History of Flight
On October 28, 2021, at 1311 Pacific time, a Cessna 172M, registration N1870V, was substantially damaged in an accident at Ukiah Municipal Airport in Ukiah, California. The student pilot, the sole occupant, was fatally injured. The airplane was operated as a Part 91 instructional flight.
The pilot was conducting a solo cross-country flight in pursuit of a private pilot's license and had planned a full stop landing at Ukiah. According to FAA ADS-B data, the airplane departed Napa County Airport at 1219 and flew directly to Ukiah, entering the traffic pattern from the southeast at 1308.
A witness near the north end of Runway 15 observed the airplane porpoising at the approach end. The pilot initiated a go-around, and the airplane climbed with flaps deployed. A security camera captured the initial climb: the airplane reached about 60 ft AGL, then leveled off while tracking over the runway. After midfield, it pitched down and descended, striking the ground nose-first. The nosewheel separated, and the airplane continued along the runway before passing out of view. The engine was heard operating throughout, with no smoke or vapors.
Another witness on the east side saw a dust cloud at the end of Runway 15 and then observed the tail lift as the airplane pitched onto its nose and rolled inverted.
Personnel Information
The pilot began flight training in July 2021, accumulating 31.3 total flight hours, all in the same make and model. This was his fifth solo flight and second solo cross-country.
Aircraft Information
The airplane was owned and operated by Mike Smith Aviation, a Part 61 flight school. The owner performed most maintenance, including annual and 100-hour inspections.
Wreckage and Impact
The airplane came to rest inverted on a grass verge adjacent to a diagonal taxiway on the right side of Runway 15. Damage was limited to the vertical stabilizer, rudder, left wing leading edge tip, and shattered windshield. The propeller showed evidence of runway contact with tip curl and gouges. Runway examination revealed a tire skid mark and a gouge matching the nose wheel rim and fork, which detached and was recovered 350 ft downrange. A scrape mark with 20 slash marks from propeller blades continued 700 ft, moving right of centerline to the main wreckage.
Following the accident, water was drained: 1 oz from the gascolator, 3 oz from the left tank drain, and an additional 3 oz from the left tank after full drainage. The flaps were retracted, elevator trim set for takeoff, and carburetor heat control off.
Maintenance discrepancies were found: seat rails worn beyond limits, inoperative throttle friction lock, engine camshaft-lobe wear with metallic debris in oil screen, and degraded spark plug ignition cables and P-lead wires.
Fuel Tanks
The left tank had a leak around the filler neck adapter; the outboard tank strap snapped; brown staining trailed aft of the filler cap. The gasket sealing the filler neck adapter was degraded, allowing leaks. Silicon sealant was present from previous repair attempts. Forward tank support pads wore away, causing rivet contact and fretting damage to the tank underside. A buckle in the lower tank skin created a raised area near the fuel supply screen, with corrosion discoloration. A fuel level dipstick was found loose in the left tank, and a fuel cap chain in the right tank.
Cessna Service Bulletin SEB 92-26, revision 1, which provides additional fuel drains for water detection, had not been applied to the accident airplane. Although Cessna stated compliance was mandatory, FAA regulations do not require adherence for Part 91 operations.
Additional Information
Significant rainfall occurred in the region during the week before the accident, breaking daily precipitation records. The airplane was stored outside at Napa County Airport during those showers.
A flight instructor who endorsed the accident flight flew the airplane earlier that morning and found a small amount of water in the gascolator during preflight—the first such occurrence for that airplane. The airplane performed without issue on that flight.
Before departure, the pilot requested fuel to capacity; 7 gallons of 100LL were added. A line technician observed the pilot checking fuel quantity at the caps and collecting a sample at the wing tank drains. A photo from the pilot's phone taken 21 minutes before departure showed a fuel-check sumping tool containing clear blue fluid and a small clear globule appearing as water.
The fuel supplier reported no other pilot complaints; fueling logs showed no contamination. A sample from the fuel truck drain was clear and bright, with no water.
Flight Recorders
The pilot had installed a GoPro camera on the windshield, recording audio and video from preflight through approach. The video showed the pilot reciting checklists, including seatbelt confirmation. After takeoff, he chatted about losing and finding a pen. The camera was turned off about 12 minutes after takeoff and restarted near Ukiah.
During the approach, two aircraft were in the pattern. The accident pilot coordinated with them. On downwind, he began the before-landing checklist but was interrupted by a bird. He stopped talking, and completion of checklist items (including seatbelt confirmation) was not heard. He extended downwind for a departing helicopter. On final, he stated, “alright, flap’s in, carb heat’s out, lights on, seventy.”
The approach was nominal; after flaring, the airplane reached the 1000-ft markings. A stroboscopic effect indicated increased engine speed, and the pilot transmitted, “Cessna 172 going around.” The airplane climbed, then 5 seconds later the propeller effect changed, and it stopped climbing. The nose pitched down slightly, the pilot said “whoa, whoa, whoa,” and the recording ended.
Medical and Pathological Information
Autopsy performed by Bennet Omalu Pathology listed cause of death as head and face injury. The pilot had heart disease with 90-95% narrowing of the proximal left anterior descending coronary artery. Toxicological testing by Central Valley Toxicology detected no substances. FAA Forensic Sciences Laboratory detected codeine (47 ng/mL) and morphine (90 ng/mL) in urine but not in heart blood. The pilot's wife stated he never used prescription pain medication and had eaten a poppy seed bagel in days before.
Survival Aspects
The airplane came to rest inverted; the pilot was partially ejected through the upper windshield. The seat was locked in midrange, with intact locking pins and no evidence of preimpact movement. The 3-point harness had its lap buckle found unlatched and strap fully extended. The seat belt and buckle showed no damage or failure. Damage in the cabin was limited to the left instrument panel, circuit breaker panel, etc., with crush damage to the overhead speaker. Tests indicated that if the pilot had been securely buckled, he could not have contacted those damaged areas.
The flight instructor stated his students are taught the GUMPS pre-landing flow (Gas, Undercarriage, Mixture, Propeller, Seatbelts, Switches). He said the pilot always wore his seatbelt and flying without it was not an option. The pilot's wife also stated he always used seatbelts.
Tests and Research
Analysis of the security camera video showed that after the go-around, the airplane reached 52 kts ground speed at 50 ft AGL. Over 7 seconds, it accelerated to 60 kts and climbed to 68 ft. With about 2,000 ft of runway remaining, it began a 1,350 ft/min descent, striking the ground at 77 kts about 1,670 ft from the runway end. It then traveled along the ground for 20 seconds until the engine stopped. Audio analysis indicated engine speed varied between 2,415-2,505 rpm during flight and about 2,150 rpm after ground collision.