MIA02FA104

NTSB accident investigation · Cessna 172S · Lutz, FL · June 4, 2002

Accident · FatalField investigationFinal report
Date
June 4, 2002, 08:23 local (12:23 UTC)
Place
Lutz, FL
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N942SPCessna 172S
Weather
Visual (VMC) · Day
Status
Completed · report December 20, 2005
Report
Approved by Office Director
Parties
Cessna Aircraft Company, FAA FSDO, Textron Lycoming
FAA report
20020604019999A
Case key
54879

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

The suicidal act by the pilot resulting in the in-flight collision with trees then the ground. A contributing factor in the accident was the pilot's depression. Findings in the investigation were the pilot's overdose of zolpidem and citalopram before the accident flight departed, and his intentional operation of the airplane while impaired by alcohol.

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 objectDescent
Object - tree(s)
DepressionPilot in commandFactor
Suicide - intentionalPilot in commandCause

Analysis

The pilot had been involved in a helicopter accident that occurred 10 hours 52 minutes before the airplane accident which the helicopter he was flying solo crashed onto the roof of a house. He sustained minor injuries and there were no injuries to the three occupants of the house. The pilot was transported to a hospital where a testing of a blood specimen taken 1 hour 40 minutes after the accident indicates 136 g/dL ethanol detected. Testing of a sample from the same specimen by the FAA Toxicology and Accident Research Laboratory (CAMI) indicated 105 mg/dL ethanol in blood, or .105 percent by weight in blood. CAMI also detected acetone (1 mg/dL, mg/hg), acetaldehyde (8 mg/dL, mg/hg), citalopram (0.017 ug/ml,ug/g), and zolpidem (0.433 ug/ml,ug/g) in the blood specimen. The medical records from the hospital indicate a physician note at 2300 hours (approximately 1.5 hours after the accident), indicating slurred speech. A nursing note without a time stamp indicates the pilot admitted to ingesting ethanol "earlier today." The primary diagnosis on the emergency department physician note is, "ethanol intoxication, concussion." The pilot was released from the hospital to his parents at 0235 hours on the 4th of June, and he was transported to his apartment which he shared with a roommate. The roommate reported to the pilot's mother that on the day of the airplane accident, the pilot was watching television at 0630 hours. On the morning of the airplane accident sometime before 0710 hours, the pilot was observed taxiing the airplane to runway 36. Several witnesses reported hearing the pilot abruptly apply power to the engine several times before departing about 0709 hours. After takeoff the flight proceeded in a northwesterly direction and without establishing contact with the Tampa Approach Control or Tampa Air Traffic Control Tower, orbited for approximately 62 minutes while flying at approximately 2,200 feet. During this time an airplane that was inbound to KTPA was vectored by a controller to where the airplane was orbiting in an attempt to identify the airplane to controllers; the pilot reported seeing the pilot in the left side of the airplane. The pilot assisting air traffic control also reported that he believed the orbiting pilot was aware of the close proximity of the two airplane because it appeared to him that the orbiting pilot was maneuvering to avoid him. Attempts to communicate with the pilot on the departure airport CTAF were negative. Additionally, attempts by a flight crew member of a law enforcement helicopter to communicate with the pilot on guard (121.5 MHz) were also unsuccessful. After orbiting for 62 minutes, the airplane departed the orbits flying in a northwesterly direction for 1.6 minutes, then completed a 180 degree turn to the right. The airplane then flew in a southeasterly direction for 36 seconds, turned to the left flying in a northwesterly direction, then completed a right 360 degree descending turn. The airplane continued in a northwesterly direction, where the last primary radar target was noted in close proximity to the accident site. A witness located near the accident site area reported hearing the airplane flying at what she thought was a low altitude then heard the engine "revving" up followed by hearing the impact. Several other witnesses across the street from the crash site reported hearing the engine sound that was steady with no sputtering. The engine sound remained the same from the time they heard it until the impact. Another witness reported that he first observed the airplane when it was approximately 30-40 feet above the tops of trees. The airplane at that time was in a 80-degree nose low attitude on a southeast heading. He observed the airplane collide with the trees then heard the impact. Examination of the accident site revealed damage to trees at decreasing heights. All components necessary to sustain flight were either attached or partially attached to the airplane or were found in close proximity to the main wreckage. Examination of the flight controls for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. The flaps were retracted. Examination of the engine revealed no evidence of preimpact failure or malfunction. The No. 1 communication/navigation transceiver was in the on position with maximum volume and the active communication frequency was set to 119.9 MHz, which is the frequency for the East Satellite sector of the Tampa Air Traffic Control Tower. The autopsy report indicates the cause of death as blunt trauma, while the manner of death was listed as "undetermined." A toxicology analysis by CAMI of postmortem specimens was positive in the blood for ethanol (69 mg/dL), acetaldehyde (82 mg/dL), citalopram (0.205 ug/ml, and zolpidem (1.54 ug/ml). The kidney tested positive for ethanol (84 mg/dL), citalopram, di-n-desmethylcitalopram, n-desmethylcitalopram, and zolpidem. The muscle tested positive for ethanol (105 mg/dL). The liver tested positive for citalopram, di-n-desmethylcitalopram, n-desmethylcitalopram, and zolpidem. The gastric contents tested positive for citalopram, di-n-desmethylcitalopram, n-desmethylcitalopram, and zolpidem. Carbon monoxide and cyanide testing was not performed. A note on the CAMI toxicology report indicates, "The ethanol found in this case may potentially be from postmortem ethanol formation and not from the ingestion of ethanol." The levels of citalopram and zolpidem detected in the post mortem blood specimen are more than 12 times and more than 3 times, respectively, greater than the levels of each detected in a hospital blood specimen taken 1 hour 40 minutes following the first accident. Additionally, the CAMI toxicology report indicates citalopram and zolpidem were detected in the submitted postmortem gastric specimen. The pilot had been charged with DUI in May 2001, and reported such on his FAA medical application dated June 1, 2001. The pilot plead nolo contendere to the DUI charge on October 4, 2001. The pilot's medical records from his private physician indicate on May 23, 2002, he complained of insomnia, and depression. The doctor provided samples of 20 mg Celexa (citalopram), one-half tablet daily, and prescribed 10 mg Ambien, 1/2 to 1 tablet to be taken at bedtime. His physician did not request a psychiatric consultation or an inquiry regarding suicidal intent or alcohol/drug use.

Factual narrative

History of flight

On June 4, 2002, about 0823 eastern daylight time, a Cessna 172S, N942SP, registered to Helicopters & Airplanes, Inc., collided with trees then the ground near Lutz, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 CFR Part 91 personal, local flight. The airplane was destroyed by impact and the private-rated pilot, the sole occupant, was fatally injured. The flight originated about 0709 from Vandenberg Airport, Tampa, Florida.

The pilot was observed taxiing the airplane to runway 36 at the Vandenberg Airport, and one witness located on the airport reported the pilot did not perform an engine run-up before takeoff but he "gunned the throttle two times and took off at 0710 am." Another witness on the airport reported hearing the pilot run up the engine abruptly several times before observing the pilot taxi onto runway 36. An individual who was working at a fixed-base operator (FBO) at the Vandenberg airport reported that on the day of the accident sometime after 0730 hours, Tampa Approach Control contacted the FBO and asked for someone there to attempt to contact the pilot on the airport's common traffic advisory frequency (CTAF). She reported making repeated broadcasts on the CTAF for the accident pilot, but he did not respond.

According to a chronological sequence of events prepared by the air traffic manager of the Tampa International Airport Air Traffic Control Tower, at approximately 0716, a radar target associated with the accident airplane was noted orbiting at 2,000 feet north-northeast of the Tampa International Airport (KTPA). At approximately 0718, the departure controller questioned the tower controller about the orbiting airplane; the tower controller advised he was not aware of the airplane and it must be a class B airspace violator. At approximately 0726, the pilot of Flight Express 820 which was inbound to KTPA was vectored by a controller in the area of the orbiting airplane to help identify the airplane; he provided the registration of the airplane to the controller at approximately 0730. At approximately 0734, the Flight Express 820 pilot advised the controller that he thought the airplane was based at the Vandenberg Airport. At 0738, the operations supervisor contacted the FBO at Vandenberg who provided the name of the owner of the airplane. The FBO was also asked to attempt to communicate with the pilot on the airport UNICOM frequency. At 0742, the operations supervisor advised the tower controller that a police helicopter would become airborne to track the orbiting airplane. At approximately 0753, the operations supervisor contacted the U.S. Coast Guard requesting their assistance. At approximately 0758, the operations supervisor contacted the St. Petersburg Automated Flight Service Station and requested personnel attempt to communicate with the pilot of the orbiting airplane on the appropriate PIE VORTAC frequency. At approximately 0803, a flightcrew member of a police department helicopter reported on the frequency and the flight was vectored to the area of the orbiting airplane. A flightcrew member of the police department helicopter broadcast on 121.5 for the orbiting airplane, but there was no response from the pilot. At approximately 0812, a flightcrew member of the police department helicopter advised they would return to get a Cessna which had a camera. At approximately 0821:24, the radar target was lost momentarily, a target was reacquired at 0821:35, and the radar target was finally lost at 0823:10, with the last recorded altitude of 700 feet mean sea level.

The pilot of Flight Express 820 later reported in writing to the National Transportation Safety Board (NTSB) that while flying in close proximity to the accident airplane, he observed the pilot of the orbiting airplane sitting upright in the "left side of the aircraft." He also reported he thought the pilot of the orbiting airplane was aware of the close proximity of both airplanes because, "...it appeared that he was maneuvering to avoid me, although I was unable to see the pilot moving at any time nor was I close enough to see any facial expressions or physical gestures of any kind."

The pilot of the Tampa Police Department helicopter which was dispatched to the orbiting airplane reported observing the airplane from 3/4 mile away. He later reported the airplane was flying left orbits.

A witness near the accident site reported hearing the airplane flying at what she thought was a low altitude then heard the engine "revving" up followed by hearing the impact. Several other witnesses across the street from the crash site reported hearing the engine sound that was steady with no sputtering. The engine sound remained the same from the time they heard it until the impact. Another witness reported that he first observed the airplane when it was approximately 30-40 feet above the tops of trees. The airplane at that time was in a 80-degree nose low attitude on a southeast heading. He observed the airplane collide with the trees then heard the impact.

Several law enforcement aircraft and a U.S. Coast Guard helicopter were dispatched to the area of the last known position of the orbiting airplane. Additionally, a ground search for the airplane was initiated by local law enforcement personnel.

National Transportation Safety Board (NTSB) review of recorded radar data for beacon code 1200 radar returns revealed a target was first observed at 0709:07, at 400 feet mean sea level (msl) just north of runway 36 at the Vandenberg Airport. The flight proceeded in a northwest then westerly direction where from approximately 0715 to 0817, the flight orbited at approximately 2,200 feet over the intersection of Ehrlich Road and Dale Mabry Highway. At approximately 0817, the flight departed from the orbiting area and proceeded in a northwesterly direction for approximately 1.6 minutes, then turned to the right completing a 180-degree turn. The airplane then proceeded in a southeasterly direction for approximately 36 seconds and at approximately 0819:55, the airplane turned to the left and proceeded in a northerly direction flying at 2,100 feet until 0820:31. The airplane then turned to the left, climbed 100 feet over the next 12 seconds, then the airplane turned to the right and performed a right descending 360-degree turn. The airplane then proceeded in a northwesterly direction where at 0822:31, the last radar return with altitude was reported. The last radar target at 0822:43, was a primary only radar return.

Personnel information

According to Federal Aviation Administration (FAA) records, the pilot was issued a private pilot certificate with airplane single engine land rating on July 2, 2000. He was issued a third class medical certificate with no limitations on June 1, 2001. A review of FAA records indicated the pilot did not have any previous accident or incidents, or previous enforcement actions.

A review of the medical application for the June 2001 medical revealed he listed his total flight time as 292 hours. Further review of the application revealed the pilot checked the "yes" block in response to the question, "History of ...any conviction(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug...."

Review of the pilot's driver license records revealed he was charged with driving under the influence (DUI) on May 9, 2001; he pleaded nolo contendere to the charge on October 4, 2001.

Aircraft information

The airplane was manufactured by Cessna Aircraft Company in 1999, as model 172S, and was designated serial number 172S8137. It was certificated in the normal and utility categories, and was equipped with a 180-horsepower Lycoming IO-360-L2A engine, and a fixed pitch McCauley propeller.

A review of the maintenance records revealed the airplane was last inspected on June 3, 2002, in accordance with an ann

Aircraft

Registration
N942SP
Reported as
Cessna 172S
Category
Airplane
Serial number
172S8137
Airframe hours
283.6
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Michael P. Antinori
Registered owner
Helicopters & Airplanes, Inc.
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · June 3, 2002 · 1.2 hours before
Departed
KVDF · Tampa, FL
Destination
KVDF · Tampa, FL

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
30
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--no waivers/lim.
Last flight review
July 2, 2000
Seat
Left
Toxicology
Performed
Flight hours
292 total

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
25,000 ft overcast
Temperature
81 °F, dew point 70 °F
Altimeter
29.96 inHg
Observed at
KTPA, 9 nm away

Docket · 24

The files NTSB released with the investigation on January 3, 2005, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.7 MB in all.

Factual Medical InformationItem 1 · .PDF · 10 KBATC 3 - Radar PlotsItem 2 · .PDF · 1.7 MBATC 3 - USAF Radar Data for N942SPItem 3 · .CSV · 13 KBMap of Accident Area, Wreckage DiagramsItem 4 · .PDF · 44 KBWitness StatementsItem 5 · .PDF · 242 KBAir Traffic Control InformationItem 6 · .PDF · 219 KBReports from Local Agencies: Hillsborough County Sheriff's OfficeItem 7 · .PDF · 1.0 MBOther Pertinent Forms and Reports: Driving Record InformationItem 8 · .PDF · 108 KBOther Pertinent Forms and Reports: Record of NTSB InterviewsItem 9 · .PDF · 418 KBOther Pertinent Forms and Reports: Excerpt from Airplane Information ManualItem 10 · .PDF · 40 KBStatement of Party Representatives to NTSB InvestigationItem 11 · .PDF · 59 KBToxicological ReportsItem 12 · .PDF · 195 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 13 · .PDF · 142 KBPhoto 1: Law enforcement photograph. Aerial photograph. Arrow points to wreckage location. No negative.Item 14 · .PDF · 251 KBPhoto 2: View looking from the area of the cockpit towards the initial tree contact location.Item 15 · .PDF · 527 KBPhoto 3: Closer view of the initially contacted trees.Item 16 · .PDF · 649 KBPhoto 4: View of the main wreckage.Item 17 · .PDF · 788 KBPhoto 5: View of the cockpit and cabin area.Item 18 · .PDF · 675 KBPhoto 6: View of the propeller after being unearthed.Item 19 · .PDF · 602 KBPhoto 7: View showing tree trunk with 45-degree cuts at both ends.Item 20 · .PDF · 703 KBPhoto 8: View of the right front restraint.Item 21 · .PDF · 713 KBPhoto 9: Closer view of the right front restraint. Pen points to gouge on pin, which secures the webbing of the lapbelt to the buckle.Item 22 · .PDF · 670 KBPhoto 10: View of the wreckage laid out following recovery.Item 23 · .PDF · 432 KBPhoto 11: View of the wreckage laid out following recovery.Item 24 · .PDF · 512 KB

FAA reports on this event · 1

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