Bethel - Bethel

The pilot departed on a postmaintenance test flight during day visual meteorological conditions. According to the operator, the purpose of the flight was to break in six recently installed engine cylinders, and the flight was expected to last 3.5 hours. Recorded automatic dependent surveillance-broadcast data showed that the airplane was operating at altitudes of less than 500 ft mean sea level for the majority of the flight. The data ended about 3 hours after takeoff with the airplane located about 23 miles from the accident site. There were no witnesses to the accident, which occurred in a remote area. When the airplane did not return, the operator reported to the Federal Aviation Administration that the airplane was overdue. Searchers subsequently discovered the fragmented wreckage submerged in a swift moving river, about 40 miles southeast of the departure/destination airport. Postmortem toxicology tests identified 21% carboxyhemoglobin (carbon monoxide) in the pilot's blood. The pilot was a nonsmoker, and nonsmokers normally have no more than 3% carboxyhemoglobin. There was no evidence of postimpact fire; therefore, it is likely that the pilot's elevated carboxyhemoglobin level was from acute exposure to carbon monoxide during the 3 hours of flight time before the accident. As the pilot did not notify air traffic control or the operator's home base of any problems during the flight, it is unlikely that he was aware that there was carbon monoxide present. Early symptoms of carbon monoxide exposure may include headache, malaise, nausea, and dizziness. Carboxyhemoglobin levels between 10% and 20% can result in confusion, impaired judgment, and difficulty concentrating. While it is not possible to determine the exact symptoms the pilot experienced, it is likely that the pilot had symptoms that may have been distracting as well as some degree of impairment in his judgment and concentration. Given the low altitudes at which he was operating the airplane, he had little margin for error. Thus, it is likely that the carbon monoxide exposure adversely affected the pilot's performance and contributed to his failure to maintain clearance from the terrain. According to the operator, the airplane had a "winter heat kit" installed, which modified the airplane's original cabin heat system. The modification incorporated an additional exhaust/heat shroud system designed to provide increased cabin heat during wintertime operations. Review of maintenance records revealed that the modification had not been installed in accordance with Federal Aviation Administration field approval procedures. Examination of the recovered wreckage did not reveal evidence of any preexisting mechanical anomalies that would have precluded normal operation of the airplane. Examination of the airplane's right side exhaust/heat exchanger did not reveal any leaks or fractures that would have led to carbon monoxide in the cabin. Because the left side exhaust/heat exchanger was not recovered, it was not possible to determine whether it was the source of the carbon monoxide.

Flight / Schedule

Bethel - Bethel

Registration

N1653U

MSN

207-0253

Year of Manufacture

1974

Operator

Yute Air Alaska

Date

May 30, 2015 at 11:30 AM

Type

CRASH

Flight Type

Test

Flight Phase

Flight

Crash Site

Lake, Sea, Ocean, River

Crash Location

Bethel Alaska

Region

North America • United States of America

Coordinates

60.7922°, -161.7558°

Crash Cause

Human factor

Narrative Report

On May 30, 2015 at 11:30 AM, Bethel - Bethel experienced a crash involving Cessna 207 Skywagon/Stationair, operated by Yute Air Alaska, with the event recorded near Bethel Alaska.

The flight was categorized as test and the reported phase was flight at a lake, sea, ocean, river crash site.

1 people were known to be on board, 1 fatalities were recorded, 0 survivors were identified or estimated. This corresponds to an estimated fatality rate of 100.0%.

Crew on board: 1, crew fatalities: 1, passengers on board: 0, passenger fatalities: 0, other fatalities: 0.

The listed crash cause is human factor. The pilot departed on a postmaintenance test flight during day visual meteorological conditions. According to the operator, the purpose of the flight was to break in six recently installed engine cylinders, and the flight was expected to last 3.5 hours. Recorded automatic dependent surveillance-broadcast data showed that the airplane was operating at altitudes of less than 500 ft mean sea level for the majority of the flight. The data ended about 3 hours after takeoff with the airplane located about 23 miles from the accident site. There were no witnesses to the accident, which occurred in a remote area. When the airplane did not return, the operator reported to the Federal Aviation Administration that the airplane was overdue. Searchers subsequently discovered the fragmented wreckage submerged in a swift moving river, about 40 miles southeast of the departure/destination airport. Postmortem toxicology tests identified 21% carboxyhemoglobin (carbon monoxide) in the pilot's blood. The pilot was a nonsmoker, and nonsmokers normally have no more than 3% carboxyhemoglobin. There was no evidence of postimpact fire; therefore, it is likely that the pilot's elevated carboxyhemoglobin level was from acute exposure to carbon monoxide during the 3 hours of flight time before the accident. As the pilot did not notify air traffic control or the operator's home base of any problems during the flight, it is unlikely that he was aware that there was carbon monoxide present. Early symptoms of carbon monoxide exposure may include headache, malaise, nausea, and dizziness. Carboxyhemoglobin levels between 10% and 20% can result in confusion, impaired judgment, and difficulty concentrating. While it is not possible to determine the exact symptoms the pilot experienced, it is likely that the pilot had symptoms that may have been distracting as well as some degree of impairment in his judgment and concentration. Given the low altitudes at which he was operating the airplane, he had little margin for error. Thus, it is likely that the carbon monoxide exposure adversely affected the pilot's performance and contributed to his failure to maintain clearance from the terrain. According to the operator, the airplane had a "winter heat kit" installed, which modified the airplane's original cabin heat system. The modification incorporated an additional exhaust/heat shroud system designed to provide increased cabin heat during wintertime operations. Review of maintenance records revealed that the modification had not been installed in accordance with Federal Aviation Administration field approval procedures. Examination of the recovered wreckage did not reveal evidence of any preexisting mechanical anomalies that would have precluded normal operation of the airplane. Examination of the airplane's right side exhaust/heat exchanger did not reveal any leaks or fractures that would have led to carbon monoxide in the cabin. Because the left side exhaust/heat exchanger was not recovered, it was not possible to determine whether it was the source of the carbon monoxide.

Aircraft reference details include registration N1653U, MSN 207-0253, year of manufacture 1974.

Geospatial coordinates for this crash are approximately 60.7922°, -161.7558°.

Fatalities

Total

1

Crew

1

Passengers

0

Other

0

Crash Summary

The pilot departed on a postmaintenance test flight during day visual meteorological conditions. According to the operator, the purpose of the flight was to break in six recently installed engine cylinders, and the flight was expected to last 3.5 hours. Recorded automatic dependent surveillance-broadcast data showed that the airplane was operating at altitudes of less than 500 ft mean sea level for the majority of the flight. The data ended about 3 hours after takeoff with the airplane located about 23 miles from the accident site. There were no witnesses to the accident, which occurred in a remote area. When the airplane did not return, the operator reported to the Federal Aviation Administration that the airplane was overdue. Searchers subsequently discovered the fragmented wreckage submerged in a swift moving river, about 40 miles southeast of the departure/destination airport. Postmortem toxicology tests identified 21% carboxyhemoglobin (carbon monoxide) in the pilot's blood. The pilot was a nonsmoker, and nonsmokers normally have no more than 3% carboxyhemoglobin. There was no evidence of postimpact fire; therefore, it is likely that the pilot's elevated carboxyhemoglobin level was from acute exposure to carbon monoxide during the 3 hours of flight time before the accident. As the pilot did not notify air traffic control or the operator's home base of any problems during the flight, it is unlikely that he was aware that there was carbon monoxide present. Early symptoms of carbon monoxide exposure may include headache, malaise, nausea, and dizziness. Carboxyhemoglobin levels between 10% and 20% can result in confusion, impaired judgment, and difficulty concentrating. While it is not possible to determine the exact symptoms the pilot experienced, it is likely that the pilot had symptoms that may have been distracting as well as some degree of impairment in his judgment and concentration. Given the low altitudes at which he was operating the airplane, he had little margin for error. Thus, it is likely that the carbon monoxide exposure adversely affected the pilot's performance and contributed to his failure to maintain clearance from the terrain. According to the operator, the airplane had a "winter heat kit" installed, which modified the airplane's original cabin heat system. The modification incorporated an additional exhaust/heat shroud system designed to provide increased cabin heat during wintertime operations. Review of maintenance records revealed that the modification had not been installed in accordance with Federal Aviation Administration field approval procedures. Examination of the recovered wreckage did not reveal evidence of any preexisting mechanical anomalies that would have precluded normal operation of the airplane. Examination of the airplane's right side exhaust/heat exchanger did not reveal any leaks or fractures that would have led to carbon monoxide in the cabin. Because the left side exhaust/heat exchanger was not recovered, it was not possible to determine whether it was the source of the carbon monoxide.

Cause: Human factor

Occupants & Outcome

Crew On Board

1

Passengers On Board

0

Estimated Survivors

0

Fatality Rate

100.0%

Known people on board: 1

Operational Details

Schedule / Flight

Bethel - Bethel

Operator

Yute Air Alaska

Flight Type

Test

Flight Phase

Flight

Crash Site

Lake, Sea, Ocean, River

Region / Country

North America • United States of America

Aircraft Details

Registration

N1653U

MSN

207-0253

Year of Manufacture

1974