behind the seat, the lap belts were stowed to either side of the seat pan, and the mold growth, dirt, and corrosion visible on the belts, buckle, and male tabs suggested they had not been used for an extended period of time. Examination of airplane records revealed that the airplane's most recent annual inspection was 5 years before the accident. Whether the pilot confirmed the amount of fuel onboard before departure could not be determined, but his failure to appropriately address the "faltering" engine before attempting another takeoff reflects poor hazard recognition and impaired decision making. Given the lack of fuel found onboard after the accident, the loss of engine power was likely the result of fuel exhaustion. Additionally, toxicology testing of the pilot identified the use of butalbital (a barbiturate) and marijuana, both of which can affect decision-making. Thus, it is likely that the effects from the pilot's use of two psychoactive substances contributed to his decision to conduct the takeoff after observing an engine anomaly. Because the pilot was over 40 years old, his medical certificate expired 2 years after issuance; thus it was not valid at the time of the accident. ## Factual narrative According to FAA records, the two-seat, tandem-configured, low-wing airplane was manufactured in 1961 and was powered by a Lycoming O-320, 150-horsepower engine. The tachometer displayed 2,858.48 aircraft hours at the accident site. A review of the airplane's maintenance records revealed that the most recent annual inspection was completed by the previous owner on July 12, 2012, at 2,825 tachometer hours. The gross weight and horsepower rating of the accident airplane required pilots to possess a third-class medical certificate for its operation. According to FAA records, the airplane was purchased by the pilot/owner in May 2016. He took delivery of the airplane in Mt. Holly, New Jersey, and flew the airplane to N30; however, there was no record of an application for the required special flight permit to perform that flight. On July 6, 2017, at 1645 eastern daylight time, a Morrissey 2150A, N917JL, was substantially damaged during a collision with trees and terrain during a forced landing after takeoff from Cherry Ridge Airport (N30), Honesdale, Pennsylvania. The private pilot was fatally injured. The airplane was privately owned and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. According to a witness who was both a pilot and a mechanic, he watched the airplane perform takeoffs and at least one landing before the accident flight but did not witness the accident. On the first takeoff, the airplane sounded "normal" and returned for landing. After touchdown, the airplane continued for a touch-and-go landing, but the engine, "fumbled… faltered drastically for 3 or 4 seconds" before the pilot aborted the takeoff, taxied back to the beginning of the runway, and took off again. On the following takeoff, the airplane reached traffic pattern altitude "or close to it" on the downwind leg when the witness heard the engine "miss" and heard further power interruptions before his attention was diverted away from the airplane. He said he was unaware of any additional takeoffs or landings that involved the accident airplane. Airport surveillance videos showed the airplane on its takeoff roll from runway 18, followed by an initial climb and a left turn in the vicinity of the crosswind leg of the traffic pattern. The airplane was then seen in a shallow descent and a shallow bank angle as it descended from view behind trees. The video was a compilation collected from multiple cameras, and the resolution of the images diminished as the airplane's distance from the cameras increased. The Forensic Associates of Northeast Pennsylvania, Clarks Summit, Pennsylvania, performed a postmortem examination on the pilot. The cause of death was multiple traumatic injuries. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on specimens of the pilot. Testing identified 0.972ug/ml of butalbital, 0.0191 ug/ml of tetrahydrocannabinol (THC, the primary psychoactive compound in marijuana), and 0.047 ug/ml of tetrahydrocannabinol carboxylic acid (THC-COOH, an inactive metabolite of THC) in cavity blood. These substances, along with oxymetazoline and acetaminophen, were also identified in urine. Butalbital is a barbiturate commonly prescribed in combination with acetaminophen and caffeine and marketed as Fioricet, a medication intended to treat headaches. It carries this warning for patients, as the butalbital component can be impairing: "This product may impair mental and/or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery. Such tasks should be avoided while taking this product." Blood levels of butalbital thought to cause psychoactive effects are between 1.0 and 10.0 ug/ml. The THC in marijuana is a psychoactive drug with psychoactive effects with levels as low as 0.001 ug/ml. It has mood-altering effects, including inducing euphoria and relaxation. In addition, marijuana causes alterations in motor behavior, perception, cognition, memory, learning, endocrine function, food intake, and regulation of body temperature. Specific performance effects include decreased ability to concentrate and maintain attention; impairment of hand-eye coordination is dose-related over a wide range of dosages. Impairment in retention time and tracking, subjective sleepiness, distortion of time and distance, vigilance, and loss of coordination in divided attention tasks have been reported. Oxymetazoline is a potent vasoconstrictor available over the counter as a nasal spray intended to treat nasal congestion. It is not considered impairing. Acetaminophen is an over-the-counter analgesic often sold with the name Tylenol. It is not considered impairing. At 1653, the weather recorded at Pocono Mountain Municipal Airport (MPO), Mount Pocono, Pennsylvania, located 24 miles south of N30, included few clouds at 1,900 ft, wind from 170° at 7 knots, and visibility 10 statute miles. The temperature was 21°C, and the dew point was 17°C. The altimeter setting was 30.09 inches of mercury. The pilot held a private pilot certificate with a rating for airplane single-engine land, and a mechanic certificate with ratings for airframe and powerplant. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued June 27, 2014. He reported 480 total hours of flight experience on that date. The wreckage was examined at the accident site, and all major components were accounted for at the scene. The accident site was about 800 ft southeast of the departure end of runway 18. The wreckage path was about 450 ft long, oriented on a 351° magnetic heading, and ended in densely wooded terrain. The initial impact points were in treetops about 50 ft above the ground. The cockpit and engine compartment were suspended against a tree about 8 ft above the ground, andthe tail section rested on the ground. The forward cockpit and instrument panel were destroyed. The pitch trim actuator handle was not installed; instead a pair of locking pliers were in its place. The lap belt and shoulder harnesses were not buckled. The shoulder harnesses were stowed behind the seat, and the lap belts were stowed to either side of the seat pan. The mold growth, dirt, and corrosion visible on the belts, buckle, and male tabs was undisturbed, and showed no movement of the buckle on the belt, no finger smudges, or metal-to-metal contact. The left wing was separated at its root but remained largely intact. The right wing was attached, but the wing outboard of the main fuel tank was separated. Both the left wing and right outboard wing remained adjacent to the main wreckage and their respective fuel tanks were intact. Control continuity was established from the cockpit controls to the flight control surfaces through multiple breaks. The breaks were all consistent with impact and overload separations. Continuity of the fuel system was confirmed. The left main tank was empty, and the right main tank contained 3 ounces of fuel. The remainder of the fuel system contained only trace amounts of fuel. The left and right fuel selectors were in the "On" position. There was no odor of fuel and no evidence of fuel spillage at the scene. The engine remained attached to its mounts and the crankshaft was fractured at the propeller flange. External examination revealed heavy corrosion on most visible surfaces and a bird's nest between the No. 2 and 4 cylinders. The propeller and crankshaft flange were separated from the engine and came to rest about 30 ft beyond the main wreckage. One propeller blade was undamaged and buried in the ground. The blade above ground was bent aft mid-span and displayed mud and wood smudges along both the chord and the span of the blade. The engine was placed in a stand and rotated by hand through the vacuum pump drive. Continuity was established through the accessory section to the powertrain and valvetrain. Thumb compression was confirmed. The magnetos were removed and each produced spark at all terminal leads when actuated by a power drill. The engine-driven fuel pump, electric fuel pump, and the vacuum pump were each tested. When actuated, they each produced suction and compression at the inlet and outlet ports, respectively. The carburetor was removed and disassembled. The copper floats were intact, moved freely, and displayed no hydraulic deformation. The carburetor and the fuel pumps all contained trace amounts of fuel. ## Aircraft - Registration: [N917JL](https://openairdocs.org/deregistered/N917JL-2018-04-03), registration cancelled 2018-04-03, S/N SP-26, built 1961 (OpenAirDocs) - Reported make and model: MORRISEY 2150A - Registry model: [Morrisey 2150A](https://openairdocs.org/model/morrisey-2150a) (registry code 5940204) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: SP-26 - Year built: 1961 - Airframe hours: 2858.48 - Engines: Lycoming O-320-A2C 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 12, 2012, 33 hours before - Departed: N30, Honesdale, PA - Destination: N30, Honesdale, PA - Airport: N30, Cherry Ridge, runway 18, 2,986 × 50 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 52; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: front; restraint: none; toxicology performed; flight hours: 480 total, 5 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 63 °F - Altimeter: 30.09 inHg - Observed at: KMPO, 24 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 20170706010569A](https://openairdocs.org/incident/20170706010569A), Jul 6, 2017: Morrisey 2150A, Honesdale, PA, Substantial damage, 1 fatal. The aircraft took off runway 18 at approximately 200 feet AGL the aircraft turned left and descended into a wooded area. Prior to that take off the pilot had… ## Other investigations on N917JL (1) 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. - [NTSB IAD76FLQ16](https://openairdocs.org/ntsb/IAD76FLQ16-201307), Nov 3, 1975: Morrisey 2150A (N917JL), Carrboro, NC, substantial damage ## Docket (9 files) The files NTSB released with the investigation on June 21, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95506. 2.6 MB in all. - FAA Inspector's Statement (item 1, .PDF, 11 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464403&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Witness - Memorandum for Record (item 2, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464404&FileExtension=.PDF&FileName=Witness%20-%20Memorandum%20for%20Record-Master.PDF - Video File - Memorandum for Record (item 3, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464405&FileExtension=.PDF&FileName=Video%20File%20-%20Memorandum%20for%20Record-Master.PDF - Maintenance Records (Annual Inspection) (item 4, .PDF, 337 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464406&FileExtension=.PDF&FileName=Maintenance%20Records%20(Annual%20Inspection)-Master.PDF - Photos (item 5, .PDF, 7 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464407&FileExtension=.PDF&FileName=Photos-Master.PDF - Toxicological Report (item 6, .PDF, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464408&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - NTSB Medical Factual Report (item 7, .PDF, 234 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464409&FileExtension=.PDF&FileName=NTSB%20Medical%20Factual%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 260 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464410&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464411&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.