CESSNA 182

Full Narrative

HISTORY OF FLIGHTOn May 28, 2023, about 1452 eastern daylight time, a Cessna 182D, N8775X, was
substantially damaged when it was involved in an accident near Plymouth, New York.
The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 skydiving flight.

The flight departed from runway 1 at the Lt Warren Eaton Airport (OIC), Norwich, New York, about 1422 with four skydivers on board. ADS-B data indicated that the airplane climbed to about 11,000 ft msl (10,000 ft above ground level). About 1444, when in close proximity to OIC, the pilot informed air traffic control that the four skydivers were away, and then the airplane continued its descent to OIC. A co-owner of the skydiving operation reported that the pilot announced over the common traffic advisory frequency (CTAF) that he was at 6,000 ft msl descending for downwind. She reported hearing yet another transmission from the pilot but the “…call did not sound like a normal one and I could not identify what he said. I thought by the sound of his voice something was off.” She went outside to spot the airplane then went back into the hangar and attempted to communicate with the pilot, but he did not reply. About 1450, the last ADS-B data point placed the airplane about 1.74 nautical miles west-northwest from the approach end of runway 01 at OIC, flying in a northeasterly direction. The accident location was about .8 nautical mile east-northeast from the last ADS-B data point.
A witness, who was located about 0.9 nautical mile (nm) west-southwest from the accident site, reported she and her husband were looking east and heard a strange noise that was “really close.” She then heard an airplane fly over their house, “very low,” just clearing the tops of nearby trees. As it flew over their house with a view of the left side of the airplane, they heard the engine sputtering, and when the airplane was over trees, the engine shut off. She indicated that the pilot tried to start it. They didn’t hear any more engine sounds and then heard the impact. They could not see where the airplane went down and there were no flames or an explosion. She called 911 to report the accident. PERSONNEL INFORMATIONThe pilot was a part-time contract pilot for Just Jump SkyDiving, LLC. According to
a co-owner of the airplane/operator, he began flying with them in the Spring of 2022, and flew until the end of October, with some intermittent flying in the winter, weather permitting. They began their 2023 flying “season” in April.

According to the “Flight Competency and Proficiency Checks” paperwork provided by Just Jump SkyDiving, LLC, the pilot’s last recurrent check was performed in the accident airplane on October 8, 2022. The flight time was reported to be 1.3 hours, and the results were marked “Approved.” All items on the form were marked “S” or satisfactory. He was also qualified in their other Cessna 182E.

Inspection of his personal effects located at the operator’s facility revealed a fuel dipstick that was identical to the dipstick located in the accident airplane. There was no conversion chart located in his personal effects, or in the wreckage, to correlate the readings on the stick with actual fuel load in each tank. The operator later provided a copy of the conversion paperwork for the dipstick. AIRCRAFT INFORMATIONThe airplane was equipped with a cellular phone, an iPad for use with the Foreflight application, and an Electronics International engine monitor. The engine monitor did not store non-volatile memory, and the cellular phone did not have any accident-related data. The iPad was accessed, and a ForeFlight application was in the recently used app bin, but potential data was not recovered from the application due to account and user permission restrictions.
According to the airplane Owner’s Manual, the total volume of each wing fuel tank was 32.5 gallons, while the usable amount of fuel in each fuel tank for all flight conditions was 27.5 gallons, resulting in a total usable amount of fuel in all flight conditions of 55.0 gallons. The manual also indicated that in level flight an additional 3.5 gallons of fuel is available, resulting in an unusable fuel load in level flight of 1.5 gallons. One co-owner of the airplane, who had owned it for about 9 months, reported that the typical fuel burn for a skydiving flight was 7 to 9 gallons.
Fuel records indicated that the pilot added 30.3 gallons of 100 low lead fuel to the airplane on May 27, 2023, likely after the first flight of the day. The fuel level in the airplane before he added the fuel is unknown. Two more skydiving flights were flown that day.
A co-owner of the airplane/operator reported the pilot performed a preflight inspection of the airplane about 1000 hours on May 28, 2023, and then flew a skydiving flight lasting about .7 hours, based on the tachometer time. After landing, the pilot used a dipstick and informed one co-owner that the airplane had 40 gallons of fuel. Including the accident flight, the airplane was subsequently flown on two additional skydiving flights, about 12,000 ft msl. The accident flight was the fifth flight since the airplane was refueled.
Located at the accident site was a “Navigation Log” page and a small log each containing handwritten entries. The Navigation Log contained entries including the registration of the accident airplane, winds aloft, date (May 28, 2023), number of flights, “3041.57,” and “fuel,” and two columns immediately beneath it specifying “R23” and “L20.” The small log contained entries including date, numbers consistent with tachometer time out and in, and for one entry of the accident date the accident pilot’s first name. Correlation of the Navigation Log and the small log revealed the entry on the Navigation Log of “3041.57” was consistent with the tachometer start time for the 1st flight of May 28, 2023.
The pilot used a fuel dipstick to assist in determining the fuel level in the tanks. However, the fuel dipstick used was not made for the make and model of the accident airplane. Therefore, a fuel conversion chart was created to indicate how much fuel was actually in the tank when the dipstick was used. A review of the dipstick conversion chart provided by the operator revealed the actual fuel level did not go higher than “19” gallons, and there was no dipstick reading of 23. Correlating the values of 20 and 23 as annotated on the Navigation Log to the conversion chart, either by exact entry or interpolation, resulted in actual fuel levels of 11 gallons and 13.5 gallons, respectively, for a total of 24.5 gallons. METEOROLOGICAL INFORMATIONThe weather recorded at the Greater Binghamton Airport (BGM), Johnson City, New York, located about 29 miles from the accident site, indicated the temperature and dew point spread was 27°C and 8°C, respectively. According to FAA Special Airworthiness Information Bulletin CE-09-35, Carburetor Icing Prevention, these conditions were conducive for carburetor icing at glide or cruise power. About 1443, the ADS-B data indicated that the airplane began its descent from about 11,000 ft msl and 3 minutes later it descended through 6,000 ft msl, about a 1,666 ft per minute rate of descent. The last ADS-B radar point was about 1450, and the airplane was about 1,500 ft msl. AIRPORT INFORMATIONThe airplane was equipped with a cellular phone, an iPad for use with the Foreflight application, and an Electronics International engine monitor. The engine monitor did not store non-volatile memory, and the cellular phone did not have any accident-related data. The iPad was accessed, and a ForeFlight application was in the recently used app bin, but potential data was not recovered from the application due to account and user permission restrictions.
According to the airplane Owner’s Manual, the total volume of each wing fuel tank was 32.5 gallons, while the usable amount of fuel in each fuel tank for all flight conditions was 27.5 gallons, resulting in a total usable amount of fuel in all flight conditions of 55.0 gallons. The manual also indicated that in level flight an additional 3.5 gallons of fuel is available, resulting in an unusable fuel load in level flight of 1.5 gallons. One co-owner of the airplane, who had owned it for about 9 months, reported that the typical fuel burn for a skydiving flight was 7 to 9 gallons.
Fuel records indicated that the pilot added 30.3 gallons of 100 low lead fuel to the airplane on May 27, 2023, likely after the first flight of the day. The fuel level in the airplane before he added the fuel is unknown. Two more skydiving flights were flown that day.
A co-owner of the airplane/operator reported the pilot performed a preflight inspection of the airplane about 1000 hours on May 28, 2023, and then flew a skydiving flight lasting about .7 hours, based on the tachometer time. After landing, the pilot used a dipstick and informed one co-owner that the airplane had 40 gallons of fuel. Including the accident flight, the airplane was subsequently flown on two additional skydiving flights, about 12,000 ft msl. The accident flight was the fifth flight since the airplane was refueled.
Located at the accident site was a “Navigation Log” page and a small log each containing handwritten entries. The Navigation Log contained entries including the registration of the accident airplane, winds aloft, date (May 28, 2023), number of flights, “3041.57,” and “fuel,” and two columns immediately beneath it specifying “R23” and “L20.” The small log contained entries including date, numbers consistent with tachometer time out and in, and for one entry of the accident date the accident pilot’s first name. Correlation of the Navigation Log and the small log revealed the entry on the Navigation Log of “3041.57” was consistent with the tachometer start time for the 1st flight of May 28, 2023.
The pilot used a fuel dipstick to assist in determining the fuel level in the tanks. However, the fuel dipstick used was not made for the make and model of the accident airplane. Therefore, a fuel conversion chart was created to indicate how much fuel was actually in the tank when the dipstick was used. A review of the dipstick conversion chart provided by the operator revealed the actual fuel level did not go higher than “19” gallons, and there was no dipstick reading of 23. Correlating the values of 20 and 23 as annotated on the Navigation Log to the conversion chart, either by exact entry or interpolation, resulted in actual fuel levels of 11 gallons and 13.5 gallons, respectively, for a total of 24.5 gallons. WRECKAGE AND IMPACT INFORMATIONThe airplane crashed in a wooded area located about 1 nautical mile west-northwest of the center of OIC. The wreckage came to rest on a magnetic heading of about 189° on a slight down sloping terrain and was in a 49° nose-low and tail-high attitude. It was also in a right-wing-high attitude; the left wing was separated at the wing root, which remained in close proximity to the main wreckage.
Further examination of the accident site revealed a very slight smell of fuel in the area of the separated left wing. Very slight fuel blight of tree leaves adjacent to the resting
position of the left-wing root was noted. A broken tree limb near the resting
position of the left wing was noted about 30 ft above ground level. An impact mark was noted on the south side of the tree.

Further examination of the wreckage revealed both horizontals, elevators, vertical stabilizer, and rudder remained attached. No fuel was at either left or right inlet fuel lines or the outlet line of the fuel selector valve. No fuel stains were noted on the interior panel below the fuel selector valve. About 5 ounces of fuel were drained from the airframe fuel strainer; no contaminants were noted in the drained fuel from the strainer.

Examination of the separated left wing revealed the forward spar attach bolt was in place. The sections of the forward spars were fractured in overload. The full span of the flap and aileron remained installed. The fuel tank bladder was breached. Impact gouges on the inboard and outboard flap tracks depicted the flap in a retracted position. The flap rod end exhibited bending overload. The lift strut exhibited overload fracture about 3 ft outboard of the lower attach point. An impact mark was noted on the leading edge inboard of the pitot tube consistent with the airplane being in a left bank of about 30°. Another impact mark was noted on the leading edge near wing station 154 associated with tree contact. A vented fuel cap was installed, and it checked satisfactory. There were no fuel stains aft of the fuel cap and a placard by it did not specify the total capacity or usable capacity. The fuel sender moved freely to the up and down stop positions.

Examination of the connected right wing revealed 25 ounces of blue fuel
consistent with 100 low-lead fuel were drained from the bladder fuel tank. The lift strut
remained attached at both ends. A vented fuel cap was in place, and it checked
satisfactory. There were no fuel stains aft of the fuel cap and a placard by it did not specify the total capacity or usable capacity. The flap and aileron remained
connected; the flap appeared to be retracted. The fuel sender moved freely to the up and down stop positions.

Examination of the flight controls revealed elevator and rudder flight control continuity from the cockpit to each control surface. The aileron balance cable was connected at the bellcrank near both ailerons and exhibited tension overload at the right wing root area. The right aileron direct cable was continuous from the bellcrank at the aileron to the cockpit, while the left aileron direct cable was connected at the bellcrank near the control surface and exhibited tension overload fracture at the wing root area. The right flap up and down cables were continuous from the flap pull handle to the bellcrank near the flap. The left flap down cable was separated at the turnbuckle at the upper door post and exhibited overload separation at the lower door post. The left flap up cable was fractured at the upper door post in the area of a pulley. The two ends of the fractured left up cable were retained for examination by the NTSB Materials Laboratory; the examination revealed several strands exhibited fatigue and rubbing was noted on several strands; however, the majority of the strands exhibited overload fracture. The flap handle was in the flaps retracted position and the horizontal stabilizer trim measured 6.14 inches, which equated to neutral or 0°.

Examination of the cockpit revealed the carburetor heat was in the off position, the throttle was within 1/2 inch of being full in, and the mixture and propeller controls were full in. The fuel selector valve was in the left tank detent.

Examination of the engine before separation from the airframe revealed the crankshaft was fractured at the crankshaft flange, which remained attached to the propeller hub flange. The propeller with attached crankshaft flange was located in close proximity to the main wreckage. Throttle, mixture, and propeller control cable continuity was confirmed from cockpit to each engine control. The propeller lever was impact damaged, which prevented full movement of the propeller governor control head.

Examination of the engine following recovery was performed by placing a splined shaft in the vacuum pump drive pad. Rotation of the crankshaft in the direction of rotation was performed for 720°; crankshaft, camshaft, and valvetrain continuity were confirmed. The oil level was above 12 quarts, but the engine was slightly canted aft. The oil screen was clean but did contain some carbon particles. Following the removal of the propeller governor, the governor driveshaft rotated freely and the governor pumped oil that remained inside the unit.

Examination of the air induction, exhaust, and lubrication systems revealed no evidence of preimpact failure or malfunction. Some out-of-tolerance conditions were noted during resistance testing of the spark plugs, though all plugs and magnetos operationally tested satisfactory.

Examination of the carburetor revealed the accelerator pump operationally tested satisfactory and sprayed fuel when the throttle was activated. About 4 ounces of blue fuel consistent with 100LL with no contamination was noted in the carburetor bowl. The needle valve and seat checked satisfactory, and a blue float was installed and appeared to be operational with no absorbed fuel. The inlet screen was clean.

Examination of the propeller revealed that the No. 1 blade was bent aft about 30°
beginning about 11 inches from the hub. Chordwise scratches were noted on the blade face, or cambered side, of the blade. Abrasion was noted near full span of the blade on the leading edge. The propeller blade was in an abnormal position inside the hub and could not be moved with hand pressure. The leading edge appeared to be twisted toward low pitch beginning about mid-span. Examination of the No. 2 blade revealed it was relatively unremarkable. There was evidence of very slight contact to the leading edge. The blade appeared to be in a normal position in the hub. ADDITIONAL INFORMATIONAccording to FAA Advisory Circular 20-113, "To prevent accident due to induction system icing, the pilot should regularly use [carburetor] heat under conditions known to be conducive to atmospheric icing and be alert at all times for indications of icing in the fuel system." The circular recommended that when operating in conditions where the relative humidity is greater than 50 percent, “Heat should be applied for a short time to warm the induction system before beginning a prolonged descent with the engine throttled and left on during the descent. Power lever advancement should be performed periodically during descent to assure that power recovery can be achieved.” MEDICAL AND PATHOLOGICAL INFORMATIONA postmortem examination of the pilot was performed at the Lourdes Hospital Department of Pathology, Binghamton, New York. The cause of death was reported to be multiple blunt force injuries, and the manner of death was accident.
Forensic toxicology was performed on specimens of the pilot by the FAA Forensic Sciences Laboratory, Oklahoma City, Oklahoma. The toxicology report indicated glucose was detected in the vitreous and urine at 13 mg/dL and 14 mg/dL, respectively, and an unquantified amount of metformin was detected in the submitted blood and urine specimens.
According to the NTSB Medical Officer’s Factual Report, the pilot had a history of diabetes and moderate non-proliferative diabetic retinopathy treated with laser therapy. He reported taking metformin, a prescription medication commonly used to treat diabetes. His last aviation medical examination was April 4, 2023; at that time, he was issued a second-class medical certificate by Special Issuance, with the limitation that the certificate was not valid for any class after April 30, 2024. The pilot’s most recent Authorization for Aviation-Medical-Examiner Assisted Special Issuance for diabetes and diabetic retinopathy was granted May 1, 2023. The pilot’s last hemoglobin A1c in March 2023 was 7.6%. (HbA1c is an indirect measure of a person’s average blood sugar over approximately the preceding 3 months. For a person with diabetes, an HbA1c of less than 7% generally indicates good diabetes control.) The FAA Forensic Sciences Laboratory considered glucose levels above 125 mg/dL in vitreous fluid or above 100 mg/dL in urine to be abnormal.
The NTSB Medical Factual report also indicated the autopsy report documented severe coronary artery atherosclerosis, including 90% narrowing of the left anterior descending artery, and mild atherosclerosis of the aorta and cerebral arteries. Cardiac hypertrophy and a mild increase in perivascular and interstitial fibrosis in the left ventricular wall on microscopy was also reported.
Metformin is a prescription medication commonly used to help control blood sugar in diabetes and prediabetes and is not typically impairing.