Takeoff & Initial Climb · NTSB WPR09LA022

STINSON 108-1 — Concrete, WA

1 fatal High-time pilotNight
DateOctober 23, 2008
LocationConcrete, WA
AircraftSTINSON 108-1
Purpose of flightPersonal
ConditionsNight/Dark · Visual Meteorological Cond
Phase / occurrenceInitial climb Miscellaneous/other
Pilot age71
Pilot total time34,100 hrs · High time
Time in type113 hrs
Fatalities1, 2 serious

Probable cause

The loss of engine power during initial climb due to the pilot's improper exhaust system maintenance, which resulted in restriction of the carburetor's air intake.

NTSB findings

  • Aircraft-Aircraft power plant-Power plant-(general)-Failure - C
  • Aircraft-Aircraft power plant-Engine exhaust-(general)-Incorrect service/maintenance - C
  • Personnel issues-Task performance-Maintenance-(general)-Pilot - C
  • Environmental issues-Physical environment-Object/animal/substance-Tree(s)-Contributed to outcome
  • Environmental issues-Conditions/weather/phenomena-Light condition-(general)-Contributed to outcome

What happened

For 7 years, the pilot had performed maintenance, which included 100-hour and annual inspections of his airplane's engine. On an undetermined date, a rope-like material had been placed between the exhaust's heater shroud and muffler. At an undetermined date/time, this material became separated from its installed location. During takeoff on the accident flight, the rope-like material became lodged in the carburetor's air intake. This resulted in restricting the flow of air into the carburetor, and the engine lost power. It was a dark night, and the airplane collided with trees during the ensuing forced landing. Toxicology results were consistent with the relatively recent use of diphenhydramine, an over-the-counter antihistamine with sedative and impairing effects, and propoxyphene, a prescription narcotic medication with impairing effects. The levels detected on toxicology evaluation were not consistent with impairment at the time of the accident. The pilot had indicated to the FAA a history of diabetes and kidney stones, but not the use of diphenhydramine or propoxyphene, and it could not be determined whether medical conditions or the use of medication may have played a role in his decision to insert the rope-like material in the engine compartment.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →