Aircraft Accident/Incident Report

Kerman, California 93630
Thursday, April 7, 1994 23:35 PDT

NTSB Narrative Summary Released at Completion of Accident

RECORDED RADAR & VOICE TAPES REVEALED THAT 15 MINUTES AFTER TAKEOFF, THE AIRCRAFT BEGAN DEVIATING FROM HEADINGS, ALTITUDES, & ATC INSTRUCTIONS. THE FACILITIES WORKING THE FLIGHT SAID THE AIRCRAFT'S COURSE OF FLIGHT WAS ERRATIC, WITH THE ERRATIC BEHAVIOR BECOMING WORSE AS THE FLIGHT CONTINUED. THE PILOT SEEMED TO BE DISORIENTED. THE AIRCRAFT DRIFTED SIGNIFICANTLY OFF ASSIGNED AIRWAYS & HEADINGS, & DID SEVERAL 360 & 180 DEGREE TURNS. THE PILOT SAID THAT AFTER REACHING CRUISE ALTITUDE, HE BEGAN TO EXPERIENCE BLURRED VISION, HEADACHES, & NAUSEA. HE SAID HIS BREATHING BECAME LABORED, & THE CONTROLS BECAME DIFFICULT TO MOVE. THE FLIGHTPATH OF THE AIRPLANE KEPT CHANGING DIRECTION & ALTITUDE, & THE PILOT COULD NOT STAY AWAKE. MANY SMALL LEAKS WERE FOUND IN THE EXHAUST SYSTEM, WITH GAS PATHWAYS FOUND INTO THE CABIN. HOSPITAL TESTS FOR ALCOHOL & DRUGS WERE NEGATIVE. AN FAA FLIGHT SURGEON AT CAMI REVIEWED THE CASE & REPORTED THAT THE SYMPTOMS WERE CONSISTENT WITH CARBON MONOXIDE POISONING. BLOOD DRAWN 11 HRS AFTER ENTERING A HOSPITAL RETAINED 3% SATURATION WITH CARBON MONOXIDE.

NTSB Probable Cause Narrative

AN EXHAUST GAS LEAK, DUE TO INADEQUATE MAINTENANCE, WHICH RESULTED IN CARBON MONOXIDE POISONING, INCAPACITION OF THE PILOT, AND LOSS OF AIRCRAFT CONTROL.

Event Information

Type of Event Accident
Event Date 4/7/1994
Event Day of the Week Thursday
Time of Event 2335
Event Time Zone Pacific Daylight Time
Event City KERMAN
Event State CALIFORNIA
Event Country --
Zipcode of the event site 93630
Event Date Year 1994
Event Date Month 4
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Not pertinent
Investigator's weather source Unknown
Time of the weather observation 2250 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 70
Weather Observation Facility ID FAT
Elevation of weather observation facility 333
Distance of event from weather observation facility (units?) 13
Time Zone of the weather observation PDT
Lighting Conditions Night/Dark
Lowest Ceiling Height 13000
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Unknown
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 15
Air Temperature at event time (in degrees celsius) 14
Dew Point at event time (in degress fahrenheit) 6
Wind Direction (degrees magnetic) 300
Variable Wind Indicator Unknown
Wind Speed (knots) 6
Wind Velocity Indicator Unknown
Wind Gust Indicator Not Gusting
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 30
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor --
Injury Total None --
Injury Total Serious 1
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 931
NTSB Notification Source --
NTSB Notification Date Apr 8 1994 12:00AM
NTSB Notification Time 130
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 6 2000 11:02AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N9124G
NTSB Number LAX94LA184
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name CESSNA
Aircraft Model 182N
Aircraft Series Identifier 182N
Aircraft Serial Number 18260664
Certified Max Gross Weight 2900
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 4
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Sep 1 1993 12:00AM
Airframe hours since last inspection 49
Airframe Hours 3075
ELT Installed Yes
ELT Activated Yes
ELT Aided Location of Event Site Yes
ELT Type --
Aircraft Owner Name PETER L. HEDEGARD
Aircraft Owner Street Address 10838 EAST MARGINAL WAY SOUTH
Aircraft Owner City SEATTLE
Aircraft Owner State WA
Aircraft Owner Country
Aircraft Owner Zipcode 98168
Operator is an individual? --
Operator Name PETER L. HEDEGARD
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 16800 NE 31ST
Operator City BELLEVUE
Operator State WA
Operator Country
Operator Zip code 98008
Operator Code
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code LGB
Departure City LONG BEACH
Departure State CA
Departure Country
Departure Time 2113
Departure Time Zone PDT
Destination Same as Local Flt --
Destination Airport Code MOD
Destination City MODESTO
Destination State CA
Destination Country
Specific Phase of Flight Descent
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jan 2 2001 10:34AM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --