NYC00FA106
NYC00FA106

HISTORY OF FLIGHT

On March 30, 2000, at 1424 Eastern Standard Time, a Cessna 172P, N98574, operated by Richmor Aviation, Inc. was destroyed when it struck the ground after departure from Saratoga County Airport, Ballston Spa, New York. The certificated flight instructor and student pilot were fatally injured. Visual meteorological conditions prevailed for the local instructional flight. No flight plan had been filed for the flight that was conducted under 14 CFR Part 91.

Witnesses reported the airplane departed on Runway 23.

One witness reported:

"...The plane was ascending and looked like a good take-off with a slight flutter, meaning that the wings dipped slightly right to left which is not uncommon. Then I heard the engine throttle down for a few seconds, then it seemed to rev back up again, and everything seemed fine as the plane gained more altitude. Then the plane banked a little to the left. I thought it seemed a little early for the pilot to be banking. Then kind of suddenly, the plane banked steeply to the left. I remember not hearing any engine noise from the plane at this point. The attitude of the airplane did not seem like a steep climb to me, just a normal slight nose up. When the plane banked over steeply. I saw it nose down and go down into the trees...."

A second witness reported:

"...I heard an airplanes engine and I looked up toward it. I saw a plane heading south toward Geyser Road flying about 20-30 feet above tree level. The plane was light in color...The plane started to bank to the left heading east on Geyser Road. Once the plane started to make the turn, I did not hear the engine running. I observed the plane start to roll to the left, heading north. I then observed the plane roll over upside down, it then nose dived into the ground...."

A third witness stated:

"...I saw a plane, white in color going straight up in the air...I continued to observe as the plane went straight up. I don't recall if the engine stalled as I was in awe knowing that the maneuver did not appear normal. I saw the plane then do like a twist as it was descending with what sounded like the engine was wide open...."

In a follow-up interview, the third witness reported that he did not see the airplane transition from a normal climb to steep climb. When he first observed the airplane it was already in a steep climb. He equated the climb attitude to bi-planes that he had seen performing at airports during airshows.

One other witness saw the takeoff, but lost sight of the airplane prior to the accident.

The accident occurred during the hours of daylight at 43 degrees, 2.669 minutes north latitude, and 73 degrees, 51.856 minutes west longitude.

PERSONNEL INFORMATION

Flight Instructor

The flight instructor held a commercial pilot certificate and flight instructor certificate for single and multi-engine airplanes and instrument airplane. According to the pilot's logbook and records from the Federal Aviation Administration (FAA), his total flight experience was 498 hours, with 175 hours in make and model. He had logged 117 hours and 67 hours in the preceding 90 days and 30 days respectively. He was last issued a FAA first class airman medical certificate with no limitations on December 6, 1999.

According to the flight instructor's most recent medical, he was 5 feet 10 inches tall, and weighed 156 pounds.

Student Pilot

The student pilot had not soloed. According to his log book, he had flown 12.1 hours with 3.1 hours in the preceding 90 days and 30 days. He was issued a FAA third class airman medical certificate on December 21, 1999.

According to the student pilot's medical, he was 6 feet, 3 inches tall, and weighed 288 pounds.

AIRCRAFT INFORMATION

The airplane was a 1985 Cessna 172P. On April 28, 1996, the airplane was involved in a landing accident at Rutland, Vermont. The engine installed on April 28, 1996, was not the same engine that was installed on the airplane on March 30, 2000.

METEOROLOGICAL INFORMATION

Saratoga County Airport had an automated weather observation system (AWOS) installed. Following are the winds recorded before and after the accident:

1415 Winds from 260 degrees at 10 knots 1435 Winds from 250 degrees at 14 knots, with gusts to 18 knots

WRECKAGE AND IMPACT INFORMATION

The accident site was located in a wooded area 870 feet southeast of the centerline of Runway 23, and 130 feet prior to the end of the runway. The airplane impacted the ground and came to rest inverted, on a heading of 050 degrees magnetic.

The center section of the fuselage and inboard portion of both wings was destroyed by fire. The pre-impact positions of the throttle, mixture control, and carburetor heat cockpit controls could not be determined because the supporting aluminum structure that retained the controls was melted. Documentation of cockpit instruments and control settings could not be obtained due to fire damage. The leading edge of both wings was crushed. The crushing on the left wing was to the same depth along the span of the wing. The crushing on the right wing was deeper on the outboard portion of the wing.

The seat rails, seats, and primary seat locks, which were made of aluminum, were not identifiable due to the post-impact fire. The pre-impact position of the seats could not be determined. All seatbelts were burned. No latched seatbelt buckles were found. The left side control yoke was found with the right side control horn broken off.

Flight control continuity was verified. All control cables were attached to their respective attach points. The wing flap jackscrew was found in the fully retracted position. The elevator trim jackscrew measured 1.2 inches of extension, which corresponded to a setting of 1-degree trailing edge tab down.

Both blades of the propeller were bent rearward. There was light compression wrinkling or "S" bending on the trailing edge of one blade. Paint on the front surface of both propeller blades had been worn away. There was light chordwise scratching on the front surface of both propeller blades.

The engine was rotated, and compression was obtained in all cylinders. Valve train continuity was observed on all cylinders. The spark plugs were gray in appearance with no fouling of electrodes observed. The magnetos had been exposed to fire and would not produce spark. The ignition harness was burned.

The carburetor was separated from the engine and broken open. The floats were metal and had experienced compression buckling. The main jet was absent of debris.

The emergency locator transmitter (ELT) case was found in the burn area without its batteries. Several batteries similar to those installed in the ELT were found scattered throughout the burn area. The three-position switch REMOTE/ARMED OFF ON located on the ELT case was found in the REMOTE/ARMED position.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were conducted on both pilots by the Saratoga County Medical Examiner on March 30, 2000.

The FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma conducted toxicological testing on both pilots.

The toxicological report for the flight instructor revealed no drugs or alcohol.

The toxicological report for the student pilot indicated that fluoxetine (prescription anti-depressant) and norfluoxetine (metabolite of fluoxetine) were detected in the student pilot at the following levels:

0.19 ug/ml fluoxetine detected in muscle 0.27 ug/ml norfluoxetine detected in muscle 1.023 ug/ml norfluxoetine detected in liver

The pilot's wife reported her husband had been taking Prozac (prescription anti-depressant, chemical name fluoxetine) for about six months prior to the accident. He was taking it for depression, and was taking one 20 mg tablet a day. She also reported that flying was relaxing to her husband, and he looked forward to his flights.

Examination of the student pilot's airman medical application dated December 21, 1999, and signed by the applicant, revealed that he answered question 17a, "Do You Currently Use Any Medication (Prescription or Nonprescription)?" with a NO.

According to page 70 of the October 1999, Guide for Aviation Medical Examiners:

"The use of a physchotropic drug is considered disqualifying. This includes all sedatives, tranquilizers, antipsychotic drugs, antidepressant drugs (including SSRI's), analeptics, anxiolytics, and hallucinogens. The Examiner should defer issuance and forward the medical records to the Aeromedical Certification Division AAM-300."

ADDITIONAL INFORMATION

The last refueling occurred on March 28, 2000, when it was serviced with 7.4 gallons of 100 low lead aviation grade gasoline. There were no records of any flights other than the accident flight after the last refueling.

The airplane received an annual inspection on March 23, 2000. According to work records, the alternator and battery were changed.

Interviews were conducted with several pilots who had flown the airplane after the annual inspection. Other than a problem with the electrical system involving the battery, no discrepancies were reported. Several pilots commented that the accident airplane was a good airplane and they enjoyed flying it.

The last flight of the airplane prior to the accident was March 28, 2000. There were no records of any discrepancies for the flight. An interview with the flight instructor on the last flight prior to the accident flight revealed nothing unusual or out of the ordinary with the airplane.

The airplane was equipped with individual pilot seats in the front, which were adjustable fore and aft, and a bench seat in the back. Both pilot seats had adjustable seat backs. In addition, the left seat also had vertical adjustment

A private pilot, who was taking flight lessons at Richmor, reported that on February 23, 2000, while taking his private pilot flight test in N98574, he experienced a seat slippage of the left pilot seat during takeoff ground roll. He said that the seat slid back far enough that he released his hands from the flight controls, and his feet were off the rudder pedals. When this occurred, the check airman continued with the takeoff. He also reported that he had flown the airplane prior to and subsequent to the occurrence, and had not experienced any further seat slippage. He was aware of the necessity of rocking the seat once he "thought" it was locked in place to ensure it was in fact locked.

According to the Cessna 172 checklist used by Richmor Aviation, the seats were checked prior to engine start, and again prior to landing.

The following was found in Section 9 - Restraint Systems of the Cessna Pilot Safety and Warning Supplements

"The pilot should visually check the seat for security on the seat tracks and assure that the seat is locked in position. This can be accomplished by visually ascertaining pin engagement and physically attempting to move the seat fore and aft to verify the seat is secured in position. Failure to ensure that the seat is locked in position could result in the seat sliding aft during a critical phase of flight, such as initial climb...."

On October 23, 1987, the FAA issued Airworthiness Directive 87-20-03, which established a repetitive inspection for the seat rails, to check for conditions that could contribute to seat slippage.

The maintenance work sheet from the last inspection revealed that AD 87-20-03, Revision 2, had been performed with no action noted.

The investigation revealed that Cessna had two types of seat locks, designated primary and secondary. Primary seat locks were designed to prevent seat movement into the rear cut-out of the rails, which was where the seats were removed from the seat rails. Secondary seat locks were installed prior to the end of travel and were designed to prevent the seat from slipping beyond the reach of most occupants.

Cessna had issued a service bulletin for secondary seat locks with subsequent upgrades. The urgency was changed from recommended to mandatory; however, the airplane was maintained under a 100-hour/annual-inspection program and was not required to follow the manufacturer's service bulletins.

According to the Director of Maintenance for Richmor at Ballston Spa, the airplane was delivered from Cessna and maintained with the primary seat locks installed. Secondary seat locks had not been installed on N98574.

The aircraft wreckage was released to Richmor Aviation on March 31, 2000.

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