LAX95LA261

NTSB accident investigation · Aero Commander S2R · Huron, CA · July 21, 1995

Accident · Minor injuriesLimited investigationFinal report
Date
July 21, 1995, 05:00 local (12:00 UTC)
Place
Huron, CA
Injuries
1 minor
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N5609XAero Commander S2R
Weather
Visual (VMC) · Night/dark
Status
Completed · report July 15, 1996
Report
Approved by Office Director
FAA report
19950721019359A
Case key
29158

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

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Probable cause

Failure of the pilot to maintain sufficient altitude above the ground after diverting his attention to read a map. Factors relating to the accident were: darkness, which reduced the pilot's visual cues concerning outside references while reading the map; and the pilot's use of a drug.

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.

In flight collision with terrain/waterManeuvering - aerial application
Light condition - dark nightFactor
Altitude - not maintainedPilot in commandCause
Diverted attentionPilot in commandCause
Impairment(drugs)Pilot in commandFactor

Analysis

The pilot was conducting a night aerial application flight, and had just taken off to start on a new field (at about 0500 PDT). He reported that the ground flaggers were not in the proper position when he made the initial pass. The pilot said he pulled up and reached down to get his map to verify the flaggers' proper position, and turned on the interior lighting to read the map. After reading the map, he reached for the interior lighting switch. At about that time, the airplane struck the ground. Toxicology tests of the pilot's urine indicated an unquantified level of valium and a pain medication (opiate positive). The pilot stated that he took a pain pill before going to the hospital (emergency room), and that he had taken 1/2 of a 5 milligram (mg) valium tablet at about noon on the previous day so he could get some sleep before reporting for work at 2100 hours. Valium is an antianxiety agent and muscle relaxant, not approved for use while flying. Pharmacy records showed that on 5/26/95, the pilot had prescriptions filled for 90 valium tablets and 90 tylenol/codeine tablets.

Factual narrative

On July 21, 1995, at 0500 hours Pacific daylight time, an Aero Commander S2R, N5609X, collided with the terrain near Huron, California. The pilot completed the initial aerial application pass on a visual flight rules aerial application flight under 14 CFR 137. The airplane, registered to and operated by Willett Flying Service, Inc., Huron, California, sustained substantial damage. The certificated commercial pilot, the sole occupant, sustained minor injuries. Visual meteorological conditions prevailed. The flight originated from a private airstrip at Huron at 0457 hours.

The operator reported that the field the pilot was spraying is about 1 mile east of the airstrip.

The pilot said in his written accident report that the ground flaggers were not in the proper position when he made the initial pass. He pulled up and reached down to get his map to verify the flaggers proper position and turned on the overhead light. He trimmed the airplane to a "slightly nose up" position. When he was reaching to turn the light out, the airplane struck the ground.

The pilot sent a letter to the Federal Aviation Administration (FAA), Fresno [California] Flight Standards District Office. He said that the accident was ". . . caused by engine failure while I was checking my map to confirm the flaggers were positioned incorrectly while I had my overhead light on. . . ."

The pilot said in the letter that after the accident he took a pain pill before going to the hospital. He said that on July 20, 1995, between 1200 and 1300 hours he took 1/2 of the 5-milligram (mg) Valium tablet. He took the Valium so that he could get some sleep before reporting to work at 2100 hours.

The pilot told the inspector that he began his aerial application activities at 2300 hours. These activities continued until the accident.

A ground flagger reported that he was flagging the airplane from the north center position of the field. The airplane made the first pass from the south to the north on the east side of the field. After completing the pass, the airplane pulled up and made a left turn. The airplane struck the ground as it continued the turn. The flagger said that he did not hear any unusual noises from the airplane before it struck the ground.

The pilot's son took the pilot to Hanford Community Medical Center, Hanford, California, for treatment. The doctors treated the pilot for a cracked sternum and a sprained foot, and suggested that he be hospitalized for additional tests. The pilot elected not to be hospitalized and left the hospital against medical advice.

A Hanford Community Medical Center laboratory technician did toxicological examinations on the pilot on July 21, 1995, at 0839 hours.

The National Transportation Safety Board subpoenaed the pilot's medical treatment and toxicological records from Hanford Community Medical Center. The toxicological examinations were positive for benzodiazapine (Valium) and opiates (codeine). The concentration of these drugs was not quantified. The laboratory technician told Safety Board investigators that the threshold cutoff for the benzodiazapine and opiates was 300 nanograms per milliliter (ng/ml).

The FAA, Fresno Flight Standards District Office sent the Safety Board a record of the pilot's pharmaceutical purchases beginning on January 2, 1990. Examination of the records showed that the pilot continually purchased many drugs, including multiple purchases of Valium and Tylenol with codeine, until May 26, 1995.

Aircraft

Registration
N5609X
Reported as
Aero Commander S2R
Category
Airplane
Serial number
1809R
Airframe hours
5,500
Engine
P&W R-1340, 600 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial application · Part 137
Registered owner
Willett Flying Service, Inc
Airworthiness certificate
Special, Restricted (Special)

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
57
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Center
Toxicology
Performed
Flight hours
22,000 total · 10,000 in this make and model · 21,900 as pilot in command · 60 in the last 90 days · 25 in the last 30 days · 5 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night/dark
Wind
Calm
Visibility
15 statute miles
Lowest ceiling
None
Temperature
64 °F

FAA reports on this event · 1

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