NTSB Factual Report

HISTORY OF FLIGHT:

On May 8, 1997, at 1630 central daylight time, a Cessna 172RG, N6505V, owned and operated by Zapata Protein (USA), Inc., under Title 14 CFR Part 91, impacted offshore waters following a loss of control near Intracoastal City, Louisiana. The commercial pilot, sole occupant of the airplane, received fatal injuries and the airplane was destroyed. Visual meteorological conditions prevailed for the fish spotting flight and a company flight plan was filed. The flight departed the Abbeville Municipal Airport, Abbeville, Texas, at 1610.

During personal interviews, conducted by the investigator-in-charge (IIC), operator personnel and pilots reported that the pilot-in-command (PIC) of N6505V had six years of experience as a fish spotter, and during the last fish spotting season, April 1996 through October 1996, the pilot flew 763 hours. The 1997 fish spotting season began on April 21 with this PIC working the morning (0900-1300) and evening shifts (1600-dark).

On the day of the accident, the PIC had breakfast before his morning flight at 0900. Following the morning flight, the PIC and other company pilots were required to attend the second company procedures and safety meeting held during the 1997 fish spotting season. The safety meeting covered shift changes, aircraft traffic in the working area, situational awareness, GPS equipment, aircraft radio usage, and vouchers. During the safety meeting, the pilots were reminded, by the chief pilot, not to purchase and claim cooking equipment on their food voucher. The PIC was sited as an example of what not to do since he had purchased a chicken rotisserie and claimed it on his voucher. He was then asked if he was "Ok with all this" and he indicated to the chief pilot that he was. The pilots were also reminded that "chit chat chatter" over the radio was not within company policies. The PIC had been previously reprimanded by the chief pilot, over the company aircraft frequency, during the fish spotting flights, and these reprimands were heard by the other company pilots and the boat captains.

Company pilots stated that the nature of the job environment was a challenge (maneuvering, airplane traffic, helicopter traffic, weather, communication) and to meet the challenge required self induced pressure, discipline, integrity, and a conscientious personality to be successful doing the job. Company pilot's expressed the opinions that this PIC was a survivor, coper, met the job qualities, liked the pilots that he worked with, and would go out even if he was fatigued and/or not feeling well.

There was a personal camaraderie among the company pilots, and each would not want to let the other pilot's on the shift down by not flying. The company pilots were aware that the PIC had been trying to get a loan approved for purchasing land in Gorman, Texas; however, the day before the accident, they had understood from the PIC that his loan had been approved. One company pilot felt as if the PIC was upset from the safety meeting, stressed for monetary reasons, and worried for his job because production for spotting the fish was lower than the other pilots. Another company pilot felt that the PIC was very honest and did not want company personnel to think that he was stealing on his food voucher by buying the chicken rotisserie or abusing other company privileges, such as flying the company airplane home during his leave days. Another company pilot felt as if the PIC was under pressure to find a place to live because he had been offered the company trailer only until he could locate another place to live for the season. The company trailer was normally used for first time pilot's who were being evaluated for continued employment by the company.

Company pilots stated that the PIC was health conscious and worked out about 3 times per week. One of the company pilots and the PIC went to the local health club for a workout after their morning shift and the safety meeting. This company pilot was not aware of any medical problems with the PIC; however, he was aware that the PIC had been concerned about his blood pressure and was trying to develop healthy eating habits and do cardiac workouts. During the drive to the health club and the workout, the PIC commented that he was not feeling good and had not slept well the night before. The PIC did not finish the workout portion on the Stairmaster because his left leg was cramping and he did not want to push himself. The PIC went to the steam room and when the other company pilot found him, he was outside the steam room holding his head in his hands and commented that he "did it again, stayed in the steam room too long." The company pilot further stated that the PIC felt "quizzy like was going to throw up, like over doing it." The PIC took a shower before departing the health club. When the pilots returned to the company trailer, the PIC did not eat lunch and stated that he was not feeling too good and was going to lie down and take a nap before the evening flight. It was this company pilot's opinion that the PIC was "sick." At approximately 1545, the PIC exited his room and stated that he was going to the airplane. This was the first time during the 1997 fish spotting season that company pilots recalled this PIC being the first pilot to depart for the Gulf of Mexico. During the previous months, this PIC was usually the last PIC to depart during the shift changes.

During personal interviews, conducted by the IIC, and on the enclosed tape recording, the chief pilot stated that the company operates the aircraft Monday through Friday, weather permitting, with 8 pilots (one of whom is an assistant chief pilot) and the chief pilot. Each day there are four shifts (daylight-0900; 0900-1300; 1300-1600; 1600-dark) with 4 aircraft per shift. The pilots who fly the 0900 shift also fly the 1600 shift, and the pilots flying at daylight also fly the 1300 shift. The company pilots fly the airplanes at increments of 500 foot altitude separation standards and coordinate their en route locations over the radio frequency 129.27. At the shift change, the pilot coming onto the shift calls, via his aircraft radio on the company frequency of 129.27, to the pilot that he is replacing. The pilot being replaced will communicate with his replacement the location, altitude, and route for the change over flight.

During all company flights, the pilots monitor frequency 130.150 (East of Grand Isle) or 130.65 (West of Grand Isle) for other aircraft movement in the area. An aircraft penetrating the ADIZ is assigned the discrete transponder code of 6047. Aircraft operating East of Grand Isle are flown at altitudes from 500 feet MSL up to and including 5,000 feet MSL and the aircraft West of Grand Isle are flown from 1,000 feet MSL up to and including 7,000 feet MSL. When the pilots are fish spotting and working the fishing vessels, the pilots coordinate their location West of Grand Isle over the radio frequency 130.15 and 130.65 East of Grand Isle. The airplanes fly an average distance of 10 miles offshore; however, the week of the accident some of the fishing vessels were operating 18 to 19 miles offshore. Company pilots reported 7 to 8 miles of visibility with scattered clouds at 2,500 feet AGL and the winds from the southeast at 5 knots.

During the shift change on May 8, the chief pilot was flying his airplane on an east to west route. Flight routes were coordinated between the PIC of N6505V and the pilot that he was relieving for the shift change. The airplane (N6505V) was in cruise flight at 126 knots airspeed on the outbound flight, when the PIC of N6505V reported that he was crossing the beach at Ghost Town (last onshore landmark) at 1,000 feet MSL. The chief pilot recalled that 2 to 3 minutes later the PIC transmitted to his shift leader "I'm returning to the airport, I'm not feeling well." The shift leader recalled the PIC transmitting "I really feel bad and I am going back in." The chief pilot immediately called the PIC and inquired "Where are you?" There was no reply, as the chief pilot repeatedly called for 5 to 10 minutes. Other company pilots recalled the transmission as: "I am going back to the airport; I don't feel well; didn't feel good; ill; sick; not feeling good and was going back in; turning around heading back not feeling good; not feeling good little nauseated; don't feel good have to go back in." Company pilots made repeated attempts to contact the PIC on the radio; however, there was no reply. There were no reported eye witnesses to the accident.

The chief pilot initiated and coordinated search and rescue procedures with the other 8 aircraft from Intracoastal City, Louisiana, and 3 company aircraft from Cameron, Louisiana, local authorities and the Coast Guard. The aircraft was located, offshore from Intracoastal City that evening, and the pilot was recovered on May 12, 1997, offshore from Cameron.

PERSONNEL INFORMATION:

FAA pilot records and a pilot logbook, reviewed by the investigator-in-charge, revealed that the pilot obtained the commercial pilot certificate on November 29, 1979. From June 1980 through October 1984, the pilot flew 3,835.3 hours as the PIC during fish spotting flights. On November 11, 1985, the pilot logged a one hour biennial flight review in a Cessna 172. In February 1996, the pilot received 2.5 hours dual instruction in a Cessna 182.

FAA medical records revealed that the pilot was disqualified for a second class medical certificate on March 3, 1997, pending further examination. The Aviation Medical Examiner, after repeated attempts, could not get a normal blood pressure for the pilot and referred the pilot to a cardiologist. The cardiologist reported that the pilot had been under "significant stress which may be contributing to his hypertension." The pilot was diagnosed with "systemic hypertension," and his echocardiogram demonstrated "no evidence of long standing hypertensive heart disease." Further, the cardiologist stated that the pilot "had no symptoms to suggest significant obstructive coronary artery disease." The pilot was provided with samples of Tenormin for the blood pressure and Lipitor for a lipid disorder. The pilot's second class medical certificate was issued.

During the week of April 25, 1997, the pilot flew 22 hours and the following week he flew 21 hours. The pilot's flight schedule included 7 hours on May 6, 7 hours on May 7, and approximately 4 hours on the morning of May 8.

A review of the company performance evaluations (copies enclosed) revealed that the pilot "had good safety habits, [was] still gaining experience after being away 12 years, [and was the] last [pilot] off the ground in the morning and evening [shift changes].

AIRCRAFT INFORMATION:

At the Abbeville, Louisiana, base of operations, the company operates 10 aircraft with 9 pilots during the season and each pilot is assigned a specific "N" number airplane. The 10th airplane is used as a spare airplane that is flown by any pilot whose airplane is down for scheduled inspections and/or routine maintenance.

The airplane, N6505V, was manufactured in 1980 and the standard FAA Airworthiness Certificate (FAA Form 8100.1) was issued on October 20, 1980. The airplane was registered to Zapata Protein (USA), Inc., on February 27, 1989.

Maintenance records (copies enclosed) recovered from the accident site and mechanic records for the annual inspections (1992 through 1996) were reviewed by the IIC. There were no open discrepancies noted. At the last annual inspection, performed on November 11, 1996, the tachometer time was 6876.8 hours, the engine time SMOH was 920.1 hours, and the propeller time SMOH was 132.3 hours when the airplane was returned to service.

WRECKAGE AND IMPACT INFORMATION:

At 1645, a company pilot located aircraft debris and an oil slick on the surface of the Gulf of Mexico approximately 6 miles offshore (North 29 degrees 28.84 minutes West 92 degrees 10.67 minutes) in approximately 10 feet of water. The fishing vessels, Terrebonne Bay, Timbalier Bay and Frosty Morn (sonar capabilities), were summoned to the site in search of the aircraft and the pilot. The fishing vessels arrived on site within 20 minutes and began to recover the nose strut assembly and wheel, and several pages of aircraft maintenance records (copies enclosed). Company fishing vessels recovered the majority of the aircraft that night and transported it the Zapata (Protein), USA, Inc., boat dock at Intracoastal City.

MEDICAL AND PATHOLOGICAL INFORMATION:

The autopsy was performed by the Calcasieu Parish Coroner's Office and Forensic Facility, at Lake Charles, Louisiana. Aviation toxicological testing for the pilot was performed by the FAA Civil Aeromedical Institute (CAMI) at Oklahoma City, Oklahoma. According to the pathologists, there was "no evidence of significant natural disease."

The CAMI toxicological findings for the pilot were positive for alcohol and diphenhydramine. According to Dr. Canfield, CAMI, the alcohol detected in muscle is "most likely from postmortem ethanol production." Dr. Canfield further stated that the "diphenhydramine(Benadryl, antihistamine), although not generally approved by the FAA for use while flying, was detected at trace levels in liver and kidney fluid and felt to be insignificant. However, the underlying medical condition for which the medication was taken might have caused discomfort or a distraction in the pilot."

During personal interviews, conducted by the IIC, the chief pilot and another company pilot stated that following the accident, they found 4 prescription drugs on the bathroom counter in the pilot's bedroom and from the prescription labels they wrote down the names of the drugs (Prinivil 10 mg, Atenolol 50mg; Lipitor 10mg; and Zestril 10mg). However; they did not recall any additional information from the prescription labels. Subsequently, they placed the prescription drugs back onto the bathroom counter, locked the bedroom door, and departed the trailer.

The IIC, accompanied by the chief pilot, went to the trailer to obtain the prescriptions; however, they were not found. Following additional interviews, the IIC was informed that the company personnel manager had kicked the bedroom door loose so that the pilot's spouse could enter the bedroom. The personnel manager did not enter the bedroom. During an interview, conducted by the IIC and the company personnel manager, the spouse verified that she had the prescriptions; however, she declined to make any additional comments or provide medical information for the PIC.

TEST AND RESEARCH:

The airframe and engine were examined, under the surveillance of the IIC, on May 9 at the Zapata Protein (USA) Inc., Docks, Intracoastal City, Louisiana, and on May 10 at the company hangar at the Abbeville Municipal Airport, Abbeville, Louisiana.

Engine (Lycoming model O-360-F1A6, serial number L-29039-36A) continuity was confirmed. The engine driven fuel pump operated and fuel was found in the pump. The crankshaft flange was bent. Exhaust system tubes were crushed with the #1 cylinder exhaust tube and the #3 cylinder intake tube separated from the engine. The muffler was not recovered. The carburetor was found separated from the engine. The carburetor contained a metal float and a single piece venturi. The throttle cable was attached at the carburetor and the mixture control cable was pulled out at the attachment assembly. The oil filter and the alternator were not recovered. The ignition harness and one post wire on the left magneto and one post wire on the right magneto were destroyed. Each magneto produced spark at the remaining 3 posts during hand rotation. Vacuum pump vanes and drive shaft were intact. Spark plugs were contaminated with mud, water, or oil. The engine cylinders were removed and disassembled. All cylinders were contaminated with mud and mud was found on all the valves.

No pre-existing deficiencies were noted and the investigation did not produce any evidence that the engine was not capable of operating and producing power prior to the accident.

The McCauley propeller (model B2D34C220, serial number 796972) was a

NTSB Probable Cause

the pilot's decision to fly, when he was not in good physical condition; and his subsequent loss of aircraft control due to incapacitation. A related factor was: the pilot's perception of an urgency (pressure) to fly, induced by conditions/events.