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NTSB investigation record

WPR13FA138

Completed

Cessna 172M· N5129R

Date
March 3, 2013
Location
Saratoga, WY
Conditions
IMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot’s decision to attempt flight into approaching adverse weather, which led to his low-level flight, encounter with mountain obscuration and moderate turbulence, and his subsequent loss of airplane control. Contributing to the severity of the pilot’s injuries was the failure of the seat restraint assembly.

Investigator assessment

Analysis narrative

Near the time of the accident, a witness observed an airplane fly overhead in an easterly direction about 500 feet above the ground; the airplane wasn't visible until directly overhead through an opening in the low and broken clouds. The airplane continued its flight toward mountainous terrain. GPS data revealed that the airplane then conducted several 360-degree turns, which suggests that the pilot was attempting to maneuver around clouds or low visibility conditions. The airplane subsequently turned toward a nearby airport. The airplane's last recorded position revealed that it was about 900 feet above surrounding terrain in the area of the accident site. Weather conditions at the time included mountain obscuration and moderate turbulence for the area, which likely made it difficult for the pilot to maintain visual separation and the altitude necessary to remain clear of the surrounding terrain; while maneuvering, he subsequently lost airplane control. Impact damage to the airplane was indicative of a left-wing-down, near-vertical, low-speed impact with trees and terrain. A propeller strike to a large tree indicated that the engine was producing power at the time of impact. The wreckage was located 2 days after the accident, after search efforts were halted several times due to variable emergency locator transmitter position estimates and deteriorating weather conditions. First responders reported that the pilot was found beneath the airplane's wing with a sleeping bag under his torso. The pilot was dressed in multiple layers of clothes and survival gear. Food and water was found in the airplane but was not used. The pilot's cause of death was hypothermia due to the extreme winter conditions at the time of the accident; the pilot's injuries were not severe enough to be considered fatal. Postaccident examination of the airframe revealed that the pilot's shoulder harness failed during the accident. The stitched threading at the "Y" junction joining the shoulder strap webbing behind the pilot's head to the webbing leading to the fuselage connection had separated. The pilot's injuries suggest that he was using the three-point shoulder harness at the time of the accident and was exposed to strong deceleration forces. It is likely that if the pilot's shoulder harness had not separated, he would not have suffered the serious chest injuries and, therefore, would have been better able to use the survival gear and tactics needed to survive during the time it took for search and rescue to locate the wreckage. The investigation found that although the breaking strength of the webbing did not meet the requirements in effect at the time of the accident, it did meet the requirements in place at the time the supplemental type certificate for the seat restraint assembly was approved. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Source record

Factual narrative

HISTORY OF FLIGHT On March 3, 2013, about 1558 mountain standard time, a Cessna 172M, N5129R, impacted trees and snow covered mountainous terrain 11 nautical miles east northeast of Saratoga, Wyoming. The commercial pilot was fatally injured and the airplane sustained substantial damage. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91, as a cross-country flight. Visual meteorological conditions prevailed and a visual flight rules flight plan was filed. The flight originated from Bryce Canyon Airport (KBCE), Bryce Canyon, Utah, at 1225 with a destination of Laramie Regional Airport (KLAR), Laramie, Wyoming. A witness, east of Saratoga, saw an airplane fly overhead in an easterly direction near the time of the accident. She stated that the airplane wasn't visible until directly overhead through an opening in the low and broken clouds. She stated that it was about 500 feet above the ground. The sound of the engine was heard continuing east, and subsequently headed north as if it were to fly along the foothills of Pennock Mountain. She stated the foothills and Pennock Mountain were not visible because of the low clouds. According to the Federal Aviation Administration (FAA), the estimated time of arrival for the flight to KLAR was 1620, and it was considered overdue at 1650. When the VFR flight plan was not closed, an INREQ (information request) was issued by the Prescott Flight Service Station (FSS), followed thereafter by an ALNOT (alert notice) at 1719. Meanwhile, the Air Force Rescue Coordination Center (AFRCC) received an emergency locator transmitter (ELT) signal at 1558 and contacted the Casper FSS and the Carbon County Sheriff's Office in Rawlins, Wyoming. The local search and rescue were contacted about 1700. Search efforts were halted several times due to variable ELT position estimates and deteriorating weather conditions. The airplane was located about 1249 on March 5, by an Air Force helicopter crew who used the reported ELT position to visually locate the airplane. PERSONNEL INFORMATION A review of FAA airman records revealed that the 63-year-old-pilot held certificates for commercial and certified flight instructor with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He also held an airframe and powerplant mechanics certificate. His second-class medical certificate was issued June, 21, 2012, with the limitation that he must wear corrective lenses. An examination of the pilot's logbook indicated a total flight time in all airplanes of 3,415 hours. He logged 23 hours in the last 90 days. AIRCRAFT INFORMATION The Cessna 172M is a four-seat, single-engine, high-wing airplane. A review of the airplane's logbooks revealed the airplane had a total airframe time of 13,190 hours at the most recent 100-hour inspection on January 5, 2013. The Hobbs hour meter read 4,880.2 hours at the accident site. The engine was a Textron Lycoming O-320-E2D, serial number L-44988-27A. Total time recorded on the engine at the most recent 100-hour inspection was 11,977 hours, and time since major overhaul was 1,328 hours. METEOROLOGICAL INFORMATION An automated surface weather observation at Rawlins Municipal Airport/Harvey Field (KRWL), Rawlins, Wyoming (elevation 6,817 feet, 38 miles northwest of the accident site) was issued 5 minutes before the accident. It indicated wind from 250 degrees at 21 knots gusting to 28 knots, 10 miles or greater visibility, with a broken ceiling at 2,000 and 2,500 feet above ground level (agl), with an overcast ceiling at 8,000 feet agl, temperature at 3 degrees Celsius, dew point 0 degrees Celsius, and an altimeter setting at 29.79 inches of mercury. According to the weather brief that the pilot received during his preflight briefing, a low pressure system was depicted over the northeast section of Wyoming with a trough extending southeast. Station models over southern Wyoming depicted west-southwesterly winds, light rain and/or drizzle, and overcast clouds. No significant weather echoes were found over the region. At KLAR, winds were 17 to 19 knots gusting between 25 and 29 knots. Area Forecast charts revealed broken clouds, and westerly winds at 20 knots gusting to 30 knots over the southeastern region of Wyoming. Inflight weather advisories (AIRMET) were issued for mountain obscuration conditions and moderate turbulence for the area. The McIDAS satellite imagery showed low clouds over the area of the accident site with indications of mountain wave activity and other orographic clouds. AIRPORT INFORMATION According to data obtained by a personal GPS, the flight path vectored directly over Shively Field Airport (KSAA), near Saratoga, Wyoming at an altitude of 3,000 feet agl. The FAA Digital Airport/Facility Directory indicated that KSAA airport had an Automated Weather Observation System (ASOS), which broadcasts on frequency 118.175. During the postaccident examination, the ASOS frequency of 118.175 was observed in the airplane's communications radio when the unit was turned on. WRECKAGE AND IMPACT INFORMATION Examination of the accident site by the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) revealed the airplane impacted snow covered terrain and several medium sized trees that were about 5-6 inches in diameter. The airplane came to rest alongside tall trees on the east side of Pennock Mountain at an elevation of 8,570 feet, and oriented on a heading of 214 degrees magnetic. The first identified point of contact (FIPC) was a deep trough in the snow about 3 feet wide, 6 feet in length, and about 2 feet in depth. Three impacted trees were broken about 6 feet up from their bases, and were located within the 20 feet between the FIPC and the airplane's left wing tip. A section of tree, about 12 feet in length and about 5 inches in width, was severed cleanly in a diagonal linear pattern on one end, and was found on the right side of the fuselage, straddling the right horizontal stabilizer and vertical stabilizer. The diagonal linear pattern was about 18 inches in length. During the recovery process, another section of tree was found with a diagonal linear pattern similar in size. The airplane remained intact with only the separation of the left wing tip fairing. The left and right wings had leading edge impact damage, and the upper surface of the left wing had buckling near the root area. The right wing side strut was bent upwards at its mid-section. The fuselage was crushed rearward at the firewall, and buckling was observed aft of the baggage door and forward of the right horizontal stabilizer. The right horizontal stabilizer leading edge, vertical stabilizer, and rudder had impact damage. The engine and cowling assembly was pushed aft from their original position. The one visible propeller blade was bent aft near the tip. The windshield separated, and was found in several sections around the forward side of the airplane. The top side of the left door made contact with the lower side of the left wing, and was difficult to open. The pilot's control yoke separated from its control rod, and was found hanging on the exterior of the airplane from the communications cord. The left side of the instrument panel and center console was damaged and distorted. The emergency locator transmitter was found separated from its mount, and remained attached to the antenna connection. Fuel was removed from the left wing tank, and tested negative for water contamination. Due to the position of the right wing, fuel could not be removed from the right wing tank. According to first responders, the pilot was found beneath the airplane's wing near the left entry door. The left entry door was ajar and on scene evidence suggests that the pilot egressed out the broken windshield to the left side of the airplane. The pilot was dressed in multiple layers including

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