CEN16LA197 · Cessna 501
Eagle II Aero Cessna 501 · Accident: pressurization/environmental system malfunction/failure en route
From K02 · Perryville, MO to San Antonio International Airport (SAT)
Event
- NTSB case
- CEN16LA197
- Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
- Accident
- InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
- Completed
- API-reported fatalities
- 0 · all aircraft and ground
- Ground fatalities
- Unknown
- OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
- General aviation
- WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
- Visual Meteorological Cond
Cessna 501
- Aircraft type
- Cessna 501
- Category
- Airplane
- RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
- N804ST
- Operator
- Eagle II Aero
- Onboard fatalities
- Unknown
- Route
- From K02 · Perryville, MOTo San Antonio International Airport (SAT), San Antonio, TX
- Aircraft age
- About 36 years (built 1980)
- Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
- Part 91: General Aviation
- Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
- En route
- Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
- Pressurization/environmental system malfunction/failure
- DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
- Substantial
Cause areas
- Aircraft › Aircraft oper/perf/capability
- Aircraft › Aircraft systems
- Personnel issues › Action/decision
- Personnel issues › Physical
Approximate · Coordinates from the NTSB case API, which marks them as estimated or does not say; no uncertainty radius is established.
NTSB narrative
The small jet airplane, which was being operated by a single pilot, experienced a loss of cabin pressurization during cruise flight about 43,000 ft. The pilot and passengers lost consciousness and the airplane entered an uncontrolled descent. The pilot regained consciousness and control of the airplane at 7,000 ft and landed the airplane at an alternate destination without further incident. The airplane sustained substantial damage to both wings due to the excessive aerodynamic loads incurred during the descent/recovery. Given the airplane's cruise altitude, the pilot was required by Federal Aviation Regulations to wear a supplemental oxygen mask; however, he was not doing so at the time of the loss of pressurization.
Postaccident examination of the airplane revealed that the aft pressure bulkhead check valve flapper was fractured. Additionally, the air conditioning system's primary pressurization duct leading to the cabin was separated from its connection with the water separator due to a loose retaining clamp on the duct's metal worm-gear. Material analysis of the fractured flapper valve indicated the presence of progressive cracking and a loss of mechanical properties due to physical aging; exposure to atmospheric pollutants and oxygen can degrade the flapper material.
The airplane lost pressurization when the air conditioning system's primary pressurization duct separated and the pressurized air was discharged into the unpressurized section of the airplane. The subsequent failure of the flapper valve then allowed the pressurized air to escape the cabin.
Probable cause
The pilot's failure to use supplemental oxygen as required during high-altitude flight, which resulted in his loss of consciousness following a loss of cabin pressurization. Contributing to the accident was the separation of the air conditioning system's primary pressurization duct and the subsequent failure of the aft pressure bulkhead check valve flapper due to progressive weakening from age.
Verbatim NTSB analysis and probable cause from the NTSB dataset
Sources
NTSB record CEN16LA197
- Event ID
- 20160527X13034
- Case number
- CEN16LA197
- Dataset
- full-current
- Source SHA-256
- 5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
- Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
- Filled from the NTSB case API where the bulk record had no value: local date, investigation status, coordinates. Values present in the bulk record are kept.
- The date is the local date; the NTSB stores the UTC date 2016-05-24.
- API snapshot SHA-256: 1a863c683f44f5048c708ac001e29f9b5478d391c962c5c48f50a9e5d59dffba; retrieved 2026-09-16T03:26:19.681Z.