Primary finding
Probable cause
The intentional low altitude maneuvering during takeoff in response to a near-miss with an airplane departing from a converging runway, which resulted in an exceedance of the airplane's critical angle of attack and a subsequent aerodynamic stall.
Investigator assessment
Analysis narrative
The airline transport pilot and pilot-rated passenger were departing on an instrument flight rules (IFR) cross country flight from runway 4 in a Cessna 340A about the same time that a private pilot and pilot-rated passenger were departing on a visual flight rules repositioning flight from runway 36 in a Cessna 172M. Visual meteorological conditions prevailed at the airport. The runways at the nontowered airport converged and intersected near their departure ends. According to a witness, both airplanes had announced their takeoff intentions on the airport's common traffic advisory frequency (CTAF), which was not recorded; the Cessna 340A pilot's transmission occurred about 10 to 15 seconds before the Cessna 172M pilot's transmission. However, the witness stated that the Cessna 172M pilot's transmission was not clear, but he was distracted at the time. Both occupants of the Cessna 172M later reported that they were constantly monitoring the CTAF but did not hear the transmission from the Cessna 340A pilot nor did they see any inbound or outbound aircraft. Airport video that captured the takeoffs revealed that the Cessna 172M had just lifted off and was over runway 36 approaching the intersection with runway 4, when the Cessna 340A was just above runway 4 in a wings level attitude with the landing gear extended and approaching the intersection with runway 36. Almost immediately, the Cessna 340A then began a climbing left turn with an increasing bank angle while the Cessna 172M continued straight ahead. The Cessna 340A then rolled inverted and impacted the ground in a nose-low and left-wing-low attitude. The Cessna 172M, which was not damaged, continued to its destination and landed uneventfully. The Cessna 340A was likely being flown at the published takeoff and climb speed of 93 knots indicated airspeed (KIAS). The published stall speed for the airplane in a 40° bank was 93 KIAS, and, when the airplane reached that bank angle, it likely exceeded the critical angle of attack and entered an aerodynamic stall. Examination of the Cessna 340A wreckage did not reveal any preimpact mechanical malfunctions that would have precluded normal operation. Because of a postcrash fire, no determination could be made as to how the radios and audio panel were configured for transmitting and receiving or what frequencies were selected. There were no reported discrepancies with the radios of the Cessna 172M, and there were no reported difficulties with the communication between the Cessna 340A and the Federal Aviation Administration facility that issued the airplane's IFR clearance. Additionally, there were no known issues related to the CTAF at the airport. Toxicological testing detected unquantified amounts of atorvastatin, diphenhydramine, and naproxen in the Cessna 340A pilot's liver. The Cessna 340A pilot's use of atorvastatin or naproxen would not have impaired his ability to hear the radio announcements, see the other airplane taking off on the converging runway, or affected his performance once the threat had been detected. Without an available blood level of diphenhydramine, it could not be determined whether the drug was impairing or contributed to the circumstances of the accident.
Source record
Factual narrative
TPF did not have a control tower, and the CTAF of 122.725 MHz was not recorded, nor was it required to be. Following the accident, equipment that recorded the CTAF was installed at TPF. There were no reported communication difficulties with Tampa ATCT. According to an individual who provided oversight for TPF, to their knowledge, there had been no formal or informal complaints about the CTAF pertaining to reception issues related to buildings and/or structures. TPF had two runways, runway 4/22, which was 3,580 ft long and 100 ft wide, and runway 18/36, which was 2,687 ft long and 75 ft wide. The runways intersected near their northern ends. A shipping channel was located just east of and parallel to runway 18/36. The 1115 automated surface observation taken at TPF reported wind from 210° at 9 knots, 10 statute miles visibility, and clear skies. The temperature and dew point were 27°C and 20°C, respectively, and the altimeter setting was 30.00 inches of mercury. The Hillsborough County Medical Examiner Department, Tampa, Florida, performed postmortem examinations of the Cessna 340A pilot and pilot-rated passenger, and also toxicological testing. The cause of death for both was listed as blunt impact to head and neck. Toxicology testing or liver specimens of the pilot and pilot-rated passenger revealed the results for both were negative for volatiles, drugs of abuse, comprehensive drug screen, and benzodiazepines. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma performed toxicological testing of specimens from the Cessna 340A pilot and pilot-rated passenger. The toxicology report for the pilot indicated no ethanol was detected in the submitted muscle and brain specimens. Unquantified amounts of atorvastatin, diphenhydramine, and naproxen were detected in the submitted liver specimen. Atorvastatin is a cholesterol lowering prescription medication commonly called Lipitor. Naproxen is an anti-inflammatory analgesic available over the counter and by prescription, often with the names Aleve and Naprosyn. Neither of these drugs are considered impairing. Diphenhydramine is a sedating antihistamine that has been shown to impair a driver's ability to safely operate a car. Testing for carbon monoxide and cyanide was not performed. The toxicology report for the pilot-rated passenger indicated no ethanol was detected in the submitted muscle and brain specimens, and no tested drugs were detected in the submitted liver specimen. Testing for carbon monoxide and cyanide was not performed. Drug and alcohol testing was not requested or performed for the occupants of the Cessna 172M. According to Federal Aviation Administration (FAA) records, the pilot, who was seated in the left seat of the Cessna 340A, age 54, held an airline transport pilot certificate with an airplane multi-engine land rating. He also held commercial, flight instructor, and ground instructor certificates. At the commercial level, he held ratings for airplane single-engine land and sea, rotorcraft helicopter, and instrument helicopter, and, at the flight instructor level, he held ratings for airplane single- and multi-engine, rotorcraft helicopter, and instrument airplane and helicopter. His most recent FAA second-class medical certificate with no limitations was issued on June 5, 2014. As of October 2, 2015, the pilot reported a total time of 5,195 hours of which 284 hours were in multi-engine airplanes. His last flight review in accordance with Title 14 CFR Part 61 section 56 was on March 12, 2015. According to FAA records, the right seat occupant of the Cessna 340A, age 55, held a private pilot certificate with an airplane single-engine land rating. His most recent FAA second-class medical certificate with no limitations was issued on June 6, 2014. On the application for his last medical certificate, he listed a total flight time of 375 hours. According to FAA records, the pilot, who was seated in the left seat of the Cessna 172M, age 30, held a private pilot certificate with airplane single-engine land rating issued earlier that day. His most recent FAA third-class medical certificate with no limitations was issued on December 7, 2015. On the FAA 8710-1 application form for his private pilot certificate, he listed a total flight time of 40 hours of which 21.4 hours were as instruction received and 18.6 hours were solo. According to FAA records, the right seat occupant of the Cessna 172M, age 69, held airline transport, commercial, and flight instructor pilot certificates. At the airline transport pilot level, he held an airplane multi-engine land rating, and, at the commercial level, he held ratings for airplane single-engine land and sea. At the flight instructor level, he held ratings for airplane single- and multi-engine and instrument airplane. He reported a total flight time of 6,530 hours and about 3,000 hours in a Cessna 172. Cessna 340A The six-place, low-wing, retractable-gear Cessna 340A airplane, serial number 340A0436, was manufactured in 1977. It was powered by two 335-horsepower Continental Motors, Inc., TSIO-520-NB engines and equipped with Hartzell PHC-C3YF-2UF/FC7693DFB constant-speed propellers. The airplane was also equipped with RAM Option 3 vortex generators on both wings and tail that were installed in 1996 in accordance with Supplemental Type Certificate (STC) SA7975SW. The airplane's maximum allowable gross weight was 6,390 pounds. The airplane was equipped with a Garmin GNS-530W installed in the "pilots view position" that was the No. 1 communication and navigation transceiver. It was connected to the No. 1 position of the audio panel. A Garmin GNS 430 with navigation and communication capability was installed in the center instrument panel. The maintenance records were reportedly in the airplane at the time of the accident. Review of copies of the Cessna 340A's maintenance record entries indicated that the airplane's last annual inspection was signed off as being completed on February 15, 2016. At that time, the airplane's total time was 3,963.10 hours. The Cessna 340A's weight at the time of the accident was calculated using the empty weight when the airplane was modified in 1996 (about 4,478 pounds), the weights of the occupants from their most recent FAA medical examinations (208 and 207 pounds), and the weight of full usable fuel in each main fuel tank, each auxiliary fuel tank, and the locker fuel tank (1,098 pounds). The calculations indicated that the takeoff weight was about 5,991 pounds. The Flight Manual Supplement associated with the 1996 modifications specified that the takeoff and climb speed to 50 ft was 93 knots indicated airspeed (KIAS) for weights between 5,990 and 6,390 pounds. A review of the stall speed chart in the Flight Manual Supplement revealed that at 6,390 pounds, with flaps retracted and landing gear up, the stall speeds at 0°, 40°, and 60° of bank were 81, 93, and 115 KIAS, respectively. There were no published stall speeds for flaps retracted and landing gear down. Cessna 172M The four-place, high-wing, fixed-gear Cessna 172M airplane, serial number 17264811, was manufactured in 1975. It was equipped with three communication and navigation transceivers, which included a Garmin GNC-300XL GPS/Com system that was installed and interfaced to the existing audio system after the airplane was manufactured. According to the pilot-rated passenger, in November 2015, there had been static over the intercom, and the audio panel had been replaced. The pilot-rated passenger reported that all three radios were checked after the accident with no discrepancies reported. Review of the Cessna 172M's maintenance records indicated that an annual inspection was completed on July 8, 2015, at an airplane total time of 9,412.4 hours. The next annual inspection was completed on August 10, 2016, at an airplane total time of 9,601.1 hours. There was no entry between the 2015 and 201