# NTSB WPR22FA011: Cessna 175, N7584M, Reserve, NM, October 15, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: October 15, 2021, 09:59 local (15:59 UTC) - Place: Reserve, NM · Gila National Forest - Coordinates: 33.596478, -108.72155 - Nearby events: https://openairdocs.org/map.md?lat=33.5965&lon=-108.7215&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) - Highest injury: Fatal - Injuries: 1 fatal, 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Lycoming, Textron Aviation, Federal Aviation Administration - NTSB case key (mKey): 104107 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22FA011 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104107/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104107 - Page: https://openairdocs.org/ntsb/WPR22FA011 ## Probable cause The pilot’s failure to maintain clearance from terrain while maneuvering at a low altitude. Contributing to the accident was the pilot’s reduced forward visibility due to the sun. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 175, 3 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=2072502), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Light condition: bright light](https://openairdocs.org/ntsb-findings/03036010): Environmental issues › Conditions/weather/phenomena · Effect on personnel (probable cause); cases with it: [Cessna 175, 1 case](https://openairdocs.org/ntsb-findings/03036010/cases.md?model=2072502), [All aircraft, 28 cases](https://openairdocs.org/ntsb-findings/03036010/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 175, 3 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=2072502), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Loss of visual reference](https://openairdocs.org/ntsb-events/402); cases with it: [Cessna 175, 2 cases](https://openairdocs.org/ntsb-events/402/sequence.md?model=2072502), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md) - [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) (defining event); cases with it: [Cessna 175, 2 cases](https://openairdocs.org/ntsb-events/220/sequence.md?model=2072502), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md) ## Analysis The pilot was conducting a personal flight with two passengers over mountainous terrain, with the intention of scouting areas to hunt. The passengers reported that they were directing the pilot where they wanted to look, and while maneuvering, the airplane entered a “sharp” turn and started to descend. They stated it “felt/sounded” like the engine lost power and that the pilot was not able to get full power back. The pilot was able to level the airplane, but it continued to descend into the trees. The passengers also stated it was difficult to see out of the windshield during the flight because the airplane was “tilted up” the entire flight. Downloaded GPS flight track data showed that in the final 2 minutes of the flight, the airplane turned to the southeast toward rising terrain, and entered a positive rate of climb, which continued until the last recorded GPS data point, which was located about 95 ft south of the accident site. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Review of sun and moon data for the time and location of the accident revealed that the sun was just above the relative horizon and in the southeast quadrant of the sky. It is likely that when the pilot initiated a climb while on a southeasterly heading, the sun reduced the pilot’s forward visibility and her awareness of rising terrain in the immediate flight path, which led to a collision with the terrain. Although toxicology testing indicated the pilot used Diphenhydramine at some point before the accident flight, the detected blood levels could not be used to infer the level of impairment. Based on the circumstances of the accident, the effect of Diphenhydramine use was determined not to be a likely factor in the accident. ## Factual narrative On October 15, 2021, about 0959 mountain daylight time, a Cessna 175, N7584M, was substantially damaged when it was involved in an accident near Reserve, New Mexico. The pilot was fatally injured, and the two passengers were seriously injured. The aircraft was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A summary of combined statements obtained from the two passengers, was provided by their attorney. In that summary, the passengers stated that they recall that the weather was cold and clear on the day of the accident flight, and that the purpose of the flight was to scout areas to hunt. When they reached a planned hunting area, they pointed out to the pilot where they wanted to look, and the pilot turned toward that area. They recall a turn to the northeast that was “a sharp turn and then the airplane started to go down quickly.” They thought it sounded like the engine had lost power and the pilot “was having a hard time.” The airplane leveled off and the pilot did not make a distress call, but the mountains kept getting closer. They recall that it was difficult to see out of the windshield, the airplane was “tilted up”, and they impacted trees. Data downloaded from a handheld GPS showed that the airplane departed Grant County Airport, near Silver City, New Mexico about 0907. The airplane flew north-northwest for 21 minutes, then west-northwest for another 17 minutes. In the final 9 minutes of the flight, the data showed that the airplane turned to a northerly heading, before it turned to the southeast. During the last 2 minutes of the flight, the airplane remained on a southeasterly heading and ascended from 6,732 ft mean sea level (msl) to 7,530 ft msl. The last recorded GPS data point was located about 95 ft south of the accident site, at an altitude of 7,523 ft msl. Toxicology testing performed at the Federal Aviation Administration Forensic Sciences Laboratory found Losartan, Rosuvastatin, and Diphenhydramine in the pilot’s blood and urine. Losartan is a prescription medication used to treat high blood pressure, and Rosuvastatin is a prescription cholesterol medication. Neither of these medications are known to adversely affect performance. Diphenhydramine is an over-the-counter antihistamine and can impair performance, depending on the circumstances of use. Carboxyhemoglobin, Ethanol, Glucose, and drugs of abuse were not detected. A review of astronomical data from the National Oceanic and Atmospheric Administration revealed that, at the time and location of the accident, the sun was located at an azimuth of 126.2° true (117.2° magnetic), and an elevation of 29.29° above the horizon. The calculated density altitude at the accident site around the time of the accident was 8,564 ft and the calculated pressure altitude was 7,151 ft. Examination of the accident site revealed the airplane impacted mountainous terrain at an elevation of 7,521 ft msl. The first identifiable point of contact was the top of a pinetree located about 100 ft downhill from the wreckage. Branches from damaged trees were found on the ground and displayed signatures consistent with propeller strikes. The airplane came to rest on its left side. The left wing was folded upward and remained attached by the control cables. Both wings exhibited impact damage along their leading edges. The horizontal and vertical stabilizers remained attached to the empennage, and the elevator and rudder remained attached at their respective attachment points. Flight control continuity was established for all flight control surfaces. Examination of the recovered engine revealed that when the crankshaft was rotated by hand using the propeller, rotational continuity was established throughout the engine and valvetrain, and thumb compression was obtained on all cylinders. The engine was started and ran at various power settings with no anomalies noted. The propeller remained attached to the crankshaft flange and the propeller blades remained attached to the hub. The propeller blades displayed leading edge gouging, torsional twisting, chordwise striations across the cambered surface, and trailing edge “S” bending. No evidence of preexisting mechanical malfunction was observed with the airframe or engine that would have precluded normal operation. ## Aircraft - Registration: [N7584M](https://openairdocs.org/aircraft/N7584M), registered now, S/N 55884, built 1959 (OpenAirDocs) - Reported make and model: CESSNA 175 - Registry model: [Cessna 175](https://openairdocs.org/model/cessna-175) (registry code 2072502) (OpenAirDocs) - Registry engine: [Continental GO-300 series](https://openairdocs.org/engine/continental-go-300-series) (registry code 17024, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 55884 - Year built: 1959 - Airframe hours: 3866.7 - Engines: Lycoming O-360-A1A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 20, 2021, 71.6 hours before - Departed: KSVC, Silver City, NM - Airport: N/A, N/A ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: lap only; flight hours: 2,636 total ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 23 °F - Altimeter: 30.29 inHg - Observed at: KSVC, 64 nm away - METAR: KSVC 151515Z AUTO 20004KT 10SM CLR 12/M05 A3029 RMK AO2 T01151050 ## 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 20211015018699A](https://openairdocs.org/incident/20211015018699A), Oct 15, 2021: Cessna 175, Reserve, NM, Destroyed, 1 fatal. On October 15, 2021, at 1100 MST, a Cessna 175, N7584M, [privacy data omitted] crashed into a ravine about eight miles south east of Reserve, NM, while on a… ## Other investigations on N7584M (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 MKC66F0534](https://openairdocs.org/ntsb/MKC66F0534), May 14, 1966: Cessna 175 (N7584M), Sutherland, NE, substantial damage ## Docket (16 files) The files NTSB released with the investigation on November 7, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104107. 28.9 MB in all. - Surviving passenger statements (item 1, PDF, 2 pages, 143 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15944679&FileExtension=pdf&FileName=WPR22FA011%20passenger%20written%20statement_Redacted-Rel.pdf - GPS device - specialist's factual report (item 2, PDF, 10 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15944689&FileExtension=pdf&FileName=(GPS)%20Global%20Positioning%20System%20Device%20-%20Specialist%27s%20Factual%20Report%20WPR22FA011-Rel.pdf - Attachment 1 to GPS system device - specialist's factual report (item 3, PDF, 13 pages, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15946310&FileExtension=pdf&FileName=Attachment%201%20to%20Global%20Positioning%20System%20Device%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - NTSB accident site examination summary 1 (item 4, PDF, 7 pages, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16323061&FileExtension=pdf&FileName=Accident%20Site%20Summary-Rel%20(1)-Rel.pdf - ADS-B data (item 5, KMZ, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16324916&FileExtension=kmz&FileName=20211015_AA3AB1_467689577_ADSB-Rel.kmz - Astronomical data (item 6, PDF, 3 pages, 297 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15945876&FileExtension=pdf&FileName=Astronomical%20Data%20WPR22FA011-Rel.pdf - Weight & balance and performance summary (item 7, PDF, 4 pages, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15947043&FileExtension=pdf&FileName=Weight%20and%20Balance%20_%20Performance%20Summary%20WPR22FA011-Rel.pdf - Statement of party representatives to NTSB investigation (item 8, PDF, 2 pages, 483 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16213359&FileExtension=pdf&FileName=WPR22FA011%20party%20forms%20for%20dms%20_%20flat_Redacted-Rel.pdf - Textron airframe exam (item 9, PDF, 7 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13349278&FileExtension=pdf&FileName=Textron%20Tech%20Report%2055884_Redacted-Rel.pdf - Memorandum for record a�� engine examination (item 10, PDF, 2 pages, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16213614&FileExtension=pdf&FileName=Memorandum%20of%20Record%20M.Platt_Lycoming-Rel.pdf - Toxicological report (item 11, PDF, 1 page, 437 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13347643&FileExtension=pdf&FileName=toxicology_Redacted-Rel.pdf - Memorandum for record a�� autopsy memo (item 12, PDF, 1 page, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15944375&FileExtension=pdf&FileName=Autopsy%20Memo-Rel.pdf - Medical factual (item 13, PDF, 4 pages, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15534000&FileExtension=pdf&FileName=WPR22FA011_Reserve_NM_Medical_Factual_FINAL_051523-Rel.pdf - Accident location pin (item 14, PDF, 1 page, 269 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15944136&FileExtension=pdf&FileName=Accident%20Location%20Pin%20WPR22FA011-Rel.pdf - Airplane pilot operating handbook (item 15, PDF, 84 pages, 11.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15943942&FileExtension=pdf&FileName=POH%20Model%20175_175_1959_175_OM_P-175A-Rel.pdf - Photo array (item 16, PDF, 5 pages, 6.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15944385&FileExtension=pdf&FileName=WPR22FA011%20wreckage%20site%20photo%20array-Rel.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.