WPR20LA245

NTSB accident investigation · Cessna 337 · Ennis, MT · July 30, 2020

Accident · FatalClass 3 · LimitedFinal report
Date
July 30, 2020, 09:38 local (15:38 UTC)
Place
Ennis, MT
Injuries
1 fatal, 2 serious
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N337VCessna 337
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Aviation Safety Inspector, Textron Aviation
FAA report
20200730006719A
Case key
101709

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 pilot-in-command’s failure to maintain sufficient airspeed while attempting an evasive maneuver from a boxed canyon, which resulted in an aerodynamic stall/spin and impact with mountainous terrain. Contributing to the accident was the pilot-in-command’s failure to monitor the environment before flying into mountainous terrain.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 337F: 1 caseAll aircraft: 1,681 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededCessna 337F: 1 caseAll aircraft: 990 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 337F: 3 casesAll aircraft: 9,295 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Effect on operationCessna 337F: 1 caseAll aircraft: 329 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The left seat pilot-in-command (PIC) reported that, he passed the controls to the right seat student pilot once they were en route on the accident flight. The rear seat passenger’s postaccident statement indicated that the left seat pilot was at the controls for the duration of the flight; however, he may not have seen the exchange of the flight controls as he was seated behind both pilots at the time. As they were flying southbound on the cross-country flight over a valley about 3,000 ft above ground level, they agreed that they wanted to view a resort in the area. The student pilot then turned the airplane to the southeast towards higher mountainous terrain. After the airplane had entered a boxed canyon, and with a ridge in the airplane’s flightpath that it could not clear, the PIC took control of the airplane and attempted an evasive maneuver to reverse course to exit the canyon. However, during the maneuver, the PIC likely did not maintain sufficient airspeed, which resulted in an aerodynamic stall/spin and subsequent impact with remote mountainous terrain. The PIC reported no mechanical anomalies with the airplane that would have precluded normal operation. Toxicology results indicated that the student pilot had used cannabis, but likely had metabolized it such that no detectable psychoactive chemicals remained in his blood. The toxicology results and the student pilot’s limited role in the accident flight suggest that the effects of cannabis use were unlikely to have contributed to the accident.

Factual narrative

On July 30, 2020, about 0938 mountain daylight time, a Cessna 337F, N337V, was substantially damaged when it was involved in an accident near Ennis, Montana. The right-front seat student pilot was fatally injured, and the left-front seat commercial pilot-in-command (PIC) and rear-seat passenger were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal cross-country flight. According to the PIC, he planned a route of flight from Helena, Montana, to Jackson Hole, Wyoming. The PIC further reported that the right seat student pilot was flying the airplane about 3,000 ft above ground level. When they decided to fly over a ski resort at Big Bear, Montana, the flying right-seat student pilot turned the airplane to the southeast in the direction of mountainous terrain. The airplane subsequently entered a boxed canyon, and with a ridge now in the airplane’s flightpath that could not be cleared, the PIC took control of the airplane and attempted an evasive maneuver to exit the boxed canyon. However, the evasive maneuver, which was unsuccessful, resulted in a stall/spin and subsequent impact with remote mountainous terrain. The PIC opined that the accident should have been easily avoided by having more than sufficient altitude before entering mountainous terrain. Additionally, the PIC reported no mechanical anomalies with the airplane or engine prior to the accident that would have precluded normal operation. The rear seat passenger reported that they departed Helena at 0845 and that the “entirety of the flight was flown by the front left-seat pilot.” He further stated that the PIC was climbing in an attempt to clear a ridge when the airplane stalled and impacted terrain in a nose-down attitude. The Montana State Medical Examiner, Missoula, Montana, performed an autopsy on the student pilot and noted the cause of death as multiple blunt force injuries. Right Seat Student Pilot Medical Review Toxicology testing performed at the Federal Aviation Administration Forensic Sciences Laboratory identified 11-hydroxy-delta-9-THC [tetrahydrocannabinol] in the urine and its metabolite, carboxy-delta-9-THC was detected in the blood and urine. Levels of 11-hydroxy-delta-9-THC were 26.4 ng/mL and levels of carboxy-delta-9-THC were 3.1 ng/mL and 1225 ng/mL, respectively. Delta-9-THC (the primary psychoactive component in cannabis) was not detected. The cannabis plant contains chemicals called cannabinoids. Significant performance impairments are usually observed for at least 1-2 hours following cannabis use, and residual effects have been reported up to 24 hours. However, it is difficult to relate blood levels of delta-9-THC to effects, and there is no mechanism for relating levels in any other specimens to psychoactive effects.

Aircraft

Registration
N337V
Reported as
Cessna 337 (F)
Category
Airplane
Serial number
33701369
Built
1971
Airframe hours
2,028
Engines
Continental TSIO-360-C, 210 horsepower, reciprocatingContinental TSIO-360-C, 210 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2020 · 43 hours before
Departed
HLN · Helena, MT
Destination
JAC · Jackson Hole, WY
Equipment
Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
27
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
July 22, 2020
Seat
Left
Restraint
Lap only
Flight hours
671 total · 37 in this make and model · 653 as pilot in command · 200 in the last 90 days · 89 in the last 30 days · 1 in the last 24 hours
Role
Student pilot
Injuries
Fatal
Certificate
Student
Medical
Class 3, With waivers/limitations
Seat
Right
Toxicology
Performed
Flight hours
200 total

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Lowest ceiling
None
Temperature
66 °F, dew point 46 °F
Altimeter
30.37 inHg
Observed at
EKS, 8 nm away

Docket · 8

The files NTSB released with the investigation on June 9, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.5 MB in all.

FAA reports on this event · 1

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