Pilot Debrief

CESSNA 337 near Sylmar, CA — 2022-04-20

Final reportWPR22FA160
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Date
2022-04-20
Location
Sylmar, CA, USA
Airport
WHP
Aircraft
CESSNA 337
Registration
N143JB
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Initial climb

Probable cause

The pilot’s loss of airplane control while troubleshooting a landing gear issue, which resulted in an aerodynamic stall/spin at an altitude too low to recover. Contributing to the accident was the pilot’s impairment from alcohol consumption.

Contributing factors

Contributing to the accident was the pilot’s impairment from alcohol consumption.

NTSB narrative

Shortly after takeoff, the pilot reported to the tower controller that he was not able to retract the airplane’s landing gear and requested to circle the airport at 2,500 ft. The airplane climbed to and remained at about 2,000 ft for about 2 minutes before entering a descent that continued until ground contact. Witnesses saw the airplane descending in a steep, nose-down attitude, and a surveillance video showed the airplane rotating in a nose-down attitude as it collided with terrain. Examination of the airframe and engines revealed no preaccident mechanical malfunctions or failures that would have precluded normal operation. Toxicology testing of the pilot revealed 65 (mg/dL, mg/hg) ethanol in blood, 133 (mg/dL, mg/hg) ethanol in urine, and 10 (mg/dL, mg/hg) glucose in vitreous fluid. The ethanol production was not attributed to putrefaction. Based on the levels found and their distribution, it is likely that the pilot’s blood ethanol concentrations were around 0.12 gm/dL. It is likely that, while trying to troubleshoot the landing gear issue, the pilot allowed the airplane to slow and exceed its critical angle of attack. The airplane subsequently entered a spin from which the pilot was not able to recover. Given the levels of ethanol found in toxicology testing, the pilot would have likely experienced degradation of judgment, reasoning, and coordination that would have affected his ability to safely manage the airplane, and it is likely that his impairment due to alcohol consumption contributed to his loss of control.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted the flight after landing gear issue instead of continuing.

NTSB coding

Evidence available

  • Video
  • ADS-B / radar
  • 17 docket documents
View NTSB final reportView NTSB docket

Docket documents17

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