NTSB Factual Report

HISTORY OF FLIGHT

On May 26, 2012, about 0120 mountain daylight time, a Cessna 172S, N953SP, collided with terrain shortly after departing from St. George Municipal Airport, St. George, Utah. Diamond Flying LLC was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot and three passengers were fatally injured; the airplane sustained substantial damage. The local personal flight was departing from St. George with a planned destination of Mesquite, Nevada. Visual meteorological conditions prevailed, and no flight plan had been filed.

A friend of the pilot stated that he arrived at a party on the evening of May 25 and the pilot was already there. He recalled both himself and the pilot having several alcoholic beverages (two shots of Southern Comfort liqueur) between 2030 and 2200, but was not aware of his alcohol consumption before or after that time frame; there was also Bud Light and Smirnoff Vodka at the party. He recalled two of the passengers were also drinking alcohol at the party and the third passenger did not consume any alcohol because he was the designated driver for the group. Shortly thereafter, himself, the pilot, and three passengers all left the party and decided to drive to another party.

The friend further stated that while en route to the other party, the vehicle was pulled over by a police officer. While they were all waiting in the car for the officer to complete the traffic stop, one of the passengers suggested that the group should go to Mesquite, since he frequently drove there on the weekends to gamble. The group agreed to go, with the exception of the friend, who decided that he would stay in town instead and he called someone to pick him up from the car's location. Some of the passengers called him a little later to again try to encourage him to go, but he refused and made a last call to them at 0110 when he let them know he was going back to the party. Nobody ever mentioned or gave him any indication that they were going to take an airplane to Mesquite.

The airport was equipped with a video recording system that consisted of a fixed based security camera system. A review of the video files revealed that the airplane could be seen in the night time conditions by the blinking left-wing strobe light and the navigation light mounted on the tail. The airplane appeared to depart from runway 19 and maneuver at a low altitude for the length of the runway while increasing its airspeed. Near the end of the runway (about 2/3 of the way down the 9,300 ft runway), the airplane began a rapid ascent and continued out of the view of the camera. After about 7 seconds, the airplane reappears further down the frame in a rapid descent.

PERSONNEL INFORMATION

The pilot, age 23, held a commercial pilot certificate, with ratings for single and multiengine land, and instrument flight. His first-class medical certificate was issued on April 16, 2012, and contained no limitations. The pilot was employed by GoJet Airlines, LLC., as a first officer in the Bombardier CL-600 series airplanes.

The pilot's personal flight records were not recovered. On his last application for a medical certificate the pilot reported a total flight time of 3,000 hours.

The pilot's resume submitted to GoJet indicated that he had previously been employed at Comair Airlines; he additionally was employed as a line technician at St. George Jet Center from 2003 to 2006. The computerized flight logs at GoJet reported his last recorded total time as about 2,230 hours, with his last proficiency training occurring about 1.5 months prior to the accident.

The pilot's family stated that the airplane belonged to a friend of the family and the pilot would borrow the airplane occasionally. The owner was not aware that the pilot had intended to fly the airplane the morning of the accident, however, that was not unusual, and the pilot and his father had permission to use the airplane when they desired. The pilot acquired a significant portion of his flight time from the St. George Municipal Airport and would commonly take friends flying without much notice.

The pilot's friend indicated that he did not consume alcohol very often and he had only seen him drink on three occasions in the last 2 years. The pilot's family indicated that he did not consume alcohol.

AIRPLANE INFORMATION

The Cessna 172S airplane, serial number 172S8153, was manufactured in 1999. The last annual inspection record was not contained in the airplane's logbook, but was provided as a separate entry after the accident. It indicated that the last inspection was completed on August 10, 2011, at a total airframe and engine tachometer time of 1,091.4 hours.

The airplane's Hobbs sheet located within the wreckage indicated that the last recorded flights were performed by the accident pilot on October 17 and 20, where he wrote that he had amassed 18.6 and 4.4 hours, respectively.

Fuel

The last known date that the airplane was refueled at St. George was recorded from Above View Aviation on May 18, 2012. The airplane was fueled with 18.5 gallons, which the fuel technician reported was a top-off to full fuel tanks. The last known fueling occurred at Chandler Air Service, Chandler, Arizona, where the airplane received 20.54 gallons of fuel, which based on the distance calculation from the two airports, equates to additionally being topped-off to full fuel tanks on that occasion.

Using average fuel consumption rates in the airplane flight manual climb and cruise performance charts, investigators conservatively estimated that the airplane had about 28 gallons of fuel onboard at the time of the accident. The disposition of the fuel load between the two standard capacity wing tanks could not be determined. The calculations used are contained in the public docket for this accident.

Weight and Balance

Weight and balance computations were made for the accident takeoff at based on the airplane's empty weight, total moment, and center of gravity that were obtained from the operator's maintenance records. The takeoff condition used the previously estimated 28 gallons of fuel. The occupant weights and seating positions were obtained from the Utah Department Office of the Medical Examiner. The detailed computations are appended to this report.

For the takeoff condition, the gross weight was about 2,710 pounds and the center of gravity was 44.92-inches. The maximum authorized gross takeoff weight was 2,550 pounds with the center of gravity range at that weight between 41.0 and 47.3 inches forward and aft, respectively. Review of the Cessna Pilot's Operating Handbook (POH) for the Cessna 172S disclosed that with the flaps in the retracted position, at the maximum gross weight, the stall speed at zero degrees of bank is 48 knots indicated airspeed (KIAS) and altitude loss during recovery "may be as much as 230 feet." Normal initial climb segment airspeed is 73 KIAS at 3,000 feet msl, with a 620-foot-per-minute climb rate.

Cessna does not provide or supply stall speeds outside the maximum gross weight envelope. The applicable POH states that the airplane's "stall characteristics are conventional and aural warning is provided by a stall warning horn which sounds between 5 and 10 kts above the stall in all configurations."

Ground Speed

The recorded video files were captured from security cameras located at the southwest corner of the St. George's Airport Rescue and Fire Fighting Facility and at the upper southwest corner of the South Terminal Building.

One video file disclosed that at 04 seconds and 21 frames into the recording the first indication of the accident airplane appears in the right-hand portion of the frame. The only visible indication of the airplane was the port wingtip strobe, port wingtip position light and white tail navigation light. The airplane continued to cross the image plane toward the departure end of runway 19 until 16 seconds and 22 frames in the recording when the airplane began a rapid ascent in an upward facing arc. The airplane continued ascending upward until 19 seconds and 03 frames when it disappeared out of the upper region of the recorded frame. At 25 seconds and 28 frames, the airplane reappears in the upper region of the frame in a rapid descent. At 27 seconds and 24 frames, the airplane's position lights disappeared behind a bright light bloom from the South Terminal Building's ramp area. No other salient information pertaining to the accident was captured during the 51-second recording.

The other video file reveals that at 04 seconds and 01 frame into the recording the first indication of the accident airplane appears in the right-hand portion of the frame. The only visible indication of the airplane is the port wingtip strobe, port wingtip position light and white tail navigation light. The airplane continues to cross the image plane towards the departure end of runway 19 until 14 seconds and 05 frames into the recording when the last indication of the accident airplane's taillight disappears out of the image frame. No other salient information pertaining to the accident was captured during the 23-second recording.

In an effort to determine an approximate ground speed during the takeoff, geometric reference points were utilized and the time was analyzed as the airplane moved between each of the points. To accomplish this, lines of perspective were created from the center of the camera's lens through each known taxiway light position and beyond the runway centerline. Using the airplane's tail position light, a frame reference was taken at each of the perspective lines as the airplane moved through the image. As the airplane's taillight passed each perspective line, the time in whole seconds and number of carryover frames were recorded. Using mapping software, the distance between each line of perspective along the runway centerline was measured and the resulting average groundspeed of about 107 kts was calculated for the 637 feet of captured video. The last two segments of video showed a decrease of groundspeed from about 107 to 91 kts. The pitch and bank angle of the airplane could not be determined from the video.

METEOROLOGICAL INFORMATION

A routine aviation weather report (METAR) generated by an Automated Surface Observation System (ASOS) at the airport, indicated that about 5 minutes prior the accident the conditions were as follows: wind was from 260 degrees at 9 knots; temperature 66 degrees Fahrenheit; dew point 28 degrees Fahrenheit; and altimeter 29.60 inHg.

According to the U.S. Naval Observatory, on the morning of the accident, the time of sunrise was 0618. At the time of the accident, the moon was below the horizon and the sky was dark.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in the hard dirt area (the southerly primary surface) adjacent to the departure end of runway 19. Situated on the level terrain, the airplane came to rest in an inverted attitude and was oriented on a 315-degree magnetic bearing. The main wreckage, which consisted of a majority of the airframe and engine, was located about 525 feet from the edge of the runway.

The first identified point of impact was a ground scar impression about 40 feet from the main wreckage that dimensionally and geometrically resembled the wings with a crater-like impression in the center. The span of the ground disturbance was about 36.5 feet, with red lens fragments located near the east side and green fragments on the westerly side; the airplane's wingspan was 36 feet. Imbedded in the center crater was a portion of a propeller blade and the nose wheel. In the debris field from the ground scar to the main wreckage was oil sump, the propeller and engine accessories.

Contained within the wreckage were bottle caps from Bud light and Blue Moon beer bottles.

The destination airport in Mesquite (elevation 2,000 ft msl), was about 28 nm from St. George Municipal Airport (elevation 2,900 ft msl) on a bearing of about 245 degrees. A mountain range extended longitudinally between the two airports with peaks reaching up to 6,000 ft msl. The surrounding area was unpopulated desert and few lights were in the immediate vicinity. Driving an automobile between the two airports is about 37 nm and would take about 45 minutes.

MEDICAL AND PATHOLOGICAL INFORMATION

The Utah Department of Health, Office of the Medical Examiner, completed an autopsy on the pilot. The examiner's pathological diagnosis as cause of death was noted as, "Multiple blunt force injuries."

The FAA Civil Aeromedical Institute (CAMI) performed toxicological screenings on the pilot. According to CAMI's report (#201200100001) the toxicological findings were positive for ethanol (alcohol). Specifically, the following was detected in the pilot's specimens: 0.105 gm/dL ethanol in blood, 0.121 gm/dL ethanol in brain, 0.098 gm/dL ethanol in heart; methanol and n-propanol was also detected in the blood as well. The toxicology report additionally noted no evidence of putrefaction in the specimens received.

Passengers

None of the passengers were FAA certificated pilots. CAMI additionally performed toxicological screenings on the passengers, of which two were positive for ethanol. One passenger's blood contained 0.088 gm/dL ethanol and the other passenger had 0.160 gm/dL of ethanol detected in his blood.

TESTS AND RESEARCH

Following recovery, the wreckage was examined at a hangar at the St. George Municipal Airport.

Investigators established continuity for the elevators and rudders from the aft bulk head area to the control surfaces. The ailerons cables separated in the cabin overhead area location, with the cable ends exhibiting a broom straw appearance consistent with overload. Continuity was established in the wings (from cabin to their respective bellcranks), but the cockpit area's extensive damage prohibited investigators from tracing the cable paths. The wing flap actuator jackscrew was flush with the body, which, according to the Cessna representative, corresponded to a flaps being in the retracted position. The elevator trim was measured to be 1.3 inches, which the Cessna representative stated was a neutral position.

The Lycoming IO-360-L2A, serial number L-28167-51A, sustained impact damage. Despite several attempts, investigators could not rotate the crankshaft and proceeded to remove cylinders No. 1 and 3 cylinders. The No. 2 and 4 cylinders were examined through the spark plug holes utilizing a lighted borescope. The combustion chambers were mechanically undamaged, and there was no evidence of foreign object ingestion or detonation. The valves were intact and undamaged. There was no evidence of valve to piston face contact observed. The gas path and combustion signatures observed at the spark plugs, combustion chambers and exhaust system components displayed coloration that the Lycoming representative said was consistent with normal to lean operation.

There was no oil residue observed in the exhaust system gas path. Ductile bending and crushing of the exhaust system components was observed.

Removal of the fuel manifold (spider) revealed that it contained slight traces of liquid that was consistent in odor with that of Avgas. The diaphragm was pliable and the spring was intact.

The left magneto was broken as a result of impact and could not be functionally tested. The right magneto, which was located away from the engine in the debris field, was rotated by hand. Spark was obtained at each post during rotation.

The vacuum pump was disassembled and the drive gear was found intact; there was no visible evidence of damage. The rotor/vane assembly was also intact and undamaged. Light rotational scoring was observed on both the rotor and housing.

The propeller and its respective flange were broken free of the crankshaft. One blade was twisted and bent aft with leading edge gouges and chordwise polishing/scratches; about 8 to 10 inches of the tip was broken away. The other blade was found relatively straight with some evidence of twisting and chordwise scratching.

There was no evidence of mechanical malfunction or failure with the airframe or engine

NTSB Probable Cause

The pilot's failure to maintain adequate airspeed during an aggressive pitch-up maneuver, which resulted in a low-altitude aerodynamic stall shortly after takeoff. Contributing to the accident was the pilot's impairment from alcohol consumption and an over-gross-weight airplane.