WPR22FA022

A power interruption due to water-contaminated fuel, which resulted in the student pilot aborting the takeoff and landing hard. Contributing to the accident were a leak in the left fuel tank that allowed water to enter and damage to the fuel tank that prevented water from being properly drained during the preflight inspection.

The student pilot was making his second solo cross-country flight. The pilot used an onboard camera to record the ground run, takeoff, and initial cruise segments of the flight and then turned it off. The recordings showed those portions of the flight were uneventful, but he was heard talking to himself about dropping a pen and a pencil. The pilot turned the camera back on as he approached the destination airport, which was moderately busy with multiple aircraft in the traffic pattern. During the approach, the pilot’s performance of the pre-landing checklist was interrupted due to a close encounter with a bird, and he did not complete the step of checking that his seatbelt was fastened. During the landing flare, the pilot transmitted on the local frequency his intention to perform a go-around. The airplane began to climb and reached about 60 ft above ground level (agl) when a change in the stroboscopic effect of the propeller was recorded, which likely indicated an engine speed change. The airplane leveled off, and the pilot said, “whoa, whoa, whoa,” before the recording ended. Airport security video footage revealed that after reaching midfield, the airplane pitched down and struck the ground in a nose-low attitude, collapsing the nose gear. Thereafter, the propeller struck the ground, and the airplane continued under power for an additional 700 ft until it nosed over in a grass area and came to rest inverted. Sound spectrum analysis of the security video revealed that the engine was operating throughout the video and continued to operate after impact. The airplane’s cabin sustained minimal damage during the accident sequence; however, the pilot, who was not restrained by a seat belt, was partially ejected through the windshield and sustained fatal injuries. The pilot was likely incapacitated from the initial impact and therefore unable to reduce engine power after the nose gear collapsed. During the week before the accident, the airplane was stored outside during heavy rain. Postaccident examination revealed water in the left tank and the gascolator, although both the accident pilot and the pilot who flew the airplane earlier in the day followed the correct procedure for draining contaminants. Examination of the left fuel tank revealed that a longstanding leak in the left fuel tank filler neck assembly had allowed water into the tank. Pre-accident internal damage and buckling of the tank’s lower skin appeared to have trapped water and prevented it from reaching the drain port. It is likely that this water moved and entered the engine’s fuel supply system as the pilot maneuvered the airplane in the traffic pattern. The change in the stroboscopic effect of the propeller observed shortly after the pilot began the go-around was consistent with a power interruption due to water entering the engine. With sufficient runway remaining, the pilot likely decided to abort the go-around and land. The airplane manufacturer had issued a service bulletin that recommended the installation of additional drains in the fuel tanks. If installed, these drains may have revealed the water; however, the additional drains had not been installed, nor was this required per Federal Aviation Administration (FAA) regulations. The engine did not experience a total loss of power at any point during the video-recorded portions of the flight. Examination revealed that the cam lobes of the engine exhibited excessive wear; however, such damage is progressive in nature and typically occurs over an extended period. The wear would have resulted in a gradual reduction in engine performance over that time, rather than an immediate or intermittent power loss. According to the pilot’s flight instructor and his spouse, the pilot was a strong advocate of seatbelt usage. Although the reason for his failure to wear a seatbelt could not be determined, it is possible that when he dropped his writing implements during the flight, he released his seat belt to recover them and failed to resecure it. When his pre-landing checklist was interrupted due to the proximity of a bird, he became preoccupied by the busy airport environment and did not finish the checklist. Autopsy results indicated that the pilot had severe coronary artery disease; however, based on available medical and operational evidence, it is unlikely that the heart disease contributed to the accident. Although toxicology samples revealed codeine and morphine in the pilot’s urine, there was no detectable codeine or morphine in his blood, and it is unlikely that effects of those substances contributed to the accident.

Bennet Omalu Pathology performed the pilot’s autopsy at the request of the Mendocino County Sheriff-Coroner. The cause of death was head and face injury. According to the autopsy report, the pilot had heart disease and identified plaque causing a 90-95% narrowing of the proximal portion of the left anterior descending coronary artery. No other significant natural disease was identified. Central Valley Toxicology, Inc., performed toxicological testing of blood and vitreous specimens from the pilot at the request of Bennet Omalu Pathology. No tested-for substances were detected. The FAA Forensic Sciences Laboratory also performed toxicological testing of specimens from the pilot, detecting codeine in urine at 47 ng/mL and morphine in urine at 90 ng/mL. Neither codeine nor morphine was detected in heart blood. Codeine and morphine are opioid substances that may be medicinal, illicit, or associated with poppy seed consumption. Morphine is a metabolite of codeine. Both codeine and morphine have potential to cause cognitive and psychomotor impairment. Medicinally, codeine and morphine are available by prescription to treat pain, cough, and diarrhea. An open prescription for codeine or morphine is generally disqualifying for FAA medical certification, although certification may be granted by FAA decision in certain cases of infrequent use for acceptable medical conditions. Regardless, the FAA states that a pilot should not fly after using either medication until adequate time has elapsed for it to be eliminated from the pilot’s system. Both codeine and morphine may be used illicitly, and both are metabolites of the illicit opioid drug heroin. Also, because codeine and morphine occur naturally in the poppy plant, both might be detected in the urine of a person who has consumed poppy seeds. The pilot’s wife stated that she was not aware of her husband ever using prescription pain medication and that he had eaten a bagel with poppy seeds during the days leading up to the accident. The airplane was owned and operated by Mike Smith Aviation, a Part 61 flight school. The owner of the flight school performed most of the airplane’s maintenance, including the annual and 100-hour inspections. The pilot started his flight training in July 2021, about 3 months before the accident. He had accrued a total of 31.3 flight hours, all of which were in the same make and model as the accident airplane. The accident flight was the pilot’s fifth solo flight and his second solo cross-country flight. On October 28, 2021, at 1311, a Cessna 172M, N1870V, was substantially damaged when it was involved in an accident in Ukiah, California. The student pilot, the sole occupant, was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.   The pilot was making a solo cross-country flight as part of his requirements in pursuit of a private pilot's license and had planned for a full stop landing at Ukiah Municipal Airport. According to FAA automatic dependent surveillance–broadcast (ADS-B) data, the airplane departed Napa County Airport at 1219 and flew a direct course to Ukiah, arriving in the traffic pattern from the southeast at 1308. About that time, a witness, who was located near the north end of Runway 15 on the west side of the airport, noticed the airplane “porpoising” at the approach (north) end of Runway 15. He watched as the pilot initiated a go-around, and the airplane climbed with the flaps deployed. He did not think much more of it and looked away. A security camera located about midfield on the west side of the runway captured the airplane during the initial climb phase of the go-around. The video revealed that the airplane climbed to about 60 ft agl and then assumed a level attitude, while still tracking over the runway. After reaching midfield, the airplane pitched down and descended toward the runway. The airplane’s nose struck the ground, separating the nosewheel, and the airplane continued to travel along the runway, until it passed out of the camera’s field of view behind a building. The engine could be heard operating throughout, and the airplane was not trailing smoke or vapors at any time during the video (figure 1). Figure 1 - Composite image of flight path from security video – Runway 15, left to right A witness located on the east side of the airport did not initially see the airplane but saw a cloud of dust appear at the end of Runway 15. He then watched as the tail of the airplane lifted up into view as it pitched down on its nose and rolled over onto its roof. The airplane came to rest inverted on a grass verge adjacent to a diagonal taxiway on the right side of runway 15. Damage to the airframe was limited to the vertical stabilizer, rudder, leading edge tip of the left wing, and the windshield, which had shattered. The propeller exhibited evidence of runway contact including tip curl and multi-directional gouges and scratches. Examination of the runway surface revealed a tire skid mark and gouge on the centerline about two thirds of the way down the 4,423-ft-long runway. The gouge matched the shape of the nose wheel rim and fork, which had detached and was recovered 350 ft downrange from the gouge. From the initial gouge, a scrape mark, along with 20 slash marks that matched the propeller blade tips continued 700 ft, progressively moving to the right of the runway centerline, and ending at the main wreckage (figure 2). Figure 2 - Airplane flight track (red), ground track (blue). Runway damage, and airplane at accident location. Following the accident, 1 ounce of water was drained from the gascolator, and 3 ounces of water were drained from the fuel tank drain in the left wing. The complete contents of both fuel tanks were then drained, and an additional 3 ounces of water were found in the left tank. The flaps were in the retracted position: the elevator trim was set for takeoff: and the carburetor heat control and corresponding air door were in the off positions. Examination of the airframe and engine revealed a series of maintenance discrepancies. These included seat rails worn beyond serviceable limits; an inoperative throttle friction lock; engine camshaft-lobe wear with accompanying metallic debris in the engine oil screen; and degraded and worn spark plug ignition cables and P-lead wires. Fuel Tanks Examination of the left tank revealed a leak had developed around the left fuel tank filler neck adapter assembly. The outboard tank strap had snapped, and there was extensive brown staining trailing aft of the fuel filler cap. The gasket that sealed the filler neck adapter to the tank had degraded and was no longer providing a seal. Silicon sealant was present in multiple areas inside the top wing skin consistent with an attempted leak repair. The forward tank support pads had worn away, such that the lower wing skin stringer rivets were in direct contact with the tank. This contact had resulted in fretting damage to the underside of the tank. There was a buckle in the lower tank skin that had resulted in a 3/16-inch-deep, 2 1/2-inch-long, and 3-inch-wide raised area just forward of the fuel supply screen (figure 3). The buckled area inside the tank had a pronounced fold that was discolored in a manner consistent with corrosion. A fuel level dipstick was found moving free within the left tank, and a fuel cap chain was found in the right tank. Figure 3 – Inboard side of left fuel tank. Cessna Single Engine Service Bulletin SEB 92-26, revision 1, provided a modification for installing additional fuel drains in the wing fuel tanks. The modification was designed to assist in the detection and removal of water or other contaminants in the wing fuel tanks. Although Cessna stated that compliance was mandatory, FAA regulations do not require adherence to service bulletins for Part 91 operations, and the bulletin had n