WPR24FA290

Multiple witnesses described the airplane crossing over into the runway safety area shortly after the pilot’s takeoff roll on a personal flight in his single-engine airplane. The airplane crossed over a taxiway and into another runway safety area before crossing the ramp in a nose-high pitch attitude. The airplane was unable to outclimb the nearby hangars as it approached them, subsequently impacting the end hangar. A postaccident fire ensued. About 15 minutes before the pilot departed, the wind conditions for the departure runway were reported as variable between 190° to 270° with gusts to 14 knots, with the prevailing wind from 240° at 7 knots. About 5 minutes after the accident, the reported wind conditions were from 220° at 9 knots. Additionally, other pilots at the airport at the time of the accident reported gusting and variable wind conditions. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Given the left-turning tendency due to engine torque and P-factor, combined with the left crosswind and gusts during the time of the accident, exacerbated the runway excursion. The pilot was likely unable to maintain directional control during takeoff due to these combined factors, resulting in the airplane departing the runway and entering the runway safety area. The takeoff was not aborted for unknown reasons. In the setting of a post-crash fire and smoke inhalation, the pilot’s elevated carboxyhemoglobin level does not constitute evidence that the pilot was impaired by carbon monoxide during the flight. The pilot’s cardiovascular disease, including severe coronary artery disease, placed him at substantially increased risk of an impairing or incapacitating cardiovascular event, such as chest pain, arrhythmia, or heart attack. There is no autopsy evidence that such an event occurred; however, such an event does not leave reliable autopsy evidence if it occurs just before death. Notably, even severe coronary artery disease may not cause major symptoms.

The FAA Airplane Flying Handbook (FAA-H-8083-3C) defines P-factor as: A tendency for an aircraft to yaw to the left due to the descending propeller blade on the right producing more thrust than the ascending blade on the left. This occurs when the aircraft’s longitudinal axis is in a climbing attitude in relation to the relative wind. The P-factor would be to the right if the aircraft had a counterclockwise rotating propeller. The handbook further stated, in part, that for a normal takeoff, “…the rudder pedals are used to keep the nose of the airplane pointed down the runway and parallel to the centerline. The effects of engine torque and P-factor at the initial speeds tend to pull the nose to the left. The pilot should use whatever rudder pressure is needed to correct for these effects or winds.” The airplane’s Owner’s Manual reports that the airplane’s normal takeoff speed is 65 knots and takeoff distance over a 50 ft obstacle is 1,150 ft. Maintenance records were not obtained during the investigation. On August 31, 2024, about 1550 Pacific daylight time, an Aero Commander 200D airplane, N2912T, was substantially damaged when it was involved in an accident at the Gnoss Field Airport (DVO), Novato, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Family members reported that the pilot had flown from Redding, California, earlier that day. They spent a few hours with the pilot before he returned to the airport and departed on the accident flight. They further stated he was quite familiar with DVO and had been flying to the airport for years. A pilot who witnessed the accident reported that he encountered a gusty crosswind as he landed on runway 31. Before the witness could exit the runway, he heard the pilot of the accident airplane announce that he was departing on runway 31. While taxiing back on the parallel taxiway 13-31, the witness saw the accident airplane enter the runway and start its departure roll. The airplane rose a few feet off the runway but then turned left toward the runway safety area (RSA). The accident airplane crossed taxiway 13-31 in front of the witness and flew in a nose-high pitch attitude toward a row of hangars. The accident airplane impacted the hangars and immediately caught fire. Another witness, who was taxiing his airplane in the parking ramp area, saw the accident airplane at the approach end of runway 31, preparing to depart. Shortly after, as the witness was approaching the intersection of taxiway Charlie and 13-31, he saw the accident aircraft traverse the RSA to the right of the intersection and fly toward him. The accident airplane crossed about 10 ft in front of his airplane, flying left-wing-low about 5 ft above the ground. The airplane then impacted the hangar and a few seconds later erupted into flames. The pilot’s autopsy revealed soot in his airways, which is consistent with a post-crash fire and smoke inhalation.According to the pilot’s autopsy report, his cause of death was thermal burn injuries with smoke inhalation. The autopsy also identified coronary artery disease, including severe diffuse narrowing of up to 90-100% in the proximal-to-mid portions of the left anterior descending coronary artery. The right coronary artery was narrowed up to 50% by plaque, and the left circumflex coronary artery was narrowed 25-50%. The heart was described as slightly dilated; no other significant abnormalities were noted on visual examination of the heart. Slight to moderate plaque of the aorta and slight patchy plaque of the arteries at the base of the brain were present, as were some kidney tissue changes of the type that may be seen with chronic high blood pressure. Postmortem toxicological testing of aortic blood performed by NMS Labs at the request of the Coroner Division measured carboxyhemoglobin to be elevated at 17%. Postmortem toxicological testing by the FAA Forensic Sciences Laboratory did not detect carboxyhemoglobin in aortic blood at a reporting threshold of 10%. Chlorthalidone was detected in aortic blood, urine, gastric contents, liver tissue, kidney tissue, muscle tissue, and brain tissue. Tamsulosin and salicylic acid were detected in aortic blood and urine. Ibuprofen was detected in urine and was not detected in aortic blood. No other tested-for substances were detected. A review of the DVO observations disseminated surrounding the period indicated calm to light-and-variable winds of 5 knots or less during the morning hours, increasing with the diurnal heating of the day, and reaching its maximum around 1500 when wind gusts reached 17 knots. About 15 minutes before the accident, at 1535, winds were reported as variable between 190° to 270° with gusts to 14 knots, with the prevailing wind from 240° at 7 knots. About 5 minutes after the accident, at 1555, the winds were from 220° at 9 knots. Examination of the accident site revealed 3 rubber tire marks near the approach end of runway 31 (see figure 1), The marks veered to the left and continued into the RSA. Loose grass was spread out over the runway near this area. Disturbed grass and dirt, consistent with contact from the main landing gear tires, crossed over the RSA and exited at the parallel taxiway 13-31. The disturbed grass and dirt continued into the next RSA, which is adjacent to the parking ramp and taxiway Charlie, ending at a taxiway light. No other marks were found between this area and the main wreckage. Figure 1. Illustrated aerial view of the airport and accident site. The airplane was found in a hangar on the north side of the airport at the east end of a row of hangars. The airplane had impacted the hangar and was mostly consumed by post-impact fire. The empennage separated from the airplane structure and remained attached by the elevator trim and elevator control cables. The right wing had extensive thermal damage and only the inboard wing steel structure remained. The outboardleft wing had impact damage and remained attached to the inboard wing steel structure. The engine and propeller remained attached and had excessive thermal damage. The cabin area was mostly consumed by post-impact fire, revealing the surrounding steel structure.