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Williamjdoylejr.netNational Transportation Safety Board
Brief narrative statement of facts, conditions and circumstances pertinent to the accident/incident: *** Note: NTSB investigators either traveled in support of this investigation or conducted asignificant amount of investigative work without any travel, and used data obtained from varioussources to prepare this aircraft accident report. *** "THIS CASE WAS MODIFIED JANUARY 27, 2009." On November 8, 2007, about 1918 Pacific standard time, a Cessna T182T, N881CP, was destroyed afterimpacting mountainous terrain during climb to cruise near Potosi Mountain, about 13 nautical milessouthwest of Las Vegas, Nevada. The airplane was registered to the Civil Air Patrol, Maxwell AirForce Base, Montgomery, Alabama. The left-seat first pilot and right-seat second pilot, both ofwhom possessed airline transport pilot certificates, were killed. Visual meteorological dark nightconditions prevailed for the 14 Code of Federal Regulations (CFR) Part 91 personal cross-countryflight, and a visual flight rules (VFR) flight plan had been filed and activated at the time of theaccident. The flight departed the North Las Vegas Airport (VGT), Las Vegas, Nevada, about 1905, andwas destined for the Rosamond Skypark (L00), Rosamond, California.
At 1822 the pilot of N881CP filed a VFR flight plan from VGT to L00 and stated that he did not needa weather briefing. Air Traffic Control recorded the flight as CAP Flight 2793.
The Federal Aviation Administration's (FAA) recorded data indicates that after departing VGT onRunway 30L, the airplane turned to a southwesterly heading. At 1905:29, the pilot made the following transmission: "Las Vegas departure, Cap Flight 2793 iswith you. We're leaving, ah, twenty-seven hundred for ten point five." The controller responded,"Cap Flight twenty-seven ninety-three, Las Vegas departure. Ident, and ah, remain outside of classBravo airspace." The pilot acknowledged the controller's instructions.
At 1905:49, the controller transmitted, "Cap Flight twenty-seven ninety-three, radar contact twomiles south of North Las Vegas Airport. Verify climbing two-thousand seven-hundred." The pilotresponded, "That's affirmative." At 1906:05, the controller asked the pilot to verify his destination. The pilot replied, "We'regoing, ah, to Rosamond, California." The controller replied, "Cap Flight twenty-seven ninety-three,roger." At this time the airplane's altitude was 2,800 feet mean sea level (msl).
At 1906:34, the controller advised the pilot, "Cap Flight twenty-seven ninety-three, traffic eleveno'clock, four miles west bound is a metro helicopter climbing three-thousand five-hundred." Thepilot replied, "Twenty-seven ninety-three, we have him." The airplane's altitude was now 3,100 feet National Transportation Safety Board
At 1907:42, the pilot radioed to the controller, "And Cap Flight twenty-seven ninety-three, wewould like to leave frequency for a minute to open a flight plan." The controller granted thepilot's request and asked him to confirm that he still had the helicopter in sight. The pilotreplied, "That's affirmative." The controller replied, "Cap Flight, ah, twenty-seven ninety-three,roger. Maintain visual separation, and, ah, approved as requested." The pilot replied, "Alright."The airplane's altitude was 3,500 feet msl.
At 1908:25 and 1908:40 the pilot attempted to contact Reno radio to open his flight plan; theflight service station (FSS) specialist reported that both transmissions were unintelligible. Atthis time the airplane's altitude was about 3,600 feet msl.
At 1909:48 the pilot transmitted to Reno radio, "Flight two seven niner three departed North LasVegas five minutes past the hour. Open my flight plan please." The FSS specialist replied, "CapFlight two seven niner three, roger. VFR flight plan activated." The airplane was now at 4,100 feetmsl. At 1910:30, the pilot asked the controller, "Can, ah, Cap Flight twenty-seven ninety-three gethigher?" The airplane's altitude was now 4,200 feet msl.
At 1910:33, the controller responded, "Cap Flight, ah, twenty-seven ninety-three contact approachone two, or correction, climb to VFR requested altitude outside of class Bravo airspace. Contactapproach one two five point niner." The pilot replied, "Twenty-five nine, changing." The airplane'saltitude was 4,200 feet msl.
At 1910:50, the pilot transmitted to the controller, "Approach, Cap Flight twenty-sevenninety-three is with you. We're leaving forty-four hundred for ten point five." The controllerreplied, "And Cap Flight twenty-seven ninety-three, Las Vegas departure. Roger." The airplane'saltitude was 4,400 feet msl. At 1911:55, the controller asked the pilot, "Cap Flight twenty-seven ninety-three, what's yourrequested on course heading, and how high you want to go?" The pilot responded, "We would like, ah,ten point five, and we are at two one zero." The airplane's altitude was 4,800 feet msl.
At 1912:06, the controller responded, "Roger. Proceed on course. VFR climb to ten point fiveapproved." The pilot replied, "Cap Flight twenty-seven ninety-three, thank you." The airplane'saltitude was 4,900 feet msl.
At 19:17:29 radar contact was lost. There was no further radio communication received from theflight. The last recorded altitude was 7,000 feet msl.
A local law enforcement officer/pilot, who was assigned to the Las Vegas Metropolitan PoliceDepartment's Air Support/Search and Rescue Unit, reported that on the evening of the accident,while flying a helicopter patrol mission and heading in a south-southwest direction, he observed alarge fireball/explosion in the vicinity of Mount Potosi, elevation 8,514 feet msl. The officerstated that his partner also observed and confirmed that it was an explosion. The officer reportedthat while en route to the area of the fire he observed additional fireballs, and upon arriving atthe accident site his partner confirmed that the fire was the result of an airplane crash. Oneofficer described the area as void of any lighting which would aid in the illumination of terrain.
On November 10, 2007, onsite documentation of the accident site revealed that the airplane hadimpacted a near vertical rock face on the southeast side of Mount Potosi, about 1,000 feet belowits summit. A survey of the accident site revealed that all airplane components necessary forflight were identified. One propeller blade was not accounted for during the initial onsite National Transportation Safety Board
examination, nor during the recovery phase of the wreckage.
On November 13, 2007, the airplane was recovered to a secured storage facility for furtherexamination by parties to the investigation.
The left-seat first pilot, age 73, possessed an FAA airline transport pilot certificate forairplane multiengine land and commercial privileges for airplane single-engine land. The pilot alsopossessed multiple airline transport category type ratings, a turbojet flight engineer rating, aswell as flight navigator certification. It was reported by Civil Air Patrol personnel that thepilot had accumulated a total flight time of 25,000 hours. The pilot's personal logbooks were notaccounted for during the investigation.
The pilot held a second-class FAA airman's medical certificate, which was issued on September 10,2007, with the limitation "Must have available glasses for near vision." The pilot had been the CAP's Nevada Wing Commander since 2003. According to a flight log providedby the Nevada Wing of the CAP, the pilot had accumulated 74.7 hours in Garmin 1000 (G1000) equippedCessna airplanes, and 34.2 hours in the accident airplane. The pilot had received G1000 trainingfrom a CAP instructor; the instructor was factory trained at the Cessna training facility inIndependence, Missouri. The pilot's training was conducted in accordance with the CessnaFAA/Industry Training Standards (FITS) training program. The curriculum included 3 ground schoolsessions of 4 hours each, and three training flights of 2 hours each. The right-seat second pilot, age 71, possessed an airline transport pilot certificate for airplanesingle-engine land, multiengine land, and single-engine sea. The pilot also held an airlinetransport pilot certificate for rotorcraft-helicopters and commercial privileges for gliders.
Additionally, the pilot possessed a flight instructor certificate for single and multiengineairplanes, instrument airplane, helicopters, and gliders. The pilot also possessed advanced andinstrument ground instructor certification, a flight engineer certificate for turbojet andturbopropeller airplanes, airframe and powerplant mechanic certification, and flight navigatorcertification. The pilot held multiple airline transport category type ratings for both helicoptersand airplanes. CAP personnel reported that the pilot had accumulated more than 28,000 hours offlight time, comprised of both military and civilian flying experience. The pilot's personallogbooks were not accounted for during the investigation.
The pilot possessed a first-class FAA airman's medical certificate, which was issued on May 25,2007, with the limitation "Must wear corrective lenses." Civil Air Patrol personnel reported that the pilot had served in the CAP for more than 50 years. Atthe time of the accident the pilot was the Director of Operations for the CAP's Pacific Region. Thepilot was also the former National Vice Commander, serving in the capacity for one year beforeserving as the Pacific Region commander for four years. Additionally, the pilot had held theposition as the California Wing Commander. It was further reported by CAP personnel that the pilothad not been trained in CAP G1000 equipped airplanes, and was not authorized to fly G1000 equippedCAP airplanes. The 2006-model Cessna T182T airplane underwent its most recent annual inspection on September 7, National Transportation Safety Board
2007, at a total time on the airframe and engine of 300.8 hours. The airplane's most recenttachometer reading was recorded on November 7, 2007, at a total time of 338.7 hours. There was norecord of the airplane having been involved in any previous airplane accidents. The turbocharged, autopilot-equipped airplane was equipped with a Garmin G1000 Integrated CockpitSystem. The system incorporates a Primary Flight Display (PFD) and a Multi Function Display (MFD).
The MFD allows the pilot to access the Terrain Proximity Page, which provides the pilot withterrain elevation relative to the airplane's altitude, current aircraft location, range markingrings, a heading box, and obstacles. The Terrain Avoidance and Warning System (TAWS) option was notinstalled on the airplane.
The following statement is printed in the Garmin G1000 Pilot's Guide for Cessna Nav III: "CAUTION:Use of Terrain Proximity information for primary terrain avoidance is prohibited. The TerrainProximity Map is intended only to enhance situational awareness. It is the pilot's responsibilityto provide terrain avoidance at all times." A National Transportation Safety Board Air Traffic Control Investigator reviewed the radar data forthe accident flight. The investigator reported that radar data for this accident was obtained fromthe LAS Airport Surveillance Radar-9 (ASR-9) sensor as recorded by the Las Vegas Terminal RadarApproach Control (L30) Standard Terminal Automation Replacement System (STARS), which indicatedthat Cap Flight 2793 was continuously visible from departure at VGT until impact with Mt. Potosi.
The radar also displayed an image of the symbol depicting Mt. Potosi as Cap Flight 2793 approachedthe obstacle just prior to the accident. Interviews with Air Traffic Control personnel In an interview with the L30 Daggett/Mead radar controller, the controller stated that VFR aircraften route to the Bakersfield area usually pass north of Mt. Potosi, while aircraft en route to theSouthern California area pass further south. The controller reported that he does not handle VFRtraffic flying at night any differently than he does in the daytime, and that he did not noticeanything unusual about the accident aircraft as it headed toward Mt. Potosi. The controller stated,"It looked just like other aircraft passing through the area." The controller stated that he knewthat the height of Mt. Potosi was 8,500 feet.
In an interview with the Daggett radar controller, who had just relieved the L30 Daggett/Mead radarcontroller and was controlling Cap Flight 2793 at the time of the accident, the controller reportedthat when he was relieved he was informed that the accident airplane was climbing to its requestedaltitude, 10,500 feet. The controller stated, "The aircraft looked fine - there was nothingunusual about it. When questioned about where he expected the aircraft to go the controller repliedthat ".the pilot was on his own navigation." The controller stated that other aircraft he hasseen go where the accident aircraft was, and some go further south. Asked when he is required toissue a safety alert, the controller stated, in his opinion, when an aircraft is close to terrainor other aircraft. The controller stated that he knew that the height of Mt. Potosi was 8,500 feet.
(See the National Transportation Safety Board's Air Traffic Control Group Chairman's Factual Reportfor additional details.) Safety Alerts, FAA Air Traffic Control Order 7110.65 FAA Order 7110.65 states, in part, that a controller's duty priority is to "give first priority toseparating aircraft and issuing safety alerts." The safety alert is to be issued to an aircraftonce the controller observes and recognizes a situation wherein the aircraft is in unsafe proximity National Transportation Safety Board
to terrain, obstacles, or other aircraft. The controller ".must remain vigilant for suchsituations." At 1856, the Automated Surface Observing System (ASOS) at the McCarran International Airport (LAS),Las Vegas, Nevada, located about 19 nautical miles northeast of the accident site, reported wind240 degrees at 3 knots, visibility 10 miles, few clouds at 18,000 feet, broken clouds at 25,000feet, temperature 23 degrees C, dew point -1 degree C, and an altimeter setting of 29.95 inches ofMercury.
According to the U.S. Naval Observatory, Department of Astronomical Applications, the phase of themoon was waning crescent (not seen anytime before midnight) with 1% of the moon's visible diskilluminated. Moonrise was at 0605 on the following day.
On November 10, 2007, the NTSB IIC, accompanied by representatives from the FAA, United States AirForce, and Cessna Aircraft Company examined the wreckage at the accident site. The examinationrevealed that the airplane had impacted rapidly rising terrain nose first in an approximate levelflight attitude, about 21 nautical miles southwest of VGT, elevation 2,205 feet msl. The impactsite was located about .6 miles southeast of the summit of Mount Potosi, elevation 8,514 feet msl.
The airplane had impacted the terrain on a magnetic heading of about 210 degrees, subsequentlyfalling about 30 feet before coming to rest on a rock outcropping at an elevation of about 7,450feet msl. A large burn mark above the outcropping was consistent with the airplane's initial impactpoint.
An examination of the accident site revealed that the fuselage had been consumed by fire from theengine compartment aft to about fuselage station 172. All flight and engine instruments sustainedextensive impact and thermal damage. The empennage came to rest in an inverted position, with thetop of the right horizontal stabilizer observed crushed downward near its inboard edge causingdamage to the right horizontal stabilizer leading edge. The leading edge of the right horizontalstabilizer exhibited aft crushing to its top at approximately midspan. The leading edges of bothwings were observed to have been crushed aft.
Flight control cable continuity was established and confirmed for the rudder and elevators. Aileroncontrol continuity was partially confirmed, with aileron cables observed attached to theirrespective bellcranks. Elevator trim tab control cable continuity was partially established.
An autopsy was performed on each pilot by the Clark Country Coroner's Office, Las Vegas, Nevada.
According to the autopsy reports, the cause of death for both pilots was "Multiple blunt forcetrauma." The FAA Civil Aerospace Medical Institute (CAMI) prepared a Final Forensic Toxicology AccidentReport from samples taken at each pilot's autopsy. The left seat first pilot's CAMI reportindicated samples sustained putrefaction. The right seat second pilot's CAMI report indicated noputrefaction. The CAMI toxicology for the right seat second pilot was negative for the testsperformed. The CAMI toxicology report for the left seat first pilot stated: 15 (mg/dL, mg/hg) ETHANOL detected in Liver49 (mg/dL, mg/hg) ETHANOL detected in Muscle3 (mg/dL, mg/hg) N-PROPANOL detected in Muscle National Transportation Safety Board
DIPHENHYDRAMINE detected in KidneyDIPHENHYDRAMINE detected in Liver A postaccident examination of the airframe's structure and engine failed to reveal any preimpactfailures or malfunctions, which would have precluded normal operation.
An examination of the airplane's avionics components revealed that they were too thermally andimpact-damaged to provide any data.
Radar data for the last 6 minutes of flight, during which the flight was clear of class B airspaceand cleared to climb to its cruise altitude of 10,500 feet msl, indicated that the airplane'saverage groundspeed was 100 knots, its average rate of climb was 406 feet per minute (fpm), and itsaverage magnetic heading was 222 degrees. Based on this information, a calculated rate of climb of596 fpm would have been required to have safely cleared the terrain along the flight's path.
On March 1, 2003, the Federal Aviation Administration issued Advisory Circular number 61-134,"General Aviation Controlled Flight Into Terrain Awareness." The circular was issued to the generalaviation community to ".emphasize the inherent risk that controlled flight into terrain (CFIT)poses for general aviation (GA) pilots." The circular defines CFIT as a situation which ".occurs when an airworthy aircraft is flown underthe control of a qualified pilot, into terrain (water or obstacles) with inadequate awareness onthe part of the pilot of the impending collision." According to the CFIT circular, "situational awareness" is defined as ".when the pilot is awareof what is happening around the pilot's aircraft at all times in both the vertical and horizontalplane. This includes the ability to project the near term status and position of the aircraft inrelation to other aircraft, terrain, and other potential hazards."Updated on Jan 30 2009 12:36PM National Transportation Safety Board
- Emergency Locator Transmitter (ELT) Information Regulation Flight Conducted Under: Part 91: General Aviation Type of Flight Operation Conducted: Personal National Transportation Safety Board
Airline Transport; Commercial; Flight Engineer Medical Cert. Status: With Waivers/Limitations National Transportation Safety Board
National Transportation Safety Board
Additional Persons Participating in This Accident/Incident Investigation: Leslie A SpahnFederal Aviation AdministrationLas Vegas, NV Henry J SoderlundCessna Aircraft CompanyWichita, KS Mark W PlattTextron LycomingWilliamsport, PA Colonel Lyle E LetteerCivil Air PatrolDobbins AFB, GA Major James GroganUnited States Air ForceBeale Air Force Base, CA
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