GENERAL INFORMATION FOR NTSB REPORT: ANC00FA081
Data Source NTSB AVIATION ACCIDENT/INCIDENT DATABASE
NTSB Report Nbr ANC00FA081
Event Id 20001212X21134
Local Date 06/30/2000
Local Time 2220
State AK
Airport Name MARSHALL
Event Type ACCIDENT
Injury Severity FATAL
Record Status
Mid Air Collision NO
Event Location ON AIRPORT/AIRSTRIP

WEATHER INFORMATION
Weather Briefing Complete UNKNOWN
Basic Weather Conditions VISUAL METEOROLOGICAL COND
Light Condition DAY
Cloud Condition CLEAR
Cloud Height above Ground Level (ft) 0
Ceiling Height above Ground Level (ft) 0
Cloud Type NONE
Visibility RVR (ft) 0
Visibility RVV (sm) 0
Visibility (sm) 10
Wind Direction (deg) 360
Wind Condition Flag U
Wind Speed (knots) 5
Wind Condition Indicated Unknown

AIRCRAFT INFORMATION
Aircraft 1
Type of Operation PART 91: GENERAL AVIATION
Registration Number N63MR
Aircraft Make CESSNA
Aircraft Model 337
Aircraft Series C
Aircraft Damage DESTROYED
Aircraft Fire NONE
Aircraft Explosion NONE
Aircraft Type AIRPLANE
Aircraft Homebuilt UNKNOWN
Phase of Flight UNDEFINED
Aircraft Use POSITIONING
Flight Plan Filed NONE
Operator Name MISSIONARY AVIATION CENTER
Operator Doing Business As
Owner Name MISSIONARY AVIATION REPAIR CNT
Number of Seats 4
Number of Engines 2
ELT Installed YES
ELT Operated NO
Departure Airport Id MLL
Departure City
Last Departure Point YES
Destination Airport Id UNK
Destination City UNALAKLEET
Destination State ALASKA
Runway Id 11
Runway Length 1940
Runway Width 30
Air Carrier Operating Certificates NO
Air Carrier Other Operating Certificates UNKNOWN
Rotocraft/Agriculture Operating Certificate UNKNOWN
Cert Max Gross Wgt 4650
Landing Gear RETR

ENGINE INFORMATION

Aircraft 1 - Engine : #1
Engine Manufactuer Continental
Engine Model IO-360-C
Engine Horsepower 210
Engine Thrust HP
Carb/Injection FUEL INJECTED

INJURY INFORMATION
Injury Summary for Aircraft 1
Fatal Serious Minor None
Crew 0 0 0 0
Pass 0 0 0 0
Total 1 0 0 0
Sequence of Events for Aircraft 1
Occurrence #1
AIRFRAME/COMPONENT/SYSTEM FAILURE/MALFUNCTION
Phase of Operation: STANDING - PRE-FLIGHT

Events Sequence for Occurrence #1 of Aircraft 1
Event Seq # Event Group Code Subject Modifier Personnel Cause/Factor
1 1 ENGINE ACCESSORIES, ENGINE STARTER INOPERATIVE
2 2 OPERATION WITH KNOWN DEFICIENCIES IN EQUIPMENT INTENTIONAL PILOT IN COMMAND CAUSE
3 3 OVERCONFIDENCE IN AIRCARFT'S ABILITY PILOT IN COMMAND FACTOR

Occurrence #2
LOSS OF CONTROL - IN FLIGHT
Phase of Operation: TAKEOFF - INITIAL CLIMB

Events Sequence for Occurrence #2 of Aircraft 1
Event Seq # Event Group Code Subject Modifier Personnel Cause/Factor
4 2 GEAR RETRACTION IMPROPER USE OF PILOT IN COMMAND FACTOR
5 2 STALL INADVERTENT PILOT IN COMMAND CAUSE
6 3 IMPAIRMENT (DRUGS) PILOT IN COMMAND FACTOR

Occurrence #3
IN FLIGHT COLLISION WITH TERRAIN/WATER
Phase of Operation: DESCENT - UNCONTROLLED

Events Sequence for Occurrence #3 of Aircraft 1
Event Seq # Event Group Code Subject Modifier Personnel Cause/Factor
7 1 TERRAIN CONDITION WATER




AIRCRAFT 1 PRELIMINARY REPORT


HISTORY OF FLIGHT On June 30, 2000, about 2220 Alaska daylight time, a Cessna 337C airplane, N63MR, was destroyed when it collided with water shortly after takeoff from the Marshall Airport, Marshall, Alaska. The solo commercial pilot was fatally injured. The flight was operated by Missionary Aviation Repair Center of Soldotna, Alaska, under 14 CFR Part 91, as a positioning flight to Unalakleet, Alaska. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed. A witness, who is also a pilot, told the NTSB investigator-in-charge (IIC) during a telephone interview on July 1, that prior to the flight the pilot was unable to start the aft engine because of an inoperative starter motor. The witness said he suggested to the pilot that he delay the flight until a new starter could be obtained, and offered to fly the pilot to get a replacement. The witness said the pilot insisted he could takeoff, and said he had performed single engine takeoffs previously in the airplane. The witness and pilot chose a predetermined point on the dry, gravel runway, which would be the abort point if the airplane were not airborne. The witness said that as the airplane passed the abort point, the nose wheel was lifting off the ground. He said the airplane climbed to about 50 feet, the wings rocked slightly, and the airplane passed out of sight behind a low hill. No other contact was received from the accident pilot. The witness said he then departed the airport, and saw no indication of the airplane. About one hour later, the witness discovered the pilot had not arrived at his destination, and he began a search. He returned to Marshall and saw oil sheen on the surface of a lake just beyond the departure end of the runway. The pilot's body and the airplane were later recovered from the lake. INJURIES TO PERSONS The pilot received fatal injuries. DAMAGE TO AIRCRAFT The airplane was destroyed by impact forces. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with ratings for single and multiengine land airplanes. He held an instrument rating. His second-class medical certificate, issued on September 7, 1999, contained the restriction that he "shall wear corrective lenses." The pilot held an airframe and power plant mechanic certificate. According to the pilot's logbook, and the NTSB Pilot/Operator report submitted by the company, he had accumulated 1,556 hours of total flight experience at the time of the accident. Approximately 600 hours were in the Cessna 337C. In the previous 90 days, the pilot had flown about 100 hours. In the previous 30 days, he had flown about 30 hours. On the day of the accident he had flown about 6 hours. His most recent biennial flight review, and instrument competency check, was conducted on February 11, 2000, in a Piper PA-31 airplane. Initial training in the Cessna 337C was conducted on May 22, 1998, by a company check pilot. The check pilot stated that during the six hours of training provided in the Cessna 337C, no emphasis was placed on performing takeoffs with one engine inoperative, and no special emphasis was placed on cycling the landing gear if an engine failed during takeoff. AIRCRAFT INFORMATION The airplane was a 1968 Cessna 337C, equipped with two Teledyne Continental Motors, IO-360C engines, each rated at 210 horsepower. The engines were configured with McCauley D2AF34C59 constant speed, manually featherable, propellers. The most recent annual inspection was completed on April 22, 2000, at 5,042 airframe hours. At the time of the last annual inspection, the rear engine had accumulated 1,688 hours time in service, and 203 hours since the last major overhaul. The front engine had accumulated 2,092 hours time in service, and 592 hours since the last major overhaul. The airplane was equipped with a Robertson Short Take Off and Landing (STOL) kit, installed under STC number SA1627WE. METEOROLOGICAL INFORMATION The weather was described by the witness as calm winds favoring neither runway, 65 degrees Fahrenheit, and clear. AERODROME INFORMATION The airport elevation is 90 feet above mean sea level. The 1,940 feet long by 30 feet wide, gravel runway is oriented 110 degrees magnetic. The pilot who witnesses the accident airplane takeoff stated the runway was dry. There is a shed and windsock located about 1/3 of the distance from the approach end of runway 11. The witness pilot indicated the windsock was working. The runway slopes slightly downhill in the direction of takeoff. WRECKAGE AND IMPACT INFORMATION The airplane came to rest in fresh water. No on site inspection of the airplane was conducted by the NTSB or FAA. Photographs of the wreckage were provided to the NTSB by the Alaska State Troopers, and the owner, and reviewed by the NTSB IIC. The wreckage was recovered by the owner on July 3, and transported via fishing boat to the runway at Marshall. After being photographed, it was further transported to the company's Kako Landing Retreat, near Russian Mission, Alaska. The leading edges of both wings were crushed aft to the forward spars. The trailing edge flaps were extended to the 1/3 down position. The front and rear engine cowl flaps were open. All three landing gear were retracted and the gear doors were shut. The landing gear control handle was in the "UP" position. The trailing edge flaps control handle was in the full down position. The flap indicator was in the 1/3 down position. The rudder trim indicator was in the centered (neutral) position. The elevator trim indicator was in the full nose down position. The rear propeller was in the flat pitch, (not feathered) position. MEDICAL AND PATHOLOGICAL INFORMATION The Alaska State Medical Examiner, 5700 East Tudor Avenue, Anchorage, Alaska, performed a postmortem examination on July 3, 2000. The cause of death was noted to be fresh water drowning due to multiple deceleration injuries. Toxicological samples were tested at the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma, on September 6, 2000. Chlorpheniramine was present in the pilot's urine, and in the pilot's blood at a level of 0.085 (ug/ml, ug/g). Chlorpheniramine is an antihistamine, commonly used in over-the-counter cold and allergy preparations. According to the Physicians Desk Reference, in therapeutic doses, the medication may result in drowsiness, and has negative effects on the performance of complex cognitive and motor tasks. Chlorpheniramine has a long half-life (about 24 hours). According to Federal Air Regulations, a pilot is precluded from taking any medication that adversely affects their ability to safely pilot an aircraft. SURVIVAL ASPECTS The Cessna 337C has two doors, one on each side of the cabin, adjacent to the front seats. According to the Alaska State Trooper who visited the scene, the pilot was found floating in the water, outside the airplane. After the airplane was recovered, the pilot's door was found open, and the pilot's seatbelt was found unbuckled. The pilot was not wearing an inflatable life jacket. TESTS AND RESEARCH A review of the Cessna 337 operating handbook revealed no published procedure for taking off with either engine inoperative. The emergency procedures for a single-engine failure after takeoff or during climb states, in part: "Single-engine climb performance with the rear engine operating is better than with the front engine operating by approximately 85 FPM....The landing gear should not be retracted until all immediate obstacles are cleared, regardless of which engine is out....Airplane drag with the landing gear doors opened and the gear partially extended is greater than the drag with the landing gear fully extended. Corresponding rate-of-climb penalties are -240 ft/min and -110 ft/min respectively." The best rate of climb airspeed is 100 mph. The best angle of climb airspeed is 90 mph. The performance specifications provided in the Cessna 337 Owner's Manual for rate of climb are in part: "Rate of climb at sea level, 4,000 pounds gross weight, best rate of climb airspeed, landing gear retracted, rear engine feathered, front engine operating only = 425 ft/min." The NTSB IIC estimated the gross weight of the airplane at the time of the attempted takeoff to be 3,462 pounds, calculated as follows: Empty weight 2,910 pounds, oil 108 pounds, pilot 204 pounds, baggage 40 pounds, fuel 200 pounds. Maximum allowable takeoff weight was 4,630 pounds. The Robertson STOL takeoff procedures state, in part: (1) Wing Flaps - "2/3" down (3) Power - Full throttle and 2800 rpm (6) Elevator Control-Lift nose at 50 MPH (7) Accelerate to 65 MPH over 50' obstacle (8) Accelerate to 100 MPH after clearing 50' obstacle. (10) Wing Flaps - Retract to "1/3" down after reaching 100 MPH (11) Landing Gear - Retract after reaching 10 MPH (12) Accelerate to climb speed -110 to 120 MPH (13) Wing Flaps - Retract to "UP" ADDITIONAL DATA/INFORMATION None of the wreckage was taken into custody of the Safety Board. The aircraft, engine, and propeller logbooks, were returned to the company on August 2, 2000.

AIRCRAFT 1 FINAL REPORT


The pilot was unable to start the aft engine. A witness suggested the pilot delay the flight until a new starter could be obtained. The pilot insisted he could takeoff, and said he had performed single engine takeoffs previously in the airplane. He chose a point on the dry, 1,940 feet long, 90 feet msl, gravel runway where he would abort if the airplane was not airborne. The witness said that as the airplane passed the abort point, the nose wheel was lifting off the ground. The airplane climbed to about 50 feet, the wings rocked slightly, and the airplane passed out of sight behind a low hill and impacted in a lake. The pilot received fatal injuries. There is no published procedure for taking off with either engine inoperative. The landing gear was retracted in-flight, and the gear doors were shut. The rear propeller was not feathered. The emergency procedures for a single-engine failure after takeoff or during climb states, in part: 'Single-engine climb performance with the rear engine operating is better than with the front engine operating by approximately 85 FPM....The landing gear should not be retracted until all immediate obstacles are cleared, regardless of which engine is out....Airplane drag with the landing gear doors opened and the gear partially extended is greater than the drag with the landing gear fully extended. Corresponding rate-of-climb penalties are -240 ft/min and -110 ft/min respectively.' The best rate of climb airspeed is 100 mph. The performance specifications provided in the Cessna 337C Owner's Manual for rate of climb are in part: 'Rate of climb at sea level, 4,000 pounds gross weight, best rate of climb airspeed, landing gear retracted, rear engine feathered, front engine operating only = 425 ft/min.' Postmortem toxicology samples from the pilot revealed the presence of Chlorpheniramine, an over-the-counter medication which causes drowsiness and impairs cognitive and motor tasks.

AIRCRAFT 1 CAUSE REPORT


The pilot's attempted takeoff with known deficiencies in equipment (an inoperable rear engine) and an inadvertent stall. Factors associated with the accident were the pilot's improper retraction of the landing gear, his over confidence in the airplane's ability, and his impairment from an over-the-counter cold/allergy drug.


END REPORT