WPR22FA255

NTSB accident investigation · Aeronca 7BCM · Lake McMurray, WA · July 16, 2022

Accident · FatalClass 3 · FieldFinal report
Date
July 16, 2022, 07:30 local (14:30 UTC)
Place
Lake McMurray, WA · Hilly forested slope
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N2588CAeronca 7BCM
Defining event
Enroute-cruise: VFR encounter with IMC
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
FAA
FAA report
20220716012429A
Case key
105489

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

On this page

Probable cause

The pilot’s decision to continue visual flight into an area of instrument meteorological conditions, which resulted in a loss of visual reference and subsequent controlled flight into terrain.

Findings · 2

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.

Ceiling/visibility/precip: low ceilingEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionAeronca 7BCM: 1 caseAll aircraft: 190 casesProbable cause

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 pilot was enroute conducting a visual flight rules (VFR) flight at a low altitude. It is likely given the weather conditions and PIREPs that low ceilings obscured the trees and high terrain from the pilot and resulted in a controlled flight into terrain. While the closet METAR reported cloud ceilings above 1,000 ft above ground level (agl), the PIREPs and a sounding analysis program indicated that the ceiling of the clouds was about 300 ft agl near the high terrain. The accident flight likely encountered instrument meteorological conditions and mountain obscuration conditions as the flight approached higher terrain. The pilot’s autopsy revealed significant multivessel atherosclerotic coronary disease with 80-90% narrowing of the left main and left anterior descending coronary arteries, a significant restenosis of a left anterior descending coronary artery stent, and more than 95% narrowing of the right coronary artery. The heart muscle had an area of scarring in the posterior left ventricle and interventricular septum consistent with an old injury from insufficient blood flow. Microscopic examination of the coronary system did not identify any acute clot or plaque rupture. In the autopsy report, the pathologist noted that the pilot’s family had indicated that the pilot had no new health complaints in the weeks before the accident. Due to his heart disease, the pilot was at significantly increased risk of a sudden distracting, impairing, or incapacitating cardiac event, including angina, arrhythmia, or heart attack. There is no forensic evidence that such an event occurred. However, such an event cannot be excluded by forensic evidence alone. Given the available information about the circumstances of the crash, distracting or otherwise impairing symptoms such as chest pain or palpitations cannot be excluded. This pilot may have experienced a physiologic stress response to the poor weather conditions under which he was flying. A normal stress response would have included increased heart rate, an increase in blood flow demand from his heart, and increased respiratory rate. Physiological stress has been associated with an increased risk of cardiac symptoms such as chest pain or palpitations, most notable in patients with pre-existing cardiac disease. Thus, whether the pilot's heart disease contributed to the crash could not be determined.

Factual narrative

The FAA Advisory Circular 61-134, General Aviation Controlled Flight Into Terrain Awareness, states the following about flying in IMC conditions: “Operating in marginal VFR/IMC conditions is more commonly known as scud running. According to National Transportation Safety Board (NTSB) and FAA data, one of the leading causes of GA accidents is continued VFR flight into IMC.” As defined in 14 CFR part 91, ceiling, cloud, or visibility conditions less than that specified for VFR or Special VFR is IMC and IFR applies. However, some pilots, including some with instrument ratings, continue to fly VFR in conditions less than that specified for VFR. The result is often a CFIT accident when the pilot tries to continue flying or maneuvering beneath a lowering ceiling and hits an obstacle or terrain or impacts water…The importance of complete weather information, understanding the significance of the weather information, and being able to correlate the pilot’s skills and training, aircraft capabilities, and operating environment with an accurate forecast cannot be emphasized enough.” Recommendations include: “(1) Know and fly above minimum published safe altitudes. VFR: Fly a minimum of 1,000 feet above the highest terrain in your immediate operating area in non-mountainous areas. Fly a minimum of 2,000 feet in mountainous areas,” and (2) Maintain situational awareness both vertically and horizontally.” Additionally, the NTSB has identified CFIT and Unintended flight into IMC as a high-risk occurrence category. The airframe and engine maintenance logbooks revealed that the airplane had an annual inspection on August 2, 2021, at an aircraft total time of 5,484.15 hours and an engine tach time of 1329.55 hours. On July 16, 2022, about 0730 Pacific daylight time, an Aeronca 7BCM, N2588C, airplane was destroyed when it was involved in an accident near Lake McMurray, Washington. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A concerned family member reported the airplane overdue to authorities and the Federal Aviation Administration (FAA) issued an Alert Notice shortly afterwards; it indicated that the airplane departed from the vicinity of the Arlington Municipal Airport (AWO), Arlington, Washington, on a cross-country flight to Mears Field Airport (3W5) Concrete, Washington. A search for the airplane was initiated; the airplane wreckage was subsequently located about 27 miles southwest of 3W5 in heavily forested terrain about 950 ft mean sea level (msl) elevation. The pilot had received a special issuance of medical certification for angina and coronary artery disease requiring coronary artery angioplasty and stent placement with medication use. The first issuance of this authorization was in 2002 and the last was in 2017. The pilot’s autopsy report revealed the cause of death was thermal injury and inhalation of products of combustion. The heart findings revealed significantmultivessel atherosclerotic coronary disease with 80-90% narrowing of the left main and left anterior descending coronary arteries, a significant restenosis of a left anterior descending coronary artery stent, and more than 95% narrowing of the right coronary artery. Additionally, the heart muscle had an area of scarring in the posterior left ventricle and interventricular septum consistent with an old injury from insufficient blood flow. Microscopic examination of the coronary system did not identify any acute clot or plaque rupture. In the autopsy report, the pathologist noted that the pilot’s family had indicated that the pilot had no new health complaints in the weeks before the accident. Toxicology testing performed by the FAA’s Forensic Services Laboratory on the pilot’s blood, urine, liver tissue, muscle tissue, etc., identified no evidence of impairing drugs. Rosuvastatin was detected. Rosuvastatin (Crestor) is a prescription cholesterol medication and is acceptable for FAA medical certification. The NWS Surface Analysis Chart indicated a low-pressure system in eastern Washington with a cold front stretched from eastern Washington south-westward across Oregon and California. The nearest weather station to the accident site depicted overcast clouds. The area surrounding the accident site was documented by Aviation Routine Weather Reports (METARS) and special reports (SPECs). The airport in the vicinity of the departure was the closest official weather station to the accident site. AWO had an Automated Weather Observing System (AWOS). The AWO AWOS was located about 10 miles southeast of the accident site and was reporting an overcast ceiling at 1,300 ft msl and a visibility of 10 statute miles, which indicated marginal VFR conditions due to the ceiling. A sounding analysis program for the area of the accident site indicated cloud cover from about 1,000 ft msl through 5,500 ft msl with a base of about 300 ft above ground level (agl).. Further, an AIRMET was active for IMC/mountain obscuration in the area. Additionally, several PIREPS in the area had low cloud ceilings as low as 600 ft agl. A search of archived information indicated that the pilot did not request weather information from Leidos Flight Service or ForeFlight. It is unknown what, if any, weather information the accident pilot viewed before or during the accident flight. The private pilot held ratings for airplane single-engine land and instrument airplane. The pilot was issued an FAA third-class airman medical certificate on December 29, 2016, with the following limitation: “Must wear corrective lenses for near and distant vision. Not valid for any class after December, 31, 2017.” The pilot reported on his most recent application that he had accumulated 2,280 total hours of flight experience with 20 hours in the 6 months before the examination. The pilot’s Medical Certificate expired for all classes in 2017. Subsequently, the pilot had applied for BasicMed. His BasicMed CourseDate was April 21, 2018, and the Comprehensive Medical Examination Checklist date was December 11, 2017. The BasicMed had expired at the time of the accident. Examination of the wreckage site revealed a couple of treetops were cut off near where the airplane came to rest. The debris path of about 120 ft in length was oriented on northerly heading, consistent with his intended destination. All major structural components were observed with the main wreckage. The airplane came to rest upright on a southwest heading and a postimpact fire consumed most of the airplane wreckage. The site was located near the top of a hill on a slope of about 15° and populated with tall trees over 100 ft in height. The terrain elevation to the south of the site was noted to be lower. A postaccident examination of the airframe and engine revealed extensive thermal damage to the airplane wreckage. Flight control continuity was established and no preimpact anomalies were noted on the engine. The examination revealed no evidence of preimpact mechanical failures or malfunctions that would have precluded normal operation.

Aircraft

Registration
N2588C
Reported as
Aeronca 7BCM
Category
Airplane
Serial number
7BCM-85
Built
1947
Airframe hours
5,484.15
Engine
Cont Motor C85 SERIES, 85 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · August 2, 2021
Departed
WN53 · Arlington, WA
Destination
3W5 · Concrete, WA

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
76
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
BasicMed
Seat
Front
Toxicology
Performed
Flight hours
2,280 total

Weather

Conditions
Instrument (IMC) · Day
Wind
320° at 5 knots
Visibility
10 statute miles
Lowest ceiling
1,300 ft overcast
Temperature
63 °F, dew point 57 °F
Altimeter
30.10 inHg
Observed at
KAWO, 10 nm away
METAR
KAWO 161456Z AUTO 32005KT 10SM OVC013 17/14 A3010 RMK AO2 SLP195 T01670139 53007

Docket · 10

The files NTSB released with the investigation on April 25, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 30.7 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.