Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Ravenswood, West Virginia 26164
Thursday, July 30, 2009 21:49 EDT
NTSB Narrative Summary Released at Completion of Accident
The pilot of the single-engine, non-pressurized airplane in cruise flight at 25,000 feet above mean sea level requested and was issued a descent clearance to 12,000 feet. The pilot acknowledged the clearance, but the airplane did not descend. Air traffic control (ATC) noted that the pilot sounded "in distress and out of breath." The pilot was issued the clearance multiple times, but the airplane never descended. The last radio transmission received from the airplane was the pilot's labored breathing. Approximately 1 hour later, the airplane crossed directly over the destination airport at 25,000 feet, and maintained its on-course heading. National Guard aircraft scrambled to intercept the airplane were unable to gain the pilot's attention. The intercepting pilots observed an "unresponsive individual who appeared to be unconscious." The airplane continued in cruise flight at 25,000 feet for another hour after passing the destination airport before it slowed, departed controlled flight, and descended into terrain. All major components of the airplane were accounted for at the accident site. Examination of non-volatile memory from the accident airplane revealed that the onboard oxygen system had 29 percent of its total oxygen capacity remaining when the accident occurred. The airplane was equipped with a factory-installed oxygen system that the pilot had augmented by installing a supplemental pulse-demand oxygen system several months prior to the accident. The manufacturers of both systems explicitly advised against the use of non-original components with their respective systems. The pilot routinely used masks from the airplane's original oxygen system with components from the supplemental system he installed, and even noted the occurrence of a previous encounter with hypoxia in his pilot logbook as a result of this practice.
NTSB Probable Cause Narrative
The pilot's improper modification of the certified, on-board oxygen system, which resulted in incapacitation due to hypoxia, and the airplane's subsequent uncontrolled descent into terrain.
Event Information
| Type of Event | Accident |
| Event Date | 7/30/2009 |
| Event Day of the Week | Thursday |
| Time of Event | 2149 |
| Event Time Zone | Eastern Daylight Time |
| Event City | Ravenswood |
| Event State | WEST VIRGINIA |
| Event Country | -- |
| Zipcode of the event site | 26164 |
| Event Date Year | 2009 |
| Event Date Month | 7 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 390204N |
| Event Location Longitude | 0814418W |
| 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 | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 2153 Eastern Daylight Time |
| Direction of event from weather observation facility (degrees) | 35 |
| Weather Observation Facility ID | PKB |
| Elevation of weather observation facility | 806 |
| Distance of event from weather observation facility (units?) | 30 |
| Time Zone of the weather observation | EDT |
| Lighting Conditions | Night/Dark |
| Lowest Ceiling Height | 3800 |
| Lowest Non-Ceiling Height | 1600 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | Broken |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 2 |
| Air Temperature at event time (in degrees celsius) | 22 |
| Dew Point at event time (in degress fahrenheit) | 21 |
| Wind Direction (degrees magnetic) | 170 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 3 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 29.93 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| METAR weather report | -- |
| Event Highest Injury | Fatal |
| On Ground, Fatal Injuries | -- |
| On Ground, Minor Injuries | -- |
| On Ground, Serious Injuries | -- |
| Injury Total Fatal | 1 |
| Injury Total Minor | -- |
| Injury Total None | -- |
| Injury Total Serious | -- |
| Injury Total All | 1 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 27388 |
| NTSB Notification Source | NTSB Communication Center |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Oct 4 2010 8:39PM |
| User who most recently changed record | johb |
| Basic weather conditions | Instrument Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N581DS |
| NTSB Number | ERA09FA429 |
| Missing Aircraft Indicator | -- |
| Federal Aviation Reg. Part | Part 91: General Aviation |
| Type of Flight Plan filed | IFR |
| Flight plan Was Activated? | Yes |
| Damage | Destroyed |
| Aircraft Fire | None |
| Aircraft Explosion | None |
| Aircraft Manufacturer's Full Name | CIRRUS |
| Aircraft Model | SR-22 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 3164 |
| Certified Max Gross Weight | 3400 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| 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 | Jul 22 2009 12:00AM |
| Airframe hours since last inspection | 12 |
| Airframe Hours | 446 |
| ELT Installed | Yes |
| ELT Activated | No |
| ELT Aided Location of Event Site | No |
| ELT Type | Unknown |
| Aircraft Owner Name | Sequoia Airways, LLC |
| Aircraft Owner Street Address | -- |
| Aircraft Owner City | Avon |
| Aircraft Owner State | IN |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 46123 |
| Operator is an individual? | No |
| Operator Name | Sequoia Airways, LLC |
| Operator Same as Owner? | Yes |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | Yes |
| Operator Street Address | -- |
| Operator City | Avon |
| Operator State | IN |
| Operator Country | USA |
| Operator Zip code | 46123 |
| 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) | Personal |
| Second Pilot on Board | No |
| Departure Point Same as Event | No |
| Departure Airport Code | JYR |
| Departure City | York |
| Departure State | NE |
| Departure Country | USA |
| Departure Time | 1840 |
| Departure Time Zone | EDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | EYE |
| Destination City | Indianapolis |
| Destination State | IN |
| Destination Country | USA |
| Specific Phase of Flight | -- |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Aug 31 2010 2:36PM |
| User who most recently changed record | kenj |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | N/A |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |