ASN Wikibase Occurrence # 122817
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Date: | Saturday 28 May 2011 |
Time: | 20:44 |
Type: | Rockwell Commander 112 |
Owner/operator: | Private |
Registration: | N1041J |
MSN: | 41 |
Year of manufacture: | 1973 |
Total airframe hrs: | 2937 hours |
Engine model: | Lycoming IO 360-C1D6 |
Fatalities: | Fatalities: 2 / Occupants: 2 |
Aircraft damage: | Substantial |
Category: | Accident |
Location: | Bryan, Texas -
United States of America
|
Phase: | Approach |
Nature: | Private |
Departure airport: | Fort Worth, TX (FWS) |
Destination airport: | Galveston, TX (GLS) |
Investigating agency: | NTSB |
Confidence Rating: | Accident investigation report completed and information captured |
Narrative:A review of the pilot’s logbooks revealed that he had flown two flights in the airplane several days before the accident flight for a total of 2.8 flight hours. The airplane was not refueled after those flights. About 1.4 hours after takeoff on the accident flight, the pilot reported that he was “running out of fuel,” and the airplane subsequently started descending. A witness reported seeing the airplane at a low altitude and then suddenly turn and depart controlled flight, indicating than an aerodynamic stall had occurred. The airplane impacted terrain in the parking lot of an apartment complex in a congested urban area. Engine data monitor information for the accident flight showed that, for most of the flight, the airplane had an average fuel flow of about 14.7 gallons per hour. The airplane had a total useful fuel capacity of 62 gallons. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. It is likely that the pilot improperly planned how much fuel he would need for the accident flight and that the airplane ran out of fuel, which resulted in a loss of engine power due to fuel exhaustion.
The pilot's medical records revealed a diagnosis of major depression, and toxicology testing found medications in the pilot’s body consistent with the treatment of this condition. The pilot’s depression had been documented and treated since 1989, but the treatment and medications were inadequately reported to the Federal Aviation Administration on the pilot's recent airman medical applications and would have disqualified him from obtaining an airman's medical certificate. The pilot's depression and the medications he was taking would have significantly degraded his cognitive abilities, including executive functioning and judgment, and likely led to his failure to recognize the fuel shortage earlier and his improper decision to fly with disqualifying medical conditions.
Probable Cause: The pilot's inadequate fuel planning, which resulted in a loss of engine power due to fuel exhaustion, and his improper control inputs following the loss of engine power, which resulted in an aerodynamic stall and subsequent loss of control. Contributing to the accident was the pilot's impaired judgment, which led to his failure to recognize the fuel shortage earlier and his improper decision to fly with disqualifying medical conditions.
Accident investigation:
|
| |
Investigating agency: | NTSB |
Report number: | CEN11FA358 |
Status: | Investigation completed |
Duration: | 2 years and 9 months |
Download report: | Final report |
|
Sources:
NTSB
Location
Revision history:
Date/time | Contributor | Updates |
29-May-2011 03:07 |
gerard57 |
Added |
29-May-2011 05:07 |
gerard57 |
Updated [Destination airport, Source, Narrative] |
29-May-2011 05:22 |
RobertMB |
Updated [Aircraft type, Registration, Cn, Operator, Other fatalities, Location, Phase, Departure airport, Destination airport, Source, Narrative] |
29-May-2011 11:15 |
gerard57 |
Updated [Source, Narrative] |
29-May-2011 15:20 |
Taddahh |
Updated [Location] |
07-Jun-2011 11:02 |
Anon. |
Updated [Location, Narrative] |
17-Jun-2011 12:21 |
RobertMB |
Updated [Location, Departure airport, Narrative] |
28-May-2012 20:33 |
Geno |
Updated [Time, Aircraft type, Location, Destination airport, Source, Narrative] |
21-Dec-2016 19:25 |
ASN Update Bot |
Updated [Time, Damage, Category, Investigating agency] |
27-Nov-2017 16:54 |
ASN Update Bot |
Updated [Other fatalities, Departure airport, Destination airport, Source, Narrative] |
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