Like A Tractor

The owner/pilot of a Cessna 175 dies after his airplane crashes into a rocky ledge. The NTSB focused on maintenance, but was that a red herring?

On the morning of a late fall day in 2000, a Utah rancher took up two passengers in his Cessna 175 to search for stray cattle. It was part of the fall roundup, an "annual event looked upon with anticipation by many." After spotting a few head, they flew toward a bluff where several cowboys on horseback waited. The plan was for the pilot to drop them a scribbled note describing the locations of the strays they had seen. The engine was "running fine," according to a passenger, but as the airplane approached the bluff, it seemingly encountered a downdraft. The pilot banked hard to the right to avoid the terrain, but the airplane encountered another downdraft, sank again and struck a rocky slope.

One of the cowboys rode away to summon help, while the others rode to the airplane. They extricated the occupants. Despite multiple cuts, bruises, broken bones and other injuries, all were conscious and could sit up and talk. A medevac helicopter reached the scene, after a flight of more than an hour, about two hours after the crash occurred. It took another three-quarters of an hour to get the injured into the helicopter, and almost another hour to return. By the time they reached the hospital, the 55-year-old pilot had died.

The airplane was a 1958 Cessna 175, a version of the 172 originally equipped with a 175-hp geared Continental 0-300 engine and a fixed-pitch prop. It had been re-engined, under an STC, with a Lycoming O-360 and fitted with a Hartzell constant-speed propeller. The airframe had 2,842 hours when the engine change was made in 1976. The rancher had bought the airplane in 1989, but didn't get around to having an annual inspection done until four years later. At that point, the new engine had 1,488 hours, and the airframe 4,330. The airplane soldiered on another two years and 300 hours before its next annual, in 1995, which was also to be its last. In 1997, a mechanic signed it off for a "one time ferry flight...for the purpose of maintenance." There is no evidence that any airframe maintenance was performed, but the engine was removed and overhauled. It had 1,883 hours at the time. Between then and the accident three-and-a-half years later, there were no entries in the engine logbook.

The previous owner of the airplane told investigators that the rancher operated the Cessna on auto fuel, which he kept in a tank on his ranch, and treated it "like it was one of his tractors." Indeed, the yellowish liquid found in the fuel tanks of the wreck did appear to be auto fuel, which is not approved for use in the O-360 because it is a high-compression engine. The engine may have been protected from detonation by the high altitude at which the airplane operated. Investigators found the oil in the engine to be "thick and black, consistent with contaminants and extremely long service."

One can't help admiring the prelapsarian optimism of a pilot who treats his airplane "like a tractor," going years without inspections or, to judge from the inspissated substance in the engine sump, even oil changes. It says something for the fundamental soundness of this old Cessna and its engine that the fatal crash was, to all appearances, unrelated to their neglected condition. It says something, too, about the bias of the FAA employees who are delegated by the NTSB to investigate accidents like this one-small airplane, few fatalities, non-famous victims-that the NTSB report on the crash lays so much emphasis on the airplane's maintenance history, or lack of one. This information would be more pertinent if the engine had quit, the propeller had shed a blade, or the airplane had caught fire in flight. Its inclusion here seems to be intended merely to paint the pilot as a scofflaw and a generally reckless fellow.

The pharmacological information is possibly more relevant, even though it is seldom possible to prove a direct link between an accident of this sort and the contents of the deceased pilot's circulatory system and bladder. He had a history of two drunk-driving arrests, the first in 1995, the second in 1999. He ceased obtaining FAA medicals after the 1995 arrest, but reported 5,000 hours on his last application. He was subsequently cited by the FAA for falsifying a medical application (it's not clear what they thought he had falsified) and for failing to report his DUI arrest to the FAA within 60 days, as required by FAR 61.15(e). His pilot's license was suspended for 30 days. Apparently there was no FAA enforcement action after his second drunk-driving arrest, which had led to a year-long suspension of his driving license. His personal logbook, if he kept one, was never located.

The autopsy performed at a local hospital found fragments of two unidentified pills in the pilot's stomach as well as alcohol and barbiturates in his urine. Fluid samples sent to the FAA's medical examiner in Oklahoma City yielded a more detailed catalog, including ethanol (a byproduct of ingested alcohol but also of tissue decomposition), butalbital (a headache remedy), chlorpheniramine (an anti-allergenic), phenylpropanolamine (a cough medicine which, purely coincidentally, was withdrawn from use by the FDA shortly after this accident because it was thought to increase the likelihood of strokes), acetaminophen (a pain killer and fever reducer), and quinine (an erstwhile malaria treatment and, nowadays, a component of tonic water).

The probable cause of the crash, according to the NTSB, was "the pilot's failure to maintain control of the airplane while maneuvering at low altitude, and his physical impairment due to alcohol and drugs. A contributing factor was the downdraft."

Like many NTSB statements of probable cause, this one begins with a restatement of the event itself. It is not clear, however, exactly when the failure to maintain control is supposed to have occurred. The pilot was not actually maneuvering-he was flying straight toward the bluff-until the downdraft put him into a position where, if he continued straight ahead, he would fly into the bluff rather than over it. At this point the pilot banked steeply, as anyone would. The flaps were set at 10 degrees, and the pilot was getting ready to drop something out the window; we may infer from both of these circumstances that the airplane was not traveling extremely fast. If the NTSB thinks the airplane stalled, it isn't saying so; but the phrase "failure to maintain control" suggests something other than an apparently intentional steep turn.

The account (presumably by the passengers) of two separate downdrafts suggests a common situation in which wind blowing over a bluff or ridge tumbles downward on the lee side. This interpretation is consistent with the fact that the airplane was evidently quite close to the bluff-too close to turn aside-when the encounter occurred. Unfortunately, the NTSB report says nothing about the meteorological conditions other than that they were "visual." Perhaps we can infer from the fact that the rescue helicopter took an hour and 10 minutes to reach the accident site, and only 52 minutes to return, that a strong wind was blowing; but other reasons, such as difficulty in locating the wreckage, could also account for the difference.

The mention of "physical impairment due to alcohol and drugs" seems to be based on nothing other than the fact that the pilot had alcohol and drugs in his system. There is no mention, however, of the passengers or medics commenting, say, that the pilot smelled like a gin and tonic, or of his friends' being reluctant to fly with him that day because he seemed impaired.

The downdraft, which looks as much like a "cause" of the accident as anything else does, is demoted to the status of a mere "contributing factor." There is a tendency in NTSB accident reports to seek a perspective upon the events that makes the pilot, rather than blind chance or some unkind trick of nature, the responsible party. The motivation behind this tendency is logical enough, I think: since we cannot control nature or blind chance, our responsibility is to put ourselves out of their reach, and if we fail to do so, the fault is ours, not theirs.

In this case, the stage was set for the accident when the pilot elected to fly toward the ridge at low altitude and possibly against the wind. He must have known that if he had flown along the bluff, rather than across it, he could have protected himself better against the dangers of the wind. Perhaps because one of his passengers, a 70-year-old woman, was flying with him for the first time, he was tempted to provide her with the more thrilling view of the approaching bluff. Given, however, that he was a very experienced pilot flying his own airplane in familiar terrain, and that he could hardly have been unaware that downdrafts are often found along ridges and bluffs, it seems fair to say that whatever impairment he may have suffered from alcohol and drugs could have affected his judgment at least as much as his physical abilities. He judged unnecessary a precaution that would, as it turned out, have saved his life.

Such errors of judgment are easy to identify in hindsight. Recently two airplanes crashed, under control, into rugged terrain northwest of Los Angeles because they could neither turn nor climb out of a narrow canyon into which the pilots had flown for fun. The official analysis of the accidents will not be available for a long time, but there has been no suggestion that alcohol or drugs were involved in any way at all. It seems to have been a simple misjudgment; and it is possible that the 175 accident was as well.

This article is based solely on the National Transportation Safety Board's report of the accident and is intended to bring the issues raised to the attention of our readers. It is not intended to judge or to reach any definitive conclusions about the ability or capacity of any person, living or dead, or any aircraft or accessory.