NTSB Factual Report

HISTORY OF FLIGHT

On March 11, 2000, at 1016 Pacific standard time, a Cessna 182Q single engine airplane, N95996, was substantially damaged when it impacted terrain following a loss of engine power during takeoff from the Fallbrook Community Airpark, Fallbrook, California. The private pilot received fatal injuries while his passenger sustained serious injuries. The aircraft was being operated as a personal flight by the owner/pilot under 14 Code of Federal Regulations Part 91 when the accident occurred. The cross-country flight was originating from the Fallbrook Community Airpark at the time of the accident and was destined for San Jose, California. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed.

A witness on the ground stated that the pilot taxied from his hangar directly to the departure end of runway 18. He said that the pilot did not perform a pre-takeoff engine run-up or cycle the propeller prior to departure. After takeoff, the airplane climbed out on an upwind heading, reaching approximately 300 feet agl, when the engine lost power.

Another witness on the ground heard the engine being cranked in the air after it had stopped, and subsequently reported seeing a black puff of smoke from the exhaust.

According to the witnesses, the airplane cleared utility lines that ran along the airport boundary then pitched nose down, impacting the ground in a nose low attitude. After striking the ground, the airplane nosed over and came to rest on its back.

The passenger, who was the pilot's spouse, stated that the pilot usually performed an engine run-up while taxiing toward the runway. However, she did not think that the pilot performed an engine run-up prior to takeoff for the accident flight. She reported that everything appeared normal during the takeoff roll and initial climb, until the engine suddenly lost power. She added that the pilot reached down to the lower section of the center column area and turned something.

PERSONNEL INFORMATION

The private pilot held airplane ratings for single engine land and instruments. He was issued a third-class medical certificate on May 8, 1999, with a limitation that he "must have lenses available for near vision." The pilot was the registered owner of the accident airplane since 1979, and had logged a total of 1,819.5 flight hours. His most recent biennial flight review was completed on October 13, 1997.

AIRCRAFT INFORMATION

The 4-seat airplane had been modified with numerous supplemental type certificates (STC) in the past; one of which replaced the original carbureted engine with a 300-horsepower Continental IO-550-D fuel injected engine. Part of the engine modification included the addition of a fuel reservoir tank located on the backside of the firewall. The reservoir tank was located between the main fuel selector valve and the fuel control unit and held approximately 1 quart of fuel. Review of the airplane maintenance records revealed that the airplane underwent its last annual inspection on August 5, 1999, at a total time of 2,152.2 hours. The airplane had accumulated 2,178.6 hours at the time of the accident.

The fuel selector valve is located on the bottom of the center control panel column and is operated by manually rotating the selector valve handle to one of the four positions; OFF, LEFT, BOTH, and RIGHT.

The flight manual supplement's Preflight Inspection and Before Starting Engine checklists instructs pilots to place the fuel selector valve in the "BOTH" position. The supplement's Before Takeoff Checklist also instructed to ensure that the fuel selector valve is "ON." The fuel selector placard indicated that the fuel selector valve was to be positioned to "BOTH" for takeoffs and landings.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest inverted with an approximate crush angle of 35-45 degrees relative to the aircraft's longitudinal axis on the forward fuselage and engine cowling. The aft cabin area was buckled aft of the aft doorpost, and the empennage was buckled midway between the baggage area and stabilizers. All of the flight controls were in place and connected at the accident site. Flight control continuity was confirmed from the cockpit to their respective controls. Reports from first responders reported that both lap belts and shoulder harnesses were utilized by the pilot and passenger. The flap selector and position indicator were found at the 20-degree mark. The flap actuator was found positioned at 15 degrees.

The fuel selector valve was found in the left fuel tank position. The fuel boost pump switch was found in the off position. No fuel was found in the fuel line between the gascolator and the boost pump. Fuel consistent with the color and odor of 100-octane low lead aviation fuel was found in each of the main fuel tanks. After defueling the airplane, investigators found that the left tank had contained approximately 17 gallons of fuel while the right tank had contained approximately 12 gallons. The capacity of each tank was placarded for 44 gallons. The 1-quart reservoir tank was ruptured and found empty.

The 3-bladed propeller remained attached to the engine with one blade sustaining impact damage and was bent aft approximately 40 degrees from its rotational plane. The other two blades sustained little to no damage.

The engine was removed from the airplane and shipped to the manufacturer's facility in Mobile, Alabama.

TESTS AND RESEARCH

On May 10, 2000, the engine was placed on a test stand and was operated at 2,700 rpm. No anomalies were noted during the engine test run.

PATHOLOGICAL INFORMATION

A toxicological test for carbon monoxide, cyanide, ethanol, and drugs was performed on the pilot. The toxicological test was positive for the following:

"1.441 ug/ml of paroxetine in blood

An unquantified amount of paroxetine in urine

21.375 ug/ml of paroxetine in gastric

An unquantified amount of verapamil in blood

An unquantified amount of verapamil in urine

An unquantified amount of norverapamil in blood

An unquantified amount of norverapamil in urine.

Note: The total quantity of gastric contents received was approximately 116 grams. Therefore, the total amount of paroxetine present in the submitted sample of gastric contents was approximately 2.5 milligrams."

The pilot did not indicate the use of either of the above medications on his most recent application for airman medical certificate. Federal Aviation Administration (FAA) Medical Examiners are instructed to defer medical certification to the FAA Aeromedical Certification division for any airman on "mood-ameliorating" medications.

ADDITIONAL INFORMATION

The first witness, who was also an acquaintance of the pilot, reported that the pilot was in the habit of turning the fuel selector to the off position when he hangared his airplane. This was due to instances in the past in which fuel had leaked on his hangar floor when the fuel selector had not been turned off. He added that the pilot experienced a loss of engine power while taxiing in the past due to the fuel selector being in the off position.

No pilot checklist was found in the airplane. A partial copy of a pilot operating handbook (POH) was found in a map case.

NTSB Probable Cause

the loss of engine power resulting from fuel starvation due to the pilot's inadequate pre-flight inspection, inadequate performance of the pre-takeoff checklist, and failure to ensure that the fuel selector was properly positioned prior to takeoff. Also causal was the pilot's failure to maintain an adequate airspeed while attempting to clear a power line during the ensuing forced landing, which resulted in an inadvertent stall.