Report on Carnahan crash answers what happened

WASHINGTON -- The final report from federal investigators on the plane crash that killed Gov. Mel Carnahan explains what happened that night, and why.

The National Transportation Safety Board concluded that his pilot son, Randy, suffered disorientation so severe that he lost control of his Cessna 335, and the plane plummeted 7,700 feet into wooded hills.

But the agency's report did not assess blame, something most likely to be done over the next few months in a court of law.

Relatives of the governor, his son and an aide, Chris Sifford, are pursuing wrongful death lawsuits stemming from the crash in Jackson County, Mo., Circuit Court. At issue is the attitude indicator, a crucial instrument which reports a plane's position in the air, telling whether it is banking and whether the nose is high or low.

NTSB investigators concluded that the primary attitude indicator "was not displaying properly at the time of impact," although they could not determine what caused the malfunction.

The families contend that the malfunction of the vacuum pump system that powered the instrument caused or contributed to the crash. The lawsuits also claim that three of the defendants knew the part had a history of failure but did not issue proper warnings.

A transcript of Randy Carnahan's conversation with air traffic controllers, released by NTSB, shows the pilot struggled with the failed instrument as he flew through stormy skies.

The Democratic governor was battling GOP Sen. John Ashcroft in the U.S. Senate race, and his plane took off from St. Louis in darkness, rain and fog that night. The three men were traveling to a campaign stop in New Madrid, Mo.

"We got a primary attitude indicator that's not, uh, reading properly, having to try and fly off of co-pilot," Randy Carnahan said.

The "co-pilot" was a smaller, secondary attitude indicator, which investigators concluded was working. Thus, "the loss of the primary attitude indicator alone does not explain why the pilot lost control of the airplane and crashed," the report said.

Noisy, bumpy flight

Here is what Randy Carnahan probably experienced, said Paul Czysz, a professor of aerospace engineering at St. Louis University, in an interview on Friday:

"It's dark gray to black, and there are lightning flashes. You cannot resolve the horizon -- up, down, everything looks the same. It's so loud you can't hear-- you're flying at maybe 150 miles per hour, with rain and sometimes hail hitting the windscreen and water coming off the propellers, which are nearly supersonic. When it hits the fuselage, against the aluminum and glass, it sounds like you're in some kind of airstrike, like the air is just filled with marbles. And the airplane is bouncing up and down. You get disoriented."

That disorientation, called spatial disorientation, was listed by NTSB as the probable cause, with the weather and failed primary attitude indicator as contributing factors.

Because the secondary attitude indicator was smaller and located several feet away, Randy Carnahan would have had to turn his head frequently and rapidly for cross-checks with other instruments, likely causing "spatial disorientation" that probably was exacerbated by noise and turbulence from the storms, the report said.