CAA: GA News, "Accident Reports"

["Stephen Irwin" <stepheni@cwnet.com>]

Friday, May 12, 2000

Pilot dies of hypoxia because portable oxygen bottle was filled incorrectly
GA News


These 1997 Accident Reports are provided by the National Transportation
Safety Board. Published as an educational tool, they are intended to help
pilots learn from the misfortune of others.

***

Aircraft: Cessna 337D.

Location: Hickory, Pennsylvania.

Injuries: One fatal, one minor.

Aircraft damage: Destroyed.

What reportedly happened: The pilot was cleared to climb to 25,000 feet by
Air Traffic Control. He passed through the assigned altitude and leveled at
27,700 feet. The aircraft, which was not pressurized, was observed at 26,000
feet. The pilot did not respond when ATC queried him about exceeding his
assigned altitude. The aircraft sustained an in-flight breakup during an
uncontrolled descent and came to rest in a tree. According to the passenger,
who survived, the airplane was fueled and a portable oxygen bottle was
filled before takeoff. The passenger said she and the pilot were planning to
take aerial photographs at four locations. She said they shot at three of
the locations and landed at Williamsburg, Pennsylvania, where the pilot
filed a flight plan and set up the portable oxygen system for the next
flight. They departed, climbed to 10,000 feet and donned their oxygen masks.
The last altitude she remembered the pilot calling out was 20,000 feet. He
asked her if she felt well, and she said yes. The passenger said she
attempted to turn on the oxygen, but wasn’t sure how, so the pilot reached
back and turned it on. She said she knew it was on because she could feel
the cool air, and there was a little valve in each line and they went from
red to green, indicating oxygen was flowing. The passenger said she
remembered the pilot saying they had just crossed 20,000 feet when she began
feeling dizzy. She said her eyes would not focus, and she felt cross-eyed.
She said she told the pilot she was dizzy, but she thought that he was
talking to the tower because he did not respond. She recalled that she felt
better when she closed her eyes, but that was the last thing she remembered
until after the crash.

Probable cause: Tests showed that the contents of the cylinders that were
used to fill the flight’s oxygen bottle contained compressed breathing air
at about 21% oxygen instead of aviation oxygen. Postmortem examination
revealed the pilot died of hypoxia.

***

Aircraft: Boeing Stearman N2S-4.

Location: Apex, North Carolina.

Injuries: Two fatal.

Aircraft damage: Destroyed.

What reportedly happened: Witnesses said they saw the plane flying over a
lake at about 30 feet. The aircraft climbed slightly to clear a bridge and
then descended back to about 30 feet above the lake. It entered into a loop
from that altitude and crashed into the lake in a nose-down attitude.

Probable cause: The pilot’s decision to perform an aerobatic maneuver
without adequate altitude.

***

Aircraft: Cessna 150.

Location: Lehighton, Pennsylvania.

Injuries: Two minor.

Aircraft damage: Substantial.

What reportedly happened: The student pilot was undergoing a private pilot
check ride. During a go-around following a simulated forced landing, the
aircraft’s flaps failed to retract. The student pilot gave the controls to
the flight examiner and replaced the fuse for the flap-actuating system. The
fuse was installed with the flap handle in the fully retracted position,
which led to inadvertent retraction of the flaps. The student pilot said the
airplane then stalled, descended 60 to 100 feet, and landed hard in a field.

Probable cause: Replacing the fuse while the flap handle was in the fully
retracted position. That caused the flaps to retract, which led to an
inadvertent stall/mush, which caused the aircraft to crash.


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