NTSB Factual Report

HISTORY OF FLIGHT

On June 16, 2009, approximately 2015 central daylight time, a Cessna 150L, N66016, was substantially damaged when it impacted terrain near the Phillips Flying Ranch Airport (KT48), Rockwall, Texas. Visual meteorological conditions prevailed at the time of the accident. The positioning flight was being conducted under the provisions of Title 14 Code of Federal Regulations Part 91 without a flight plan. The commercial pilot was fatally injured. The flight was originating at the time of the accident and was en route to Terrell Municipal Airport (KTRL), Terrell, Texas.

According to friends and family, the pilot had scheduled a night flight lesson at 2100 with a student at KTRL. The pilot contacted a family member around 2000 and stated he was preparing to depart for the lesson. The pilot did not arrive at KTRL. Family members became aware of his absence the next morning and a search was initiated.

The wreckage was located, inverted, approximately 100 yards southeast of the departure end of runway 13. The wreckage was recovered and relocated to Lancaster, Texas, for further examination.

PERSONNEL INFORMATION

The pilot, age 65, held a commercial pilot certificate with airplane single engine land and sea, multiengine land, and instrument ratings, last issued on June 16, 2007. He held a certified flight instructor certificate with airplane single, multiengine, and instrument ratings, in addition to a ground instructor certificate with advanced and instrument ratings, and a mechanic certificate with airframe and power plant ratings. The pilot was issued a second class airman medical certificate on May 6, 2009. The certificate contained no limitations.

At the time of medical certificate application, the pilot reported he had logged no less than 13,500 hours total time, 600 hours of which were logged in the preceding six months. The family provided the pilot’s logbook number seven to the National Transportation Safety Board (Safety Board) Investigator-In-Charge for review. A review of the logbook indicated that the pilot had logged no less than 13,700 hours total flight time with 163 hours (as logged in the most recent logbook) in the make and model of the accident airplane. The pilot successfully completed the requirements for a flight review on March 4, 2009.

AIRCRAFT INFORMATION

The accident airplane, a Cessna 150L (serial number 15075777), was manufactured in 1974. It was registered with the Federal Aviation Administration (FAA) on a standard airworthiness certificate for utility operations. A Teledyne Continental Motors O-200-A engine rated at 100 horsepower at 2,750 rpm powered the airplane. The engine was equipped with a two-blade, Sensenich propeller.

The airplane was registered to Robert Cly, operated by the accident pilot, and was maintained under an annual inspection program. A review of the maintenance records indicated that an annual inspection had been completed on October 20, 2008, at an airframe total time of 6,322.2 hours. The airplane had flown 55.9 hours between the last inspection and the accident and had a total airframe time of 6,378.1 hours.

METEOROLOGICAL CONDITIONS

The closest official weather observation station was Terrell Municipal Airport (KTRL), Terrell, Texas, located 10 nautical miles (nm) south of the accident site. The elevation of the weather observation station was 474 feet mean sea level (msl). The routine aviation weather report (METAR) for KTRL, issued at 1953, reported, winds, 140 degrees at 5 knots, visibility, 10 miles; sky condition, clear; temperature 32 degrees Celsius (C); dew point, 22 degrees C; altimeter, 29.84 inches of Mercury.

A review of the carburetor icing chart revealed that the temperature and dew point spread placed the probability of carburetor icing on the line between “icing at glide and cruise power” and “serious icing at glide and cruise power.”

AIRPORT INFORMATION

Phillips Flying Ranch Airport, was a public, uncontrolled airport located 15 miles southeast of Rockwall, Texas, and 10 miles north of Terrell, Texas, at 32 degrees, 52 minutes, 05 seconds north latitude and 096 degrees, 13 minutes, 08 seconds west longitude, at a surveyed elevation of 500 feet. The airport had one runway; runway 13/31 (3,344 feet by 50 feet, turf).

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest inverted in a field southeast of the departure runway. An investigator from Cessna Aircraft Company and two inspectors from the FAA Flight Standards District Office examined the airframe on June 17, 2009.

The main wreckage consisted of the engine and propeller assembly, fuselage, empennage, and both wings. The engine was crushed aft into the firewall and separated partially from the main wreckage. Both wings were bent and wrinkled. The fuselage was bent down aft of the cabin area. The vertical stabilizer was crushed and the horizontal stabilizer was unremarkable. All control cables were continuous and correct. The aircraft was modified by a Supplemental Type Certificate permitting the use of automotive fuel; however, the fuel tanks were not properly placarded. A small amount of yellow colored fuel was observed in the right wing fuel tank. No fuel was observed in the left fuel tank. The fuel tank vent tube was blocked with mud consistent with an insect mud nest.

The engine throttle and mixture control were in the full forward position and the wing flaps were retracted. No anomalies were noted with the seat belt or shoulder harness. There was no significant penetration into the cabin space and the fuselage and cabin area maintained its original form and space. The engine ignition switch was noted in the “right” position.

MEDICAL AND PATHOLOGICAL INFORMATION

The Dallas County Medical Examiner’s Officer performed the autopsy on the pilot on June 18, 2009, as authorized by the Justice of the Peace, Precinct 4, Place 1, Hunt County Texas. The autopsy report concluded that the pilot “died as a result of blunt force injuries of the head and neck” and noted findings including “abrasions and lacerations of the face and scalp,” “subgaleal hemorrhage, frontal region,” and “extensive hemorrhage of the posterior neck with hyperextension injury of C4.”

During the autopsy, specimens were collected for toxicological testing to be performed by the FAA’s Civil Aerospace Medical Institute, Oklahoma City, Oklahoma (CAMI Reference #200900129001). Testing of the urine detected 0.027 ug/mL dihydrocodeine, 0.046 ug/ml hydrocodone, 0.093 ug/mL hyrdomorphone, 81.04 ug/ml salicylate, and irbesartan. Irbesartan was also detected in the liver. No ethanol was detected in the vitreous. No blood was received by the FAA laboratory and tests for carbon monoxide and cyanide were not performed. Dallas County Medical Examiner toxicology testing of blood was negative, and toxicology staff indicated that their testing protocols would have identified hydrocodone or dihydrocodeine if either were present at a level at or above 0.02 mg/L.

Personal medical records maintained on the pilot were reviewed. Those records documented a history of right knee and right leg surgery, and a history of right shoulder surgery in July 2003 with intermittent pain since that time treated with a combination medication containing hydrocodone and acetaminophen. The pain and the medication were each noted to interfere with the pilot’s sleep. The records also noted high blood pressure and high cholesterol since October 2006, treated respectively with a combination medication containing irbesartan/hydrochlorothiazide and with rosuvastatin, both prescribed most recently on May 6, 2009.The pilot’s blood pressure on his personal physician visit on that date was noted as 140/72.

The pilot’s FAA medical records do not note any conditions or medications, and the most recent application for airman medical certificate, dated May 6, 2009, specifically omits mention of the pilot’s prior surgeries, and of the diagnosis of and treatment for high blood pressure and high cholesterol. The pilot’s blood pressure on his aviation medical examiner evaluation on that date was noted as 140/88.

SURVIVAL FACTORS

The occupiable space within the cabin area was not compromised.

The accident aircraft was equipped with a lap belt and shoulder harness. The lap belt was unfastened to aid in recovery of the pilot. The shoulder harness was available for use, but was not being used at the time of the accident. According to friends of the pilot, he suffered from a shoulder injury which made it painful to use the shoulder harness.

TESTS AND RESEARCH

Investigators from the Safety Board, Cessna Aircraft Company, Teledyne Continental Motors, and an inspector from the FAA examined the engine on June 29, 2009.

The engine was separate from the airframe during the examination. The propeller blades were labeled “A” and “B” for identification purposes only. Blade A was twisted and exhibited polishing and scratching on the blade tip. Blade B was bent aft 90-degrees and exhibited leading edge polishing.

The mixture cable was not free to rotate within its attach joint. The number two exhaust valve was off of the valve seat. The engine was rotated by hand at the propeller flange and valve movement was noted on all four cylinders. Air movement was detected at all four spark plug orifices. Magneto engagement could be audibly detected when the engine was rotated. Dirt was noted under the exhaust valves. The exhaust system flame tubes on both sides of the engine were broken and eroded.

Both magnetos were removed from the engine and placed on a magneto test stand. Both magnetos received a slave harness and supplied a consistent spark at varying rpm settings.

Examination of the carburetor revealed that the accelerator pump expansion spring was rusted and separated into two pieces. Rust chips were noted in the bottom of the carburetor bowl.

NTSB Probable Cause

The pilot’s failure to maintain aircraft control following a loss of engine power due to contamination in the carburetor. Contributing the severity of the accident was the pilot’s failure to utilize his shoulder harness.