N4139XAero Commander 100 · 1968

On November 8, 2009, about 1840 eastern standard time, an Aero Commander 100, N4139X, registered to a private individual, crashed into the Everglades north of Interstate 75 (I-75), near Weston, Florida. Visual meteorological conditions prevailed in the area at the time and a visual flight rules (VFR) flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from Kendall-Tamiami Executive Airport (TMB), Miami, Florida, to Robins Air Force Base (WRB), Warner Robins, Georgia. The airplane sustained substantial damage and the certificated private pilot, the sole occupant was killed. The flight originated from TMB about 1818.

The VFR flight plan indicated the estimated time en route was 5 hours, with an estimated time of arrival of 2320. The flight was to be flown at 4,500 feet mean sea level (msl), with a planned fuel stop at Ocala International Airport-Jim Taylor Field (OCF), Ocala, Florida.

A witness at TMB reported observing two male individuals wearing military uniforms performing what the witness thought to be a preflight inspection of the accident airplane. The witness also reported that the accident airplane was fueled after his airplane was fueled. The witness did not observe the airplane taxi out or depart.

According to a transcription of communications with TMB air traffic control tower, the flight was cleared for takeoff at 1818:22, with a left turn approved; the pilot acknowledged this communication and there were no further recorded communications with the TMB ATCT. At 1829:01, or approximately 11 minutes before the accident, the pilot established contact with the Lockheed Martin Miami automated international flight service station (Lockheed Martin AIFSS) and remained in contact with that facility until his last transmission began at 1831:44. While in contact with that facility, the pilot requested activation of his VFR flight plan, and the briefing specialist advised the pilot of weather information and flight restrictions. Following the pilot’s last transmission, there was no further recorded contact with the Lockheed Martin AIFSS). Additionally, there was no record of any contact with Miami Approach Control.

According to a NTSB Radar Ground Track, an uncorrelated radar return about 2 minutes 24 seconds after the flight was cleared for takeoff from 9L was noted approximately 0.78 nautical mile and 038 degrees from the departure end of runway 9L. The radar targets of the uncorrelated radar data track continue in a northerly direction and depict the aircraft climbing to an altitude of 2,800 feet pressure altitude, and remaining at that altitude between 1838:26, and 1839:08. The uncorrelated radar data indicates the airplane began descending, with the last radar return of 1,000 feet pressure altitude located at 18:40:27. The target at that time was located at 26 degrees 08.833 minutes North latitude and 080 degrees 43.266 minutes West longitude.

Several witnesses reported seeing the airplane flying in a northerly direction while descending. One witness reported seeing external lights from the airplane as it passed in front of their car. No witnesses reported seeing smoke or fire trail the airplane while descending. Numerous witnesses called 911 to report the accident.

A search for the wreckage by law enforcement and fire rescue assets from the Broward Sheriff’s Office, and assets from the Florida Fish and Wildlife Conservation Commission (FWC) began immediately following the 911 phone calls. The wreckage was first spotted by the Broward Sheriff’s Office helicopter at 1916.

The airplane crashed at night in an area where the only nearby ground reference lights were from vehicles traveling on I-75, and lights from a rest stop located several miles east of the crash site. The crash site was located at 26 degrees 09.119 minutes North latitude and 080 degrees 43.204 minutes West longitude, or approximately 11 degrees and 0.29 nautical mile from the last non-correlated radar return.

The pilot, age 49, held a private pilot certificate with airplane single engine land rating first issued on December 15, 1995, and held a special issuance third class medical certificate issued on February 21, 2008, which was not valid for any class after November 30, 2008. Additionally, on October 14, 2008, the FAA Aerospace Medical Certification Division sent a letter to the pilot advising that he was eligible for continued Authorization for Special Issuance of a third-class medical certificate. The medical certificate was enclosed with a letter stating that the “time-limited certificate expires November 30, 2009.”

Review of the pilot’s pilot logbook (pilot logbook) that was found in the wreckage revealed his first logged flight (an orientation flight) occurred on July 22, 1992, and the last logged flight was dated March 13, 2009. He logged a total time of approximately 476 hours, of which approximately 390 hours were as pilot-in-command. His last flight review in accordance with 14 CFR Part 61.56 was performed in the accident airplane on November 8, 2008; the logged flight duration was 1.0 hour.

Further review of the pilot logbook revealed the pilot’s first logged flight in the accident airplane occurred on April 11, 2001. He logged a total time of approximately 196 hours in the accident airplane, and he logged three night flights which occurred on March 13, 2009; the total flight duration of all three was 2.8 hours.

The Aero Commander 100 airplane was manufactured in 1968, and was designated serial number 239. It was powered by a 150 horsepower Lycoming O-320-A2B engine and equipped with a fixed pitch propeller.

Federal Aviation Administration (FAA) records indicate that the pilot has owned the airplane since July 23, 2001.

Review of the maintenance records revealed that the airplane was last inspected in accordance with an annual inspection on October 1, 2008; the airplane total time at that time was 2,615.2 hours. The airplane had accumulated about 74 hours since the inspection at the time of the accident.

Title 14 CFR Part 91.409(a)(1) indicates that no person may operate an aircraft unless, within the preceding 12 calendar months, it has had an annual inspection in accordance with 14 CFR Part 43 and has been approved for return to service.

A surface observation weather report taken at the Fort Lauderdale/Hollywood International Airport (FLL), at 1853, or approximately 13 minutes after the accident indicates the wind was from 080 degrees at 17 knots with gusts to 25 knots, the visibility was 10 statute miles, scattered clouds existed at 3,000 and 6,500 feet above ground level, the temperature and dew point were 27 and 19 degrees Celsius respectively, and the altimeter setting was 30.05 inches of Mercury (inHg). The accident site was located approximately 31 nautical miles west-northwest from FLL.

According to the U.S. Naval Observatory Astronomical Applications Department, in close proximity to the accident site the sunset occurred at 1736, and the end of civil twilight occurred at 1801, which were 1 hour 4 minutes and 39 minutes respectively, before the accident.

The pilot was not in contact with any Federal Aviation Administration air traffic control facility at the time of the accident. A transcription of communications with the TMB Air Traffic Control Tower was prepared and there were no reported communication difficulties.

Examination of the accident site revealed the airplane crashed into the Everglades approximately 850 feet north of the west bound lanes of Interstate 75 (I-75). The wreckage came to rest heading approximately 090 degrees, with both wings, the left horizontal stabilizer, and the engine with attached propeller separated. All components necessary to sustain flight were found in close proximity to the main wreckage. No evidence of pre or post crash fire was noted on any of the recovered wreckage. A black colored case with “Garmin” was located in the wreckage; however, the GPS was not located.

Examination of the flight controls revealed no evidence of preimpact failure or malfunction for roll, pitch, and yaw.

Examination of the cockpit revealed the throttle was extended 2 3/8 inches, the carburetor heat was in, the mixture control was full rich, and the primer control was found unlocked. Inspection of the tachometer revealed a witness mark on the faceplate at approximately 2,650 rpm mark; red line is 2,700 rpm. Inspection of the stall warning light bulb revealed the bulb filament was not stretched. Visual inspection of the airspeed indicator with a 15 power eye loop revealed no obvious needle slap marks. The cockpit contained an overhead light with a red colored lens. The light also had a sliding window which allowed direct light from the bulb to exit the opening. Visual examination of the cockpit interior overhead light bulb using a 10 power eye-loop revealed stretching of the filament consistent with power applied at the time of impact.

The engine with attached propeller remained attached to the firewall by the engine mount, but the firewall was structurally separated. Examination of the engine revealed crankshaft, camshaft, and valve train continuity. The carburetor was impact separated from the engine and was fragmented. The venturi, needle valve and seat components of the carburetor were not located. The left magneto remained installed while the right magneto was separated from the accessory case but remained connected by the ignition leads. Both magnetos were rotated by hand but neither produced spark. Both magnetos and installed noise filters were retained for further examination. Examination of the spark plugs revealed medium gray combustion deposits; electrode wear was moderate and gap settings were normal. The ignition harness exhibited impact damage. The oil sump was separated from the engine. Examination of the oil filter revealed it was marked with “28 Jun 2009” and “2663” with the later numbers associated with the tachometer time. The oil filter paper element was removed and inspected which revealed no evidence of ferrous particles. No evidence of preimpact failure or malfunction of the engine or engine accessories was noted. A detailed examination report is contained in the public docket for this accident.

Examination of the propeller revealed one blade was bent aft approximately 70 degrees and the leading edge was twisted towards low pitch. A gouge was noted on the leading edge of the blade approximately 22 inches from the center of the hub, and the trailing edge exhibited wrinkles at 23.5 inches and also 12.5 inches from the center of the hub. A gouge was also noted in the trailing edge approximately 0.75 inch inboard from the tip. Heavy gouges and chordwise scratches were noted on the cambered side of the blade. The lower hub face has material missing consistent with ground contact. Examination of the other blade revealed it exhibited a slight forward bend at tip and slight aft bend approximately 5 to 10 degrees inboard from the tip. Heavy gouges were noted on the leading edge between 13 and 20 inches from the hub center. Spanwise scratches were noted between 26 and 33 inches from the hub center. Very slight chordwise scratches on cambered side of the blade were noted at 12 inches, and 23 inches from the hub center. Slight nicks were noted on the trailing edge.

A postmortem examination of the pilot was performed by the Broward County Medical Examiner's Office, Fort Lauderdale, Florida. The cause of death was listed as multiple blunt force injuries to the head, neck, trunk, pelvis, and extremities.

Forensic toxicology was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated the results were negative for carbon monoxide, cyanide, volatiles, and tested drugs.

Postaccident the FAA Bioaeronautical Sciences Research Laboratory was contacted and asked about the possibility of testing the samples for the presence of ASA, Lipitor, and Plavix. An e-mail response from a Dr. Russell Lewis of the FAA Bioaeronautical Sciences Research Laboratory indicated that, “In case 2009-271-01, we did not find salicylate, clopidogrel, or atorvastatin in our screening procedures.”

NTSB review of the pilot’s blue ribbon FAA medical file revealed on the application for his last medical certificate, he reported currently taking Lipitor (20mg), Plavix (75mg), and aspirin (81mg). Additionally, on the application he reported having a stent installed in his left anterior artery on March 9, 2007.

Acetylsalicylic acid, also known as aspirin, is a common over the counter analgesidanti-inflammatory/antipyretic. Atorvastatin (Lipitor) is an oral cholesterol-lowering medication that blocks the production of cholesterol, and Clopidogre1 (Plavix) is an oral antiplatelet agent (thienopyridine class) used to prevent blood clots after a recent heart attack or stroke, and/or to treat people with coronary artery disease, peripheral vascular disease, and cerebrovascular disease. The pilot had a history of coronary artery disease with cardiac catheterization and stent placement in March 2007, due to 95% occlusion of proximal Left Anterior Descending (LAD) artery with normal left ventricle. The pilot has a current special issuance for this condition and this pilot had submitted a normal exercise stress test on July 29, 2009. A radionuclide scan was performed during this test but

was not submitted for review. The pilot’s last cardiology visit was July 29, 2009, with a central Florida doctor.

NTSB Medical Officer review of the autopsy report, toxicology report, and pilot’s blue ribbon FAA medical file revealed the autopsy did not indicate any problem with the installed stent, but did show some other mild heart disease and evidence of a small heart attack at the tip of the heart (almost certainly the reason for the stent in the first place), but no indication of any other disease of significance. The Medical Officer also reported that Lipitor (atorvastatin) is not normally reported in FAA toxicology testing, and aspirin is typically only reported in urine. Plavix (clopidogrel) is usually given for 6 to 24 months (depending on the physician and the type of stent) after stent placement, therefore, would not generally expect the pilot to have been on it at the time of the accident. The FAA toxicology report was thus consistent with the information on the application.

At the suggestion of the NTSB Medical Officer, the pilot’s wife was asked several health related questions. She advised NTSB that to her knowledge, her husband had not been diagnosed with sleep apnea. She did advise that he had snored while sleeping, but that decreased when he lost weight.

Examination of the magnetos was performed at a Federal Aviation Administration (FAA) certified repair station. Both magnetos were equipped with noise filters which were removed for further examination at the manufacturer’s facility. The left magneto was placed on a test bench as received with a slave ignition harness and was operated between 643 and 4,704 rpm; spark was noted at two ignition leads. Debris and moisture was noted inside the magneto resulted in abnormal arching during high tension testing of the distributor block. The condenser tested 0.34 microfarads (specification is 0.33 to 0.43 microfarads), and the point gap was 0.023 inch (specification is 0.012 to 0.024 inch). The E-gap measured 5 degrees (specification is 6 degrees to 14 degrees), and the distributor gear was intact and the coil tab did not exhibit any evidence of arching, though the carbon brush was stuck in. No carbon tracking was noted on the distributor block, which was removed and placed in an oven to displace the moisture. The coil primary resistance reading was 0.2 ohms (specification is 0.2 to 0.6 ohms), and the coil secondary resistance reading was 15,500 ohms (specification is 12,000 to 16,000 ohms). The distributor block was reinstalled in the magneto which was returned to the test bench and operated between 643 and 4,704 rpm; spark was noted at all leads jumping a 7 mm gap.

The right magneto was also placed on a test bench as received with a slave ignition harness and was operated between 1,200 and 4,704 rpm but did not produce spark at any ignition leads. The points were filed lightly using an emory board and the magneto was returned to the test bench for operational testing. The magneto was again operated between 1,200 and 4,704 rpm and produced spark at all leads jumping a 7 mm gap. Inspection of the right magneto following bench testing revealed the condenser tested 0.30 microfarads (specification is 0.33 to 0.43 microfarads), and the point gap was 0.020 inch (specification is 0.012 to 0.024 inch). The E-gap measured 8 degrees (specification is 6 to 14 degrees), and the distributor gear was intact and the coil tab did not exhibit any evidence of arching, though the carbon brush was stuck in. No carbon tracking was noted on the distributor block. The coil primary resistance reading was 0.4 ohms (specification is 0.2 to 0.6 ohms), and the coil secondary resistance reading was 15,500 ohms (specification is 12,000 to 16,000 ohms).

Examination of the left and right magneto noise filters was performed with FAA oversight at the manufacturer's facility. The examination revealed both passed the functional test per the design and test data. A detailed examination report is contained in the public docket for this accident.

A digital camera with installed memory card, and an additional memory card were submitted to the NTSB’s Vehicle Recorder Division in an effort to determine whether any pictures existed of the accident flight. According to the Specialist’s Factual Report, neither memory card contained data relevant to the accident. A detailed examination report with accompanying pictures is contained in the public docket for this accident.

Fueling records at TMB indicate that on the day of the accident, a total of 22.49 gallons of 100 low lead (100LL) fuel were added by the self service pump. There were no reported fuel issues from other airplanes fueled from the same source.

The NTSB Vehicle Performance Division (RE-60) was asked to evaluate the airplane’s performance during the last few minutes of the flight. All plots were based on FAA Airport Surveillance Radar (ASR) Data from Fort Lauderdale/Hollywood International Airport. Since the airplane was not on a discrete transponder code, it could not be determined with complete certainty that the radar targets were of the accident airplane; however, a radar target was located near the departure end of the runway about the time the flight departed, and was tracked to within about ¼ nautical mile from the crash site about the time of the accident. A plot titled “Pressure Altitude” begins about 1821 with the airplane at 600 feet, and continues until just after 1840, with the airplane at 1,000 feet. Between 1821 and approximately 1823, the airplane climbed to 1,600 feet, then between 1823 and 1827, the airplane descended to approximately 1,300 feet. Between 1827, and approximately 1839, the airplane climbed from 1,300 to 2,800 feet pressure altitude. Beginning about 1839, the plot indicates a descent, which when correlated with the “Rate of Climb” plot indicates that between 1839:30, and the last radar target, the airplane descended at a rate of approximately 3,000 feet per minute. The “Groundspeed” plot indicates that during the 3,000 fpm descent, the groundspeed value increased to a maximum of 150 knots. A detailed report is contained in the public docket for this accident.

According to the pilot’s wife, her husband spent the weekend of October 31, and November 1st, at home with his family and woke up on Sunday, November 1, 2009, about 0700. He left their house about mid afternoon that same day, and drove to Warner Robbins AFB, located in Georgia, where he remained until Friday, November 6, 2009. On Friday, November 6, 2009, he flew the airplane from Warner Robbins AFB, to TMB, and landed there about 2200 hours. She reported that he went to his hotel room.

A friend of the pilot reported picked him up at the hotel on Saturday, November 7th, at 0530, and drove him to Homestead Air Reserve Base (Homestead ARB) where the friend and pilot assisted in several duties including preparation for an airshow. They drove back to the hotel where the pilot was dropped off about 2130. The following day, Sunday, November 8th, the friend picked the pilot up at the hotel at 0600, and drove to Homestead ARB, where they stopped working at 1600 hours. At that time he then drove the pilot to TMB and watched him fuel the airplane and perform a preflight inspection. At some point during the day while at Homestead ARB discussing aviation issues, the conversation turned to night flying and elevator trim. The pilot advised him that he liked to maintain a little nose-up trim, which is how he was taught by his instructor. The friend further reported that he asked the pilot if he was tired before the accident flight departing and he replied no.

The pilot’s wife further stated that since he was away from their home she did not know his sleep schedule; however, while he was away she spoke with him in the morning about 0600, and in the evening between 1800 and 2000 hours. She did not know his 7 day sleep history because he was away, but during their talks, he sounded “…fine”, and as far as she knew he, “was resting good.”