Pilot Debrief

CESSNA 152 near Concord, CA — 2018-01-29

Final reportWPR18FA075
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Date
2018-01-29
Location
Concord, CA, USA
Aircraft
CESSNA 152
Registration
N93316
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

A loss of control for reasons that could not be determined based on the available information.

NTSB narrative

The airline transport pilot departed on a personal flight in day visual flight rules conditions; a few minutes after takeoff, the airplane impacted terrain about 3.5 miles from the departure airport. The pilot's communications with the departure airport tower controller were routine; there were no witnesses and no radar information correlated to the accident. The airplane damage and ground scars at the accident site were consistent with a steep nose-down attitude at the time of impact. The airplane's right rudder cable was found separated; signatures of rubbing were found at the bulkhead passthrough. The left rudder cable remained attached, but also exhibited fraying consistent with rubbing at its aft bulkhead passthrough. It could not be determined if the cable separated in-flight or during the accident sequence. The airplane's maintenance logbooks were not located, therefore, the maintenance and inspection history of the rudder cables could not be determined. Toxicology of the pilot identified an antidepressant medication and its metabolite, as well as a sedating antihistamine and blood pressure and cholesterol medications. Autopsy identified severe coronary artery disease with history of an old heart attack and recurrent ischemic events, but no recent ischemic events. The pilot had a history of high blood pressure, elevated cholesterol, and coronary artery disease. The pilot had completed the BasicMed online course and reported that he met the requirements of the comprehensive medical examination; however, the physician listed as having conducted the exam had no patient records of a visit on or around the time the pilot reported that the exam occurred. Additionally, the pilot's personal health records documented multiple healthcare visits for anxiety. Six days before the accident, the pilot was treated in an emergency room for an exacerbation of anxiety. The pilot was determined to have marginal impulse control, insight, and judgment. During a follow-up examination 4 days before the accident, the pilot denied passive death wishes or suicidal ideations and there was no evidence of paranoia or delusions; however, the pilot described his mood as "just a mess" and was assessed as "rather anxious." It is likely that the pilot's progressively worsening anxiety degraded his insight, judgment, and cognitive function, thereby impairing his ability to safely fly the airplane. However, it could not be determined what role the anxiety ultimately played in the airplane loss of control. Although the pilot did not complain of any cardiac symptoms during his healthcare visits in the days before the accident, this does not exclude the possibility that the pilot may have experienced cardiovascular symptoms around the time of the accident, and an acute cardiac event is unlikely to leave any identifiable evidence on autopsy. Based on the available information, the reason for the loss of control and impact with terrain could not be determined; additionally, the extent to which the separated right rudder cable may have contributed to or impeded recovery from a loss of control could not be determined.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have opted for a thorough medical check before flying.

NTSB coding

Evidence available

  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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