NTSB Factual Report

HISTORY OF FLIGHT

On October 26, 2011, about 1837 Pacific daylight time, a Cessna 182R, N6545E, collided with terrain near Lexington, Oregon. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The private pilot sustained fatal injuries, and one passenger sustained serious injuries; the airplane sustained substantial damage from impact forces. The cross-country personal flight departed Pasco, Washington, about 1806, with a planned destination of Lexington. Night visual meteorological conditions prevailed, and no flight plan had been filed.

The pilot flew from Lexington to Pasco to pick up his passenger at the airport. After departing back to Lexington, the passenger tilted his seat back to rest. The passenger sat up when the pilot announced that they were approaching the airport, and on a 5-mile base for landing at Lexington. They could see the runway lights, and then the airplane reacted violently as it unexpectedly hit the ground. The passenger did not hear any warning comments from the pilot.

The passenger sustained severely injured feet and other serious injuries. The pilot was conscious; he said that he was trapped in the wreckage, and could not get free. The passenger began crawling, and eventually came to a home almost 2 miles away about 4 hours later.

A friend of the pilot reported to local law enforcement that the airplane was 2 hours overdue. Officers verified that the pilot's car was still at the airport. They began a search, and then received the call that the passenger was at the residence. From the passenger's description of his ordeal, the local first responders were able to locate the accident site.

A review of recorded radar data indicated a target that originated on the Pasco Airport (elevation 410 feet) at 1801:59, at a mode C altitude of 400 feet. At 1806:58, the mode C altitude began to increase until it reached 4,400 feet at 1812:30, and the target tracked to the southwest toward Lexington. At 1831:37, the mode C altitude began to decrease; the last target was in the vicinity of the accident site at 1837:12, at a mode C altitude of 2,300 feet.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed that the 65-year-old pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane.

The pilot held a third-class medical certificate issued on November 18, 2010. It had the limitations that the pilot must have glasses available for near vision.

A flight time logbook for the pilot was located in the wreckage; the title page indicated that it was logbook number two, and contained flights from August 1, 2003. It began at a total flight time of 552 hours, and all entries in this logbook were for N6545E. An examination of this logbook indicated that the last flight logged occurred on October 25, 2011. As of that date, the pilot had an estimated total flight time of 1,827 hours. He logged 33 hours in the previous 90 days, and 24 in the previous 30 days. He completed a biennial flight review on October 19, 2010.

AIRCRAFT INFORMATION

The airplane was a Cessna 182R, serial number 18268373. A review of the airplane's logbooks indicated that the airplane had a total airframe time of 2,750.2 hours at the last annual inspection dated March 15, 2011. The tachometer read 1,607.2 at the last inspection.

The engine was a Continental Motors International O-470-U (18), serial number 273185-R. Total time recorded on the engine at the last annual inspection was 4,601.7 hours, and time since major overhaul was 988.5 hours.

METEOROLOGICAL CONDITIONS

The closest official weather observation station was Hermiston, Oregon (KHRI), which was 28 nautical miles (nm) northeast of the accident site at an elevation of 644 feet mean sea level (msl). An aviation routine weather report (METAR) for KHRI issued at 1753 PDT stated: wind from 080 degrees at 5 knots; visibility 10 miles; sky clear; temperature 19/66 degrees Celsius/Fahrenheit; dew point 5/41 degrees Celsius/Fahrenheit; altimeter 29.91 inches of mercury. Astronomical data indicated that there was 0 percent illumination of the moon.

WRECKAGE AND IMPACT INFORMATION

The National Transportation Safety Board investigator-in-charge (IIC), an FAA inspector, and accident investigators from the airframe and engine manufacturers examined the wreckage on site. A detailed report of the onsite examination is part of the public docket for this accident.

The accident site was high on a ridge in the middle of a wheat field. The First Identified Point of Contact (FIPC) was a ground scar. The GPS coordinates of the main wreckage were 45 degrees 27.155 minutes north latitude 119 degrees 37.068 minutes west longitude, and the GPS elevation was 2,262 feet. This was about 236 feet from the FIPC. The engine separated, and was about 386 feet from the FIPC. The separated oil filter was about 100 feet forward of the engine in the direction of the debris path. It was the most distant piece of wreckage located. The debris path was along a magnetic bearing of 254 degrees, and the fuselage was heading about 330 degrees.

The main wreckage consisted of the fuselage, empennage, and wings; the wings had folded onto each other, and the airplane had rolled about 135 degrees onto its left side. The cabin area sustained upward crush damage on the bottom, and inboard crush damage on the left side.

MEDICAL AND PATHOLOGICAL INFORMATION

The Oregon State Medical Examiner completed an autopsy, and listed the cause of death as blunt force head and chest trauma. The NTSB Medical Officer reviewed the autopsy report. The chest trauma included bilateral rib fractures with a flail chest and 200 cc of blood in the right chest cavity. The head trauma included a large scalping laceration, but no indication of brain injury. The extremity injuries included a fracture dislocation of the left wrist, a fracture dislocation of the left ankle, and a compound fracture of the right ankle. There were no lung, heart, or intra-abdominal injuries noted.

The FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot.

Analysis of the specimens contained no findings for carbon monoxide, cyanide, or volatiles.

The report contained the following findings for tested drugs: diphenhydramine was detected in urine, but not in blood.

TESTS AND RESEARCH

A detailed report of the airframe and engine wreckage examination is part of the public docket for this accident.

Airframe

A postaccident examination of the airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Flight control continuity was established for the ailerons; however, the balance cable was cut by first responders during victim recovery. Flight control continuity for the elevators and rudder were established from the control surface to the cockpit controls. The elevator trim measured 1.41 inches, which equated to 5 degrees tab up. The flaps were in the up position. Flap control cable continuity was established; however, the cable was cut by first responders during victim recovery.

The fuel selector valve was in the BOTH position. The gascolator was clean with no evidence of pitting or corrosion; it was free of debris.

Engine

The engine separated, and came to rest inverted. One propeller blade and a portion of the propeller hub remained attached to the engine. The oil pan was crushed upward, and had holes in it. All cylinders remained securely attached. The vacuum pump, carburetor, and oil filter separated from their mounts.

Postaccident examination of the engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Emergency Locator Transmitter (ELT)

The airplane was equipped with an ELT that broadcast an emergency signal on 121.5 and 243.0 MHz. Although the ELT was determined to be operational by a functional test after the accident, no signal reception was reported for this accident.

As of February 2009, the International Satellite System for Search and Rescue system (COSPAS-SARSAT) no longer monitored for ELTs operating on 121.5/243 MHz. At that time, that organization only began monitoring 406 MHz. Since that time, ELTs utilizing 121.5/243 MHz required an airplane flying overhead the accident site to monitor the frequency, hear the signal, and notify air traffic control (ATC) of it. Then ATC would notify the Air Force Rescue Coordination Center (AFRCC). The FAA does not require airborne aircraft to monitor the frequency. A telephone conversation with the AFRCC revealed that they have up to 2 hours to investigate a signal to determine if it is a non-distress signal, or if a search and rescue mission needs to be initiated.

National Oceanic and Atmospheric Administration (NOAA)-SARSAT Analysis

NOAA-SARSAT provided a hypothetical analysis of what distress alerts the SARSAT system may have been able to produce if the airplane had been equipped with a functioning 406 MHz ELT. The full report is part of the public docket for this accident.

The analysis concluded that an activated 406 MHz ELT would have been quickly detected by satellites providing a near immediate accident notification to the AFRCC within minutes of impact. This notification would have contained the type of beacon, aircraft tail number, emergency point of contact, and more information that would have allowed SAR professionals to rapidly begin the response process. If the ELT had GPS capability, a GPS location of the accident site would also have been available to recue forces within minutes. An independent location using a satellite Doppler fix on the 406 MHz beacon would likely have occurred when another satellite passed about 1 ½ hours later, and would have assisted in finding the airplane in a more timely manner.

NTSB Probable Cause

The pilot’s failure to maintain situational awareness and terrain clearance on a dark night during the approach to landing.