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NTSB investigation record

WPR14FA348

Completed

Cliff Starduster ii sa300· N411TM

Date
August 17, 2014
Location
Placerville, CA
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's failure to maintain control of the airplane during a go-around in gusting wind conditions following a partial loss of engine power for reasons that could not be determined, because postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. Contributing to the accident was the pilot's impairment due to his recent use of methamphetamine.

Investigator assessment

Analysis narrative

While on approach for landing, the private pilot initiated a go-around on short final due to gusty crosswind conditions. During the climbout, the pilot reported that the airplane experienced a partial loss of engine power. The airplane subsequently collided with terrain, seriously injuring the pilot and fatally injuring the passenger. Postaccident examination of the engine and airframe revealed no evidence of any preexisting mechanical anomalies that would have precluded normal operation. Blood samples from the pilot tested positive for methamphetamine and its active metabolite, amphetamine. The methamphetamine was found at high levels, indicative of abuse. It is likely that the pilot was impaired by the psychoactive effects of illicit methamphetamine use at the time of the accident, which impaired his ability to maintain control of the airplane during the go-around attempt.

Source record

Factual narrative

The Swansboro Country Airport (01CL), Placerville, California, is a privately owned, non-towered airport and it has one runway; designated 9/27, with a left traffic pattern. The runway is measured about 3,100 feet by 50 feet and the airport is at an elevation of 2,594 feet msl. The postaccident examination of the recovered wreckage was conducted on September 3, 2014, at the facilities of Plain Parts Enterprises, Pleasant Grove, California, by the NTSB IIC, and the FAA. The postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Airframe Examination Examination of the recovered airframe revealed that the forward fuselage was crushed and buckled. The engine and propeller assembly remained intact and was removed from the airframe prior to the examination by the recovery crew. The firewall was crushed rearward into the forward seat area. The engine support structure was bent and buckled. Numerous cuts were noted to the wing interplane struts and tension members. Both sides of the upper wing from outboard of the inboard interplane struts to the tip were bent downward. The lower wings were bent downward from the wing root to the tip. The main landing gear assembly was bent rearward along the fuselage. The main fuel tank located forward of the passenger seat separated from the main wreckage. The main tank was deformed with separations at the welds. Internal surface areas were visible. The main tank fuel cap was removed and the seal was undamaged. The auxiliary tank remained attached to the upper wing. The fuel cap was removed and the cap seal was undamaged. The auxiliary tank vent line was unobstructed. The lower side of the wing structure below the auxiliary tank was broken and detached on the right side. The tank was removed and crush damage was noted to the forward corners. Fuel staining was visible near the sending unit area. The fuel selector valve remained attached to the firewall and the control rod separated from the valve. The position of the valve was obtained by applying compressed air and was found in the "Main" position. The gasculator remained attached to the firewall and was undamaged. The gasculator bowl was found safety wired backwards. The gasculator bowl was removed and a small amount of fuel was noted. Water detection paste revealed no water. The gasculator screen was clear of debris. The rear seat instrument panel was crushed forward and all instruments remained intact. The tachometer displayed 0 rpm and 790.32 hours. The manifold pressure read at 30 in-hg and fuel flow at 0. The altimeter read 680 feet and the Kollsman window was set to 30.12. Control cable continuity was established from the cabin area to the engine control levers through several cuts by first responders and by recovery efforts. All cables had impact damage between the firewall and engine. The throttle, mixture and propeller control levers were found in the full forward position. The tail section was removed from the fuselage during the recovery efforts at the accident site. The tail section was undamaged. Engine Examination The engine was fracture-separated from the engine mount assembly. During recovery efforts the engine was separated from the main wreckage by cutting various tubes, lines and cables. The propeller governor separated from the accessory section and remained attached to the engine by oil lines. The propeller governor mounting flange and a portion of the drive coupling remained attached to the engine. The magnetos were undamaged and remained attached to the engine. The ignition leads had impact damage and several separations. The upper spark plug attachments at both number three and four cylinders separated from the sparkplugs. The shell section of the number three and four spark plugs was missing. The engine driven fuel pump had impact damage and remained attached to fuel lines. The fuel pump lever arm and mounting flange remained attached to the engine. The fuel pump was disassembled and no anomalies were noted. The alternator and mounting assembly had impact damage. The oil cooler and starter had impact damage and was removed from the engine to facilitate the rotation of the crankshaft. The upper sparkplugs were removed and had (Worn Out-Normal) wear conditions when compared to the Champion AV-27 chart. The upper sparkplug electrode areas had light grey deposits. The crankshaft was rotated by hand and all cylinder compression and valve continuity was obtained. The number four cylinder exhaust and the number one inlet pushrods and housings had impact damage and the associated rocker arms did not move during the crankshaft rotation. Gear continuity was established from the crankshaft to the accessory section. The magneto impulse coupling engaged during crankshaft rotation but no spark from the leads was noted. The magnetos were removed and the drive shafts were rotated with the use of an electric drill and spark was obtained from the damaged ignition leads. The fuel injection servo inlet screen was removed and fuel was present during its removal. The injector brass plug was tight and safetied and the diaphragm stem was intact. The flow divider was undamaged and disassembled. The diaphragm, spring and valve were undamaged and showed normal operating signatures. No fuel was noted in the fuel inlet line to the flow divider or in the valve assembly. The propeller assembly remained attached to the engine and had impact damage to both blades. The blade marked "A" had a slight aft bend from near the hub to the tip. The blade had leading edge gouging near the tip and the cambered side had cord-wise scratches. The blade marked "B" had aft bending and a decreased pitch twist at its mid-section to the tip and chord-wise scratches near the tip. The spinner dome was crushed and was torn near both blade hubs. The pilot reported that 7 flight hours prior to the accident, during climbout at full throttle, he experienced a sudden loss of power for about two seconds. After he had the airplane examined, there was no cause found that would have resulted in the power loss. Following the accident, the FAA asked the pilot to report on his injuries and then initiated an enforcement action against him. The pilot surrendered his medical certificate and his airman certificate to the FAA in December, 2014, announcing his intention never to fly again. According to the FAA files, the pilot received his first aviation medical certificate in 1989 (records from this exam are not available) and then applied for a medical certificate again in 2009. At that time, he reported an appendectomy and a driving under the influence (DUI) conviction in 1988; he continued to report these events and surgery for a thumb injury thereafter but never reported any chronic medical conditions or medication use to the FAA. The pilot was transported to Sutter Roseville Medical Center for treatment of his injuries. Records from the pilot's hospitalization following the accident were reviewed. The pilot reported hypertension and regular use of a beta blocker to treat it to his treating physicians. He denied using illicit drugs. Although urine testing for drugs of abuse was ordered, no specimen was received in the hospital laboratory and the order was therefore canceled. A blood sample from the pilot while undergoing treatment was obtained by the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) and subsequently sent to the FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma. CAMI performed toxicology tests on the sample provided. According to CAMI's report, carbon monoxide and cyanide were not tested due to insufficient sample for analysis. Volatiles and drugs were tested, and had positive results for 0.027 (ug/ml, ug/g) amphetamine, 0.233 (ug/ml, ug/g) methamphetamine, and unspecified level of Atenolol was also detected. The

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