Individually Owned: 150,657
Corporate Owned: 137,281
York Municipal Airport
Aircraft Accident/Incident Report
York, Nebraska 68467
Friday, September 19, 2008 16:00 CDT
NTSB Narrative Summary Released at Completion of Accident
The flight instructor and student pilot were planning to do touch-and-go landings. A witness reported that the airplane took off on Runway 17, climbed about 100 feet, and then nosed down. The weather was clear and the wind was nearly straight down the runway. The flight instructor had logged nearly 3,000 hours of total flight time, with over 600 hours instruction and over 600 hours in the Cessna 172. Examination of the aircraft revealed no evidence of a preimpact mechanical malfunction. The flight instructor had a long history of diabetes, and had recently started a new injectable medication (exenatide, 10 micrograms twice a day) to help control his blood sugar. This medication can result in impairment due to low blood sugar, but he had not reported any adverse effects, and he was observed to be behaving normally the day prior to and the day of the accident. He was at extremely high risk of obstructive sleep apnea given his height (70 inches), weight (285 pounds), and poorly controlled blood pressure. Obstructive sleep apnea often results in impairment, but he was apparently not observed to snore while sleeping, a hallmark of the condition. Autopsy revealed an enlarged heart (it weighed 500 grams), but it was not thickened, suggesting an apparently unrecognized heart condition, dilated cardiomyopathy, that can result in sudden incapacitation. Given the failure of this experienced instructor pilot to either execute a normal climbout or appropriately oversee the climbout by his novice student, it is possible that he was incapacitated by a cardiac event. It is also possible, though less likely, that he was impaired either by unrecognized low blood sugar as a result of his new diabetes medication or by fatigue from unrecognized obstructive sleep apnea. However, the investigation could not conclusively determine if the instructor was impaired at the time of the accident.
NTSB Probable Cause Narrative
The student pilot's failure to maintain aircraft control, and the flight instructor's failure to take remedial action, for undetermined reasons.
Event Information
| Type of Event | Accident |
| Event Date | 9/19/2008 |
| Event Day of the Week | Friday |
| Time of Event | 1600 |
| Event Time Zone | Central Daylight Time |
| Event City | York |
| Event State | NEBRASKA |
| Event Country | -- |
| Zipcode of the event site | 68467 |
| Event Date Year | 2008 |
| Event Date Month | 9 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 405349N |
| Event Location Longitude | 0973722W |
| Event Location Airport | York Municipal |
| Event Location Nearest Airport ID | JYR |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | 1670 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1610 Central Daylight Time |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | JYR |
| Elevation of weather observation facility | 1670 |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | CDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | -- |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Clear |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | 27 |
| Dew Point at event time (in degress fahrenheit) | 14 |
| Wind Direction (degrees magnetic) | 200 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 8 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 30.07 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | KJYR 192030Z 21009KT 10SM FEW044 26/14 A3007 RMK A |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | 2 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 25785 |
| NTSB Notification Source | FAA ACE ROC |
| NTSB Notification Date | Sep 19 2008 12:00AM |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Sep 2 2009 2:22PM |
| User who most recently changed record | guzj |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | Lincoln, Nebraska |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N4380Q |
| NTSB Number | DEN08FA155 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | None |
| Flight plan Was Activated? | -- |
| Damage | Substantial |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | CESSNA |
| Aircraft Model | 172L |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 17260280 |
| Certified Max Gross Weight | 2300 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | 2 |
| Cabin Crew Seats | -- |
| Passenger Seats | 2 |
| 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 8 2008 12:00AM |
| Airframe hours since last inspection | 15 |
| Airframe Hours | 3945 |
| ELT Installed | Yes |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | No |
| ELT Type | C91 |
| Aircraft Owner Name | York Aviation, Inc. |
| Aircraft Owner Street Address | 1112 Highway 34 |
| Aircraft Owner City | York |
| Aircraft Owner State | NE |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 68467 |
| Operator is an individual? | No |
| Operator Name | York Aviation, Inc. |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | 1112 Highway 34 |
| Operator City | York |
| Operator State | NE |
| Operator Country | USA |
| Operator Zip code | 68467 |
| Operator Code | -- |
| Owner has at least one certificate | None |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | -- |
| 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) | Instructional |
| Second Pilot on Board | Yes |
| Departure Point Same as Event | Yes |
| Departure Airport Code | JYR |
| Departure City | York |
| Departure State | NE |
| Departure Country | USA |
| Departure Time | 1545 |
| Departure Time Zone | CDT |
| Destination Same as Local Flt | dest & departure same, accident can occur anywhere |
| Destination Airport Code | JYR |
| Destination City | -- |
| Destination State | -- |
| Destination Country | USA |
| Specific Phase of Flight | Takeoff |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Aug 18 2009 10:05AM |
| User who most recently changed record | johb |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | 17 |
| Runway Length | 5900 |
| Runway Width | 100 |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |