Loss of control Accident Cessna 172L N4380Q,
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ASN Wikibase Occurrence # 22919
 
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Date:Friday 19 September 2008
Time:16:00
Type:Silhouette image of generic C172 model; specific model in this crash may look slightly different    
Cessna 172L
Owner/operator:York Aviation, Inc.
Registration: N4380Q
MSN: 17260280
Year of manufacture:1971
Total airframe hrs:3945 hours
Engine model:Lycoming O-320
Fatalities:Fatalities: 2 / Occupants: 2
Aircraft damage: Substantial
Category:Accident
Location:York Municipal Airport (JYR), NE -   United States of America
Phase: Initial climb
Nature:Training
Departure airport:York, NE (JYR)
Destination airport:
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The flight instructor and student pilot were planning to do touch-and-go landings. A witness reported that the airplane took off on Runway 17, climbed about 100 feet, and then nosed down. The weather was clear and the wind was nearly straight down the runway. The flight instructor had logged nearly 3,000 hours of total flight time, with over 600 hours instruction and over 600 hours in the Cessna 172. Examination of the aircraft revealed no evidence of a preimpact mechanical malfunction. The flight instructor had a long history of diabetes, and had recently started a new injectable medication (exenatide, 10 micrograms twice a day) to help control his blood sugar. This medication can result in impairment due to low blood sugar, but he had not reported any adverse effects, and he was observed to be behaving normally the day prior to and the day of the accident. He was at extremely high risk of obstructive sleep apnea given his height (70 inches), weight (285 pounds), and poorly controlled blood pressure. Obstructive sleep apnea often results in impairment, but he was apparently not observed to snore while sleeping, a hallmark of the condition. Autopsy revealed an enlarged heart (it weighed 500 grams), but it was not thickened, suggesting an apparently unrecognized heart condition, dilated cardiomyopathy, that can result in sudden incapacitation. Given the failure of this experienced instructor pilot to either execute a normal climbout or appropriately oversee the climbout by his novice student, it is possible that he was incapacitated by a cardiac event. It is also possible, though less likely, that he was impaired either by unrecognized low blood sugar as a result of his new diabetes medication or by fatigue from unrecognized obstructive sleep apnea. However, the investigation could not conclusively determine if the instructor was impaired at the time of the accident.
Probable Cause: The student pilot's failure to maintain aircraft control, and the flight instructor's failure to take remedial action, for undetermined reasons.

Accident investigation:
cover
  
Investigating agency: NTSB
Report number: DEN08FA155
Status: Investigation completed
Duration: 11 months
Download report: Final report

Sources:

NTSB

Location

Images:


(c) NTSB

Revision history:

Date/timeContributorUpdates
31-Jul-2009 12:31 harro Updated
21-Dec-2016 19:14 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
21-Dec-2016 19:16 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
21-Dec-2016 19:20 ASN Update Bot Updated [Time, Damage, Category, Investigating agency]
03-Dec-2017 12:06 ASN Update Bot Updated [Operator, Other fatalities, Departure airport, Source, Narrative]

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