NTSB Factual Report

HISTORY OF FLIGHT

On February 8, 2013 about 0930 mountain standard time, after the Cessna 152, N89059, airplane was established on a right downwind leg for runway 6R at Ryan Field (RYN), Tucson, Arizona, radio and visual contact was lost by the air traffic control tower (ATCT) controller. The airplane, which impacted terrain about 1.5 miles southwest of RYN, was substantially damaged, and the private pilot received fatal injuries. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no Federal Aviation Administration (FAA) flight plan was filed for the flight.

The 75-year-old pilot rented the airplane from Arizona Aero-Tech (AAT), located at Tucson International Airport (TUS), Tucson, with the stated intent of practicing landings and takeoffs at RYN. RYN was located about 11 miles west of TUS. Although the airplane reportedly had sufficient fuel for the flight, the pilot decided to have the fuel tanks filled; a total of 15.2 gallons were added before the flight. The pilot was observed to sump the tanks both before and after the airplane was fueled. He was also observed to seat himself in, and start the airplane from, the right seat.

The airplane departed from TUS runway 11R about 0923, and was approved for an early turnout on-course. FAA ATC tracking radar data showed that the airplane flew towards RYN from TUS, at a maximum indicated altitude of 4,300 feet. The pilot contacted the RYN ATCT and, as instructed, entered a right downwind leg for runway 6R. Visual and radio contact was then lost by the controller. Shortly thereafter, the controller noticed a dust cloud rising from the ground about 1.5 miles southwest of the airport.

Multiple motorists on Ajo Highway, an east-west thoroughfare that passed just south of RYN, witnessed the airplane's final descent and resulting impact dust cloud. The first motorists on scene cut the pilot's seat belt, and extracted him from the cockpit, while others summoned emergency services. The first Pima County Sheriff Office (PCSO) officer arrived on scene about 0940, shortly after the motorists had extracted the pilot. Attempts by PCSO personnel and paramedics to resuscitate the pilot were unsuccessful. In a telephone conversation shortly after the accident, an NTSB investigator guided the first responder personnel in safing the airplane by shutting its systems and equipment off.

Three inspectors from the Scottsdale Flight Standards District Office (SDL FSDO) arrived on scene about 1130. Representatives of the NTSB and Cessna Aircraft examined the wreckage in situ the day after the accident. The airplane was recovered by Air Transport of Phoenix, AZ later that same day, and examined by representatives of the NTSB, FAA, and Cessna on February 11, 2013.

PERSONNEL INFORMATION

FAA records indicated that the pilot held a private pilot certificate with an airplane single-engine land rating. According to the pilot's flight logbook, as of February 2, 2013, he had accumulated a total flight experience of about 302 hours. His most recent flight review was completed on June 29, 2012, with a certificated flight instructor (CFI) and airplane from AAT.

AIRCRAFT INFORMATION

FAA information indicated that the airplane was manufactured in 1979, and was equipped with a Lycoming O-235 series engine. The airplane was registered to the president and owner of AAT. According to AAT records the airframe and engine had a total time in service of about 8,037 hours, and the engine had a total time since overhaul of about 3,038 hours.

METEOROLOGICAL INFORMATION

AWOS Data Capture

An automated weather observation sensor and radio transmitter known as AWOS (automated weather observation system) was installed and operating at RYN. The system operated continuously, sensing/updating conditions, and then providing that information to the ATCT and also broadcasting the observations on a radio frequency accessible by aircraft communications radios. The AWOS was commissioned by the FAA, but it was not maintained or controlled by the FAA.

In addition, hourly or more frequent observation sets of AWOS data were to be provided to the US National Airspace System (NAS) for distribution and archiving purposes as METARs (Meteorological Aviation Reports). The methods for providing AWOS data to the NAS were automated datalink, manual transmission/entry, or a combination of the two as a function of the time of day. RYN used this combination approach, where the automated datalink was used overnight, and the ATCT controllers captured and sent the data manually during their normal operating hours. However, controller air traffic management workload sometimes prevented the controllers from capturing and entering the data for the NAS archiving. Subsequent but unrelated to the accident, the RYN ATCT implemented a continuous automated data-capture and archiving system.

RYN AWOS/METAR Information

Review of archived RYN METAR data for day of the accident revealed that the AWOS data was not captured every hour. The only recorded weather observations for RYN near the time of the accident were for times of 0754 and 1051. Review of archived RYN AWOS/METAR data for the several days surrounding the accident revealed that the AWOS/METAR data for those days also had gaps in the temporal coverage.

The 0754 RYN automated weather observation included winds from 110 degrees at 5 knots, visibility 10 miles, clear skies, temperature 8 degrees C, dew point minus 1 degrees C, and an altimeter setting of 29.92 inches of mercury.

Review of the recorded radio transmissions from the ATCT to the flight revealed that when the RYN ATCT controller cleared the flight for its first touch and go, he advised the pilot that the wind was calm.

TUS METAR Information

The 0953 automated weather observation at TUS, which was located about 12 miles east of the accident site, included winds from 070 degrees at 5 knots, visibility 10 miles, clear skies, temperature 15 degrees C, dew point minus 3 degrees C, and an altimeter setting of 29.94 inches of mercury.

COMMUNICATIONS

Review of audio recordings from TUS revealed that about 0917, the pilot contacted TUS clearance delivery for "departure to Ryan" and the airplane was assigned a transponder code of 0405. The pilot then contacted TUS ground control for taxi clearance for departure. He was assigned runway 11R as the departure runway. The flight was cleared for takeoff about 0923, and about 4 minutes later, the TUS ATCT controller instructed the pilot to contact departure control. The pilot remained on the departure control frequency for less than 2 minutes before requesting a frequency change in order to contact RYN ATCT, which the departure controller approved.

There were two controllers working in the RYN ATCT at the time of the accident. Neither controller witnessed the airplane's descent or impact.

The RYN ATCT audio information was not provided with any timing track/data. Therefore the times noted below represent the best estimates, but they could not be synchronized exactly with the communications or radar data provided by TUS. TUS data indicated that the pilot left the TUS TRACON frequency no earlier than 0929, but the RYN information indicated that the pilot checked on with RYN ATCT nearly 2 minutes prior.

Review of the recorded RYN ATCT communications indicated that the pilot first contacted the facility about 0926:38, and requested "touch and goes." The controller instructed the pilot to enter a right downwind for runway 6R, verified that the pilot requested touch and goes, and asked if the pilot had the current automated terminal information service (ATIS) information. The pilot confirmed that he had the ATIS information, and that he was assigned to 6R. About 0927:37, the controller cleared the pilot for touch and goes, and announced "wind calm." The pilot then initiated an exchange clarifying his intent to conduct three landings, and then return to TUS, which the controller acknowledged by instructing the pilot to make "right closed traffic." About 0928:03, the pilot responded with "right closed traffic runway six right zero five niner." That was the last recorded communication from the airplane.

The controller then began working with one departing and one arriving airplane. About 0929:20, the controller broadcast "Cessna zero five niner say position." There was no response, and the controller repeated the broadcast. Twice more, in rapid succession, the controller tried to again contact the airplane. About 10 seconds later, the two controllers noticed the dust cloud to the southwest.

AIRPORT INFORMATION

According to FAA information RYN was equipped three paved runways designated 06-24 L and R, and 15-33. The intended landing runway, 6R, measured 5,500 by 75 feet. Airport elevation was 2,417 feet above mean sea level (msl). Traffic pattern altitude was 800 feet above ground level, or about 3,200 feet msl.

The airport was equipped with a non-federal ATCT operated by a private contractor Serco. The ATCT was located about 1,000 feet east of the threshold of runway 6R, and about 800 feet south of that runway. ATCT cab elevation was 2,484 feet msl.

WRECKAGE AND IMPACT INFORMATION

The accident site was located about 200 feet south of Ajo Highway, which passed just south of RYN. The main wreckage path was about 200 feet long, and oriented along a magnetic heading of about 240 degrees. The airplane came to rest inverted, with the nose oriented about 090 degrees magnetic.

The underside of the nose was crushed. The aft fuselage was deflected about 90 degrees airplane left, and almost fully fracture-separated from the cabin. The empennage was essentially intact, and remained attached to the aft fuselage. The right wing was fracture-separated at its aft fuselage attach point, and the left wing remained attached to the fuselage. Both wings exhibited some leading edge crush damage. There was no post-impact fire. No oil stains or puddles were observed on any of the exterior surfaces of the engine or airplane, interior surfaces of the engine compartment, or on the ground below the airplane.

With the exception of a small segment of the outboard end of the left aileron, all flight control surfaces remained attached to their respective airfoils. The aileron segment was found in the debris path between the initial impact point and the main wreckage. The two cockpit yokes remained linked to one another, and flight control continuity from the cockpit controls to all respective flight control surfaces was established. The flap actuator extension corresponded to a flap setting of about 20 degrees. The pitch trim actuator extension corresponded to a trim setting of neutral. The transponder was found set to a code of 0707.

The fuel selector valve was found between the ON and OFF positions, but its position was consistent with the airplane impact deformation.

The left seat belt assembly was partially buckled and uncut. The right shoulder harness was engaged in its lap belt receptacle, and the outboard lap belt was cut, consistent with eyewitness reports that they found the pilot in the right seat.

The engine remained attached to its mount, which remained attached to the fuselage. Continuity from the cockpit controls to the respective engine components was established. The engine did not exhibit any catastrophic failures of the case, cylinders, valve train, or intake or exhaust systems. All accessories remained attached to the engine. Manual rotation of the engine yielded thumb compressions on all cylinders, and the vacuum pump drive shaft was observed to rotate.

The propeller was separated from the engine. Both ends of the propeller were bent aft at about 12 inches inboard from the tip, and bore some chordwise scoring.

Both fuel tanks were intact, but both caps had been liberated by the impact, and were recovered on scene. Fuel stains were observed under the wreckage when it was lifted for recovery, and approximately 3 cups of fuel drained from the left wing when it was placed on the recovery trailer.

Neither the on-scene nor the follow-up examination revealed any mechanical conditions, abnormalities, or failures that would have precluded continued engine operation and normal flight.

Refer to the accident docket for additional details.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot's most recent FAA third-class medical certificate was issued in December 2011; the resulting "Special Restriction Medical Certificate" was not valid for any class medical certificate after December 31, 2013.

According to the pilot's FAA medical information, he was first medically certificated by the FAA in 2002, but his evaluation required a special issuance, time-limited certification because he was initially disqualified by having paroxysmal atrial fibrillation, mitral valve prolapse with regurgitation, and hypertension. At that time, he reported taking several medications for treating hypertension and heart failure.

The pilot's medical records indicated that he required annual FAA re-certification, with a variety of re-testing necessary for cardiac evaluation. He continued to pass those re-tests with some minor anomalies, and maintained his FAA medical certification. Over the years from 2002 forward, the degree of mitral valve regurgitation increased from "moderate" to "moderate to severe," and by 2012, his initially-mild heart enlargement became "severe bi-atrial enlargement," with moderate enlargement of the right ventricle. Throughout the time period, the pilot's left ventricle was consistently described in the echocardiogram reports as having mild diastolic dysfunction. The pilot remained asymptomatic from his cardiac disease.

The PCSO autopsy report indicated that the cause of death was blunt force trauma to the chest. Examination of the heart revealed significant cardiac disease. The heart weighed 520 grams, compared to a normal value of about 341 grams. There was no significant coronary artery stenosis, but the medical examiner found marked dilation of the right atrium and moderate dilation of the right ventricle.

Forensic toxicology examinations revealed quinidine and triamterene in both urine and blood. Those findings were consistent with the pilot's medication history. No carbon monoxide, cyanide, ethanol, or any screened drugs were detected.

ADDITIONAL INFORMATION

Radar Data

Review of ATC radar tracking data revealed that the antenna sweep and data interval rate was 5 seconds. About 0934, the airplane entered a right downwind leg for runway 6R, at an indicated altitude of 3,200 feet. About 0935:28, the airplane passed abeam of the 6R threshold, at an indicated altitude of 3,000 feet. About 5 seconds later, the flight track deviated slightly south (away from the airport), before turning first northwest, and then almost south. The last secondary radar target in the continuous data was recorded at 0936:33, and was located 1.6 miles southwest of the 6R threshold, with an indicated altitude of 3,000 feet. The final, and only other, secondary target was recorded at 0936:56, and was located about 0.4 miles southeast of the previous point, with an indicated altitude of 2,700 feet. The reason for the flight path deviations and the 20-second (three radar sweep) gap could not be determined.

No record of the 0707 code data which was found on the transponder was observed in the TUS radar target data.

Eyewitness Observations

A total of four eyewitnesses provided information for the investigation.

A motorist who was driving eastbound on Ajo Highway first saw the airplane to the southeast of his location. He estimated that the airplane was about 500 yards away, at an altitude of about 1,000 feet above the ground, and headed approximately north. He described the attitude as unusually nose down, and stated that the airplane was descending very rapidly towards the ground. He saw the indications of ground impact, and stopped his car to render assistance.

A passenger in a westbound car on the highway first saw the airplane to his south, when it was about 150 feet above the ground, and descending very rapidly. He initially thought the pilot was at

NTSB Probable Cause

The pilot's incapacitation due to his preexisting cardiac disease, which resulted in his degraded or complete loss of ability to control the airplane.