Primary finding
Probable cause
The pilot’s failure to maintain adequate airspeed and altitude to clear trees during the initial climb after takeoff.
Investigator assessment
Analysis narrative
Witnesses located at their residences adjacent to the accident site reported hearing the airplane takeoff from the airport and that the engine sounded normal. Shortly after, the sound of the engine stopped. One witness reported that while he was outside his home, he saw the accident airplane fly over 100-foot tall trees north of his position at an altitude of about 200 feet above ground level (agl) and that the engine sounded normal. The witness said that while he directed his attention away from the airplane momentarily, he heard the engine suddenly stop and he immediately looked back and observed the airplane descend into 100-foot tall trees. An iPhone was located within the wreckage and contained a 23-second video recording inside the accident airplane. Review of the video revealed that it began as the airplane initiated takeoff roll on the grass runway. The video briefly captured the engine tachometer gauge, which displayed 2,300 revolutions per minute (RPM). Throughout the video, the engine sound was consistent and did not increase or decrease. During the final 8 seconds of the video, after the airplane became airborne, a sound, similar to a stall warning horn was heard until the end of the recording. Postaccident examination of the airframe and engine run revealed no evidence of any preimpact mechanical malfunction or failure that would have preluced normal operation. Cockpit documentation revealed that the throttle was in the fully extended or idle position, and was bent downwards. Given the idle position of the throttle and downward bend, it is likely that the pilot reduced power prior to impacting trees. The sound of the stall warning horn within the recorded video suggests that the airplane was traveling at a slow airspeed immediately after takeoff and most likely continued in this state throughout the climb. While witnesses reported hearing the engine lose power, it is possible that the witnesses heard the reduction of engine power from a high power setting to an idle power setting prior to impact with trees, thus being similar to a loss of engine power. Toxicology tests on the pilot were found positive for metabolites of marijuana within the pilot’s blood and lung tissue. Most behavioral and physiological effects return to baseline levels within 3-5 hours after drug use, although some residual effects in specific behaviors have been demonstrated up to 24 hours, such as complex divided attention tasks. Psychomotor impairment can persist after the perceived high has dissipated. In long term users, even after periods of abstinence, selective attention has been shown to be adversely affected with increasing duration of use, and speed of information processing has been shown to be impaired with increasing frequency of use. The exact degree of impairments in cognition, judgment, and motor function were unable to be determined. The pilot’s use of marijuana was likely more than five hours before the accident and may have contributed to his failure to successfully manage this flight.
Source record
Factual narrative
HISTORY OF FLIGHT On June 23, 2012, about 1513 Pacific daylight time, a Cessna 172, N5781A, was substantially damaged when it collided with trees and terrain during takeoff initial climb from the Crow-Mag Airport (33OR), near Veneta, Oregon. The commercial pilot and three passengers were fatally injured. The airplane was registered to a private individual and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91, as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed. The local flight was originating at the time of the accident. Several witnesses located adjacent to the accident site reported hearing the airplane takeoff from the airport nearby their residences. Witnesses stated that the airplane's engine sounded normal and then suddenly just stopped. One witness, who was outside his home, just south of the runway, reported that he saw the accident airplane fly over 100-foot tall trees north of his position at an altitude of about 200 feet above ground level (agl) and that the engine sounded normal. The witness said that while he directed his attention away from the airplane momentarily, he heard the engine suddenly stop and he immediately looked back and observed the airplane descend into 100-foot tall trees. A friend of the pilot, reported to the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) that the purpose of the accident flight was to provide a scenic tour around the vicinity of the airport for the three passengers. He said that the accident flight was the first flight of the day and that the airplane had been flown for about 1.7 hours since the airplane had been refueled in Cottage Grove, Oregon. PERSONNEL INFORMATION The pilot, age 41, held a commercial pilot certificate with an airplane single-engine land, airplane single-engine sea, airplane multi-engine land, rotorcraft helicopter, glider, and instrument airplane and helicopter ratings. A second-class airman medical certificate was issued on August 23, 2011, with no limitations stated. The pilot reported on his most recent medical certificate application that he had accumulated 1,600 total flight hours. The pilot’s most recent logbook was not located. AIRCRAFT INFORMATION The four-seat, high-wing, fixed-gear airplane, serial number (S/N) 28381, was manufactured in 1956. It was powered by a Continental O-300-A engine, serial number 11772-D-6-A, rated at 145 horse power. The airplane was equipped with a McCauley fixed pitch propeller. As of the most recent calculated weight and balance, dated July 2, 2008, the empty weight of the airplane was 1,331.50 pounds. The maximum gross weight was 2,200 pounds. Review of the maintenance records for the airplane revealed that the most recent annual inspection was completed on August 1, 2011, at an airframe total time of 6,162.56 hours, tachometer time of 1,562.06 hours, and an engine time since major overhaul of 1,170 hours. The engine was overhauled on April 2, 1978, and was installed on the accident airplane on June 1, 1997, at a tachometer time of 1,146 hours and an engine total time of 5,745.5 hours. Using the reported weights of the pilot and three passengers, approximately 30 pounds for items within the airplane, 28 gallons of fuel, and the airplane, the IIC calculated the weight of the airplane to be about 2,139 pounds at the time of the accident and within center of gravity limits. Review of the Pilot’s Operating Handbook for the accident airplane revealed that there are no published performance charts for takeoff from a turf runway. METEOROLOGICAL INFORMATION A review of recorded weather data from the Mahlon Sweet Field Airport, Eugene, Oregon, automated weather observation station, located 8.6 miles northeast of the accident site, revealed at 1454 conditions were wind from 260-degrees at 14 knots, visibility 10 statute miles, few clouds at 4,000 feet, scattered clouds at 7,000 feet, broken clouds at 22,000 feet, temperature 16-degrees Celsius, dew point 8 degrees Celsius, and an altimeter setting of 29.86 inches of mercury, remarks Cumulonimbus Clouds in the distance north west of the airport, showers to the west of the airport. According to the Federal Aviation Administration Special Airworthiness Information Bulletin, entitled Carburetor Icing Prevention, the temperature and dew point were conducive to the formation of serious icing at glide power. AIRPORT INFORMATION The Crow-Mag Airport (33OR) is a private airport that features a single 3,200-foot long turf runway (15/33). The reported airport elevation is 450 feet mean sea level (msl). During a telephone conversation, the owner of the airport reported that he mows the runway surface to about 3 inches in height and that it was last mowed two days prior to the accident. In addition, the owner of the airport reported that there had been multiple rain showers within the vicinity of the airport prior to the accident flight and that the grass runway was damp. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that wreckage debris and broken tree limbs were scattered about 80 feet along an approximate 174-degree magnetic heading from a cluster of scraped and broken trees. The right wing was lodged in one of the damaged trees at the beginning of the debris path, about 70 to 75 feet above ground level. The right horizontal and right elevator was located about 20 feet from the first identified point of contact (FPIC). The left horizontal, left elevator, vertical stabilizer, and rudder were located about 40 feet beyond the FPIC. The main wreckage came to rest inverted about 80-feet from the FPIC, oriented on a heading of about 235-degrees magnetic. Examination of the left wing revealed that the aileron remained attached to the wing via all respective mounts. The leading edge was crushed aft about 1 foot inboard of the lift strut wing attach point, consistent with an impact with a circular object (tree trunk). The left wing fuel pickup fuel line was compromised. The fuel tank cap and seal were intact and undamaged. No fuel was found within the left wing fuel tank, however, a blue stain was observed on the top portion of the left wing about mid span. The right wing was separated from the fuselage via all its mounts. The leading edge exhibited a large circular impression about 2 feet outboard of the wing root, and extended aft to the main spar. The right wing fuel tank was dislodged from the wing structure and was located within the wreckage debris path. The fuel tank cap and seal were intact and undamaged. About 2 gallons of fuel was removed from the fuel tank and multiple holes were observed in the fuel tank. The fuselage came to rest inverted. The fuselage structure surrounding the cabin area was compressed. The left and right horizontal stabilizers, left and right elevators, rudder, and vertical stabilizer were separated from the fuselage. The right elevator remained attached to the right horizontal stabilizer via its outboard two mounts. The leading edge of the right horizontal stabilizer was crushed aft near the inboard portion of the stabilizer. The left horizontal stabilizer exhibited a circular leading edge impression about 14 inches from the inboard root, and extended aft to the spar. The elevator remained attached to the left horizontal stabilizer via its two outboard mounts. The vertical stabilizer was intact. The lower portion of the rudder was displaced right and exhibited bending and buckling. Examination of the cockpit controls revealed that the throttle was in the idle position and was bent downwards. The mixture was in the full forward or full rich position. The primer was in and locked, and the carburetor heat was pulled out about half way. The magneto key switch was in the “both” position. The fuel selector valve was in the “both” position. The flap handle was found in the stowe