Aviation Investigation Final Report
Location: Danville, Virginia Accident Number: ERA22FA114
Date & Time: February 1, 2022, 10:06 Local Registration: N622QT
Aircraft: Cessna 310 Aircraft Damage: Destroyed
Defining Event: Loss of control in flight Injuries: 1 Fatal
Flight Conducted Under: Part 91: General aviation - Aerial observation
Analysis
The pilot was performing an aerial survey flight, and after completing a preflight inspection, he
taxied toward the runway for engine run-up and surveying computer start-up. During taxi and
the subsequent run-up, the airplane was positioned for about 8-10 minutes with a quartering
tailwind. Track data revealed that shortly after takeoff, the airplane’s climb rate decreased, and
its acceleration stopped. Shortly thereafter, the airplane began a 10°-bank-angle left turn at an
airspeed of about 136 knots, followed by a rapidly descending right turn and impact with
terrain.
Postaccident examination of the wreckage revealed that the left fuel tank selector handle was
in the OFF position, the left throttle was near idle, the left propeller control was near the feather
position, and the rudder was trimmed to the right. These control positions were consistent with
the left engine being partially secured, which would result in a lack of power and the loss of
climb rate noted shortly after takeoff. Additionally, the right fuel tank selector handle was
found in the left main fuel tank position. The examination of both engines revealed no
evidence of any preimpact anomalies or malfunctions that would have precluded normal
operation, and no reason for why the pilot might have partially secured the left engine.
In the event of an engine failure during takeoff, the airplane manufacturer’s Pilot’s Operating
Handbook (POH) assumes that the inoperative propeller is feathered and that 5° of bank
toward the operating engine is used to balance the side force generated by a full rudder input.
If these conditions do not exist, the airplane can quickly become uncontrollable at airspeeds
much higher than the published single-engine minimum controllable airspeed (Vmc). The
physical evidence, along with a performance analysis of the airplane’s flight track, showed that
the left engine was not fully secured, the right engine fuel selector was set to the left tank, and
the airplane banked 10° into the inoperative engine at an airspeed of about 136 kt shortly
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before the airplane entered a steep, descending right turn. This turn toward the inoperative
engine would have dramatically increased the airplane’s minimum controllable airspeed above
that assumed by the POH (80 knots), and the pilot's ability to maintain control of the airplane
would have been significantly reduced. It is likely that during this left turn, the pilot allowed the
airplane's airspeed to decrease below a speed for which the airplane would have been
controllable, which resulted in a loss of control and led to the airplane's roll to the right and
rapid descent toward the terrain.
Postaccident toxicological testing performed by a state office of forensic science revealed
that the pilot’s carboxyhemoglobin, a marker of carbon monoxide (CO) exposure, was elevated
at 31%. Although the Federal Aviation Administration Forensic Sciences Laboratory toxicology
results did not show elevated carboxyhemoglobin, these test results might have been
misleadingly low if there was an actual postmortem decrease of carboxyhemoglobin in the
tested blood. This may have occurred if the specimens were obtained from a collection site
where blood intermixed with gastric acid. The carboxyhemoglobin percentage measured in the
blood specimen tested by the state forensic science office was confirmed by a second distinct
technique, and the probability is small that the elevated result was attributable to postmortem
changes.
Examination of the airplane’s combustion heater assembly revealed no defects that could have
allowed the combustion biproducts to intermix with the ventilation air, and examination of the
wreckage revealed no evidence of inflight or post-impact fire. A postaccident test with an
exemplar airplane (the same make/model as the accident airplane) that was equipped with an
electronic CO detector revealed that when taxiing and performing an engine run-up with a
quartering tailwind, the exhaust from the left engine was able to penetrate the cockpit. Based
on the observations from this test, it is possible that engine exhaust gasses containing CO
could have entered the cockpit while the pilot was conducting his pre-takeoff tasks. Given that
the airplane was equipped only with a disposable “spot” CO detector, the pilot would not have
been alerted to increasing CO levels unless he had looked at the device and observed a color
change. Given that the temperature on the day of the accident was 33° F, it is likely that the
airplane’s heater was operating. It is possible that its fan could have drawn additional air
containing engine exhaust gasses and CO into the cabin heater air intake, and then into the
cockpit, which would have increased the pilot’s the level of CO exposure. No other source of
abnormal CO was identified.
Based on available operational and physical evidence, it is likely that the pilot was impaired
due to CO exposure. It is possible that this impairment could have resulted in his perception of
a left engine problem, and resulted in him partially securing it, as demonstrated by the
postaccident positions of the engine controls. Ultimately, the turn into the partially secured
engine resulted in a loss of control and impact with terrain.
Page 2 of 13 ERA22FA114
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot’s impairment due to exposure to carbon monoxide as a result of undetected engine
exhaust penetration into the cockpit, resulting in the pilot's failure to maintain a minimum
controllable airspeed after partially securing an engine after takeoff.
Findings
Aircraft (general) - Not specified
Personnel issues Carbon monoxide - Pilot
Environmental issues (general) - Effect on personnel
Aircraft Engine out control - Not attained/maintained
Page 3 of 13 ERA22FA114
Factual Information
History of Flight
Enroute-climb to cruise Medical event
Enroute-climb to cruise Loss of control in flight (Defining event)
On February 1, 2022, about 1006 eastern standard time, a Cessna 310R airplane, N622QT, was
destroyed when it was involved in an accident near Danville, Virginia. The commercial pilot was
fatally injured. The airplane was operated by Sol Aerial Surveys as a Title 14 Code of Federal
Regulations Part 91 aerial surveying flight.
According to another company pilot, on the morning of the accident, he and the accident pilot
arrived at the Danville Regional Airport (DAN), Danville, Virginia, conducted their flight planning
together, and completed the preflight inspections of their respective airplanes. They then
taxied their airplanes to runway 2 for engine run-up and surveying computer start-up. During
the taxi and engine run-up, the accident airplane was heading 196º true (205° magnetic). The
company pilot estimated that the accident pilot was on that heading for about 8-10 minutes
while they completed these pre-departure tasks. The company pilot departed first, and the
accident pilot departed several minutes later at 1003.
A performance study was prepared based on automatic dependent surveillance-broadcast
(ADS-B) data obtained from the Federal Aviation Administration (FAA). The study and ADSB-B
data showed that that the airplane departed DAN and turned toward the southeast. Shortly
after takeoff, the airplane’s climb rate decreased from 1,200 ft/minute to about 500 ft/minute,
and the airplane’s acceleration stopped. The airplane reached an altitude of about 2,625 ft
above mean sea level (msl) about 2 minutes into the flight and began a 10°-bank-angle left turn
at an airspeed of 136 knots. About 10 seconds after turning left, the airplane returned to wings-
level and then rolled right at a rate of about 3º/second while descending at a rate of more than
1,000 ft/minute. The last estimated bank angle was over 60° to the right at an altitude of 1,175
ft msl. The airplane impacted a wooded area about 4 nautical miles southeast of DAN.
Page 4 of 13 ERA22FA114
Pilot Information
Certificate: Commercial Age: 23,Male
Airplane Rating(s): Single-engine land; Multi-engine Seat Occupied: Left
land
Other Aircraft Rating(s): None Restraint Used: Unknown
Instrument Rating(s): Airplane Second Pilot Present: No
Instructor Rating(s): None Toxicology Performed: Yes
Medical Certification: Class 1 With waivers/limitations Last FAA Medical Exam: May 5, 2021
Occupational Pilot: Yes Last Flight Review or Equivalent: March 16, 2020
Flight Time: 528 hours (Total, all aircraft), 85 hours (Total, this make and model), 449 hours (Pilot In
Command, all aircraft)
According to the operator, the pilot had previously flown aerial surveying and had accrued 85
hours of flight experience in the same make and model of the accident airplane. The accident
flight was his first solo aerial surveying flight for the company following several observation
flights with the company’s owner.
Interviews with friends and family of the pilot revealed that he was happy to have been hired by
the operator, got along well with the company’s owner, and was pleased that the company’s
airplanes were newer and better equipped than those at his previous surveying job.
Aircraft and Owner/Operator Information
Aircraft Make: Cessna Registration: N622QT
Model/Series: 310 R Aircraft Category: Airplane
Year of Manufacture: 1977 Amateur Built:
Airworthiness Certificate: Normal Serial Number: 310R0828
Landing Gear Type: Retractable - Tricycle Seats: 2
Date/Type of Last Inspection: January 19, 2022 Annual Certified Max Gross Wt.: 5680 lbs
Time Since Last Inspection: 18.5 Hrs Engines: 2 Reciprocating
Airframe Total Time: 6512 Hrs as of last inspection Engine Manufacturer: Continental
ELT: C126 installed, activated, aided Engine Model/Series: IO-520-MB
in locating accident
Registered Owner: On file Rated Power: 285 Horsepower
Operator: On file Operating Certificate(s) None
Held:
Page 5 of 13 ERA22FA114
Review of maintenance records revealed that the airplane’s overhauled engines and propellers
had accumulated 18.6 hours of operation before the accident.
The airplane was equipped with an adhesive, disposable “spot” carbon monoxide (CO)
detector. In the presence of CO, the spot would turn gray/black, and the spot would return to
normal color after it is exposed to fresh air.
The Pilot’s Operating Handbook (POH) and airplane checklist required the fuel selectors to be
placed in the "main" position for takeoff. In the event of an engine failure during takeoff, the
POH directed the pilot to feather the inoperative propeller and establish a 5° bank into the
operating engine. With an engine shut down, in addition to the reduction in available power, the
lateral/directional handling qualities of the airplane change significantly, and the indicated
airspeed must be maintained faster than the Vmc of 80 knots to maintain directional control.
The complete POH checklist for an engine failure after takeoff includes the following:
1. Mixtures - AS REQUIRED for flight altitude.
2. Propellers - FULL FORWARD.
3. Throttles - FULL FORWARD.
4. Landing Gear - CHECK UP.
5. Inoperative Engine:
a. Throttle - CLOSE.
b. Mixture - IDLE CUT-OFF.
c. Propeller - FEATHER.
6. Establish Bank - 5° toward operative engine.
7. Wing Flaps - UP, if extended, in small increments.
8. Climb To Clear 50-Foot Obstacle - 92 KIAS.
9. Climb At Best Single-Engine Rate-of-Climb Speed - 106 KIAS at sea level
10. Trim Tabs - ADJUST 5° bank toward operative engine with approximately ½ ball slip
indicated on the turn and bank indicator.
11. Cowl Flap - CLOSE (Inoperative Engine).
12. Inoperative Engine - SECURE as follows:
a. Fuel Selector - OFF (Feel For Detent).
b. Auxiliary Fuel Pump - OFF.
c. Magneto Switches - OFF.
d. Alternator - OFF.
13. As Soon As Practical - LAND.
Cabin Heat System
Review of maintenance records revealed that the cabin heat system was installed in December
2019 at an airframe total time of 5,878.3 hours. Records show that it was serviced and
inspected in February 2020, April 2020, and January 2022. It had accrued 317.2 hours in
service at the most recent servicing.
Page 6 of 13 ERA22FA114
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC) Condition of Light: Day
Observation Facility, Elevation: DAN,590 ft msl Distance from Accident Site: 4 Nautical Miles
Observation Time: 09:53 Local Direction from Accident Site: 284°
Lowest Cloud Condition: Clear Visibility 10 miles
Lowest Ceiling: None Visibility (RVR):
Wind Speed/Gusts: 7 knots / Turbulence Type Unknown / Unknown
Forecast/Actual:
Wind Direction: 60° Turbulence Severity N/A / Unknown
Forecast/Actual:
Altimeter Setting: 30.47 inches Hg Temperature/Dew Point: 1°C / -4°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Danville, VA (DAN) Type of Flight Plan Filed: None
Destination: Danville, VA Type of Clearance: None
Departure Time: 10:03 Local Type of Airspace: Class G
Airport Information
Airport: Danville Regional Airport DAN Runway Surface Type: Asphalt
Airport Elevation: 571 ft msl Runway Surface Condition: Unknown
Runway Used: 2 IFR Approach: None
Runway Length/Width: 5900 ft / 100 ft VFR Approach/Landing: None
Wreckage and Impact Information
Crew Injuries: 1 Fatal Aircraft Damage: Destroyed
Passenger Injuries: Aircraft Fire: None
Ground Injuries: N/A Aircraft Explosion: None
Total Injuries: 1 Fatal Latitude, 36.556292,-79.253198
Longitude:
The wreckage was highly fragmented along the 382-ft debris path oriented on a true heading
of 246°. The accident site elevation was about 488 ft mean sea level. There was a strong fuel
odor but no evidence of fire.
Page 7 of 13 ERA22FA114
The largest portion of the wreckage, consisting of the empennage, an engine, and the
remnants of the cockpit was located about 214 ft beyond the severed treetops at the base of a
16-in-diameter pine tree that was broken about 15-20 ft above the ground. A second engine
was located about 150 ft farther along the debris path. Neither the wings nor the fuselage was
intact. The flap setting could not be determined. The landing gear were fractured off from their
mounts and located in various parts of the debris field. The landing gear actuator indicated the
nose and main landing gear were in the retracted position at the time of impact. The pitch trim
actuator indicated the elevator trim tab trailing edge was about 10° tab up. Six propeller blades
were recovered, all fractured from their mounts. All blades displayed impact damage, and
some displayed leading-edge gouging, chordwise abrasion, twisting and aft bending.
Postaccident wreckage examination was limited by a high degree of fragmentation.
Examination of the wreckage revealed that no cockpit instruments were intact. The throttle
control quadrant was impact-damaged with the left throttle near idle, the left propeller near
feather, and the mixture set full rich for both left and right engines. Flight control continuity
could not be confirmed for the elevators, rudder, and ailerons due to impact damage. The
rudder trim actuator indicated that the rudder trim tab was about 14° right. The left fuel
selector handle was found in the OFF position. The right fuel selector handle was found in the
left main position. The left and right fuel selector valves were impact separated and had
tumbled through the trees. The left fuel selector valve displayed a witness mark indicating it
had been forced from the off position toward the auxiliary tank position.
Both engines exhibited significant impact damage. Continuity of the crankshafts and
camshafts on both engines was observed. Thumb compression was achieved for all but one
cylinder on the right engine which was impact damaged. Examination of the cylinders using a
lighted borescope revealed no anomalies to the pistons and valves. All magnetos sparked at
all towers. All spark plugs which remained intact displayed normal coloration when compared
to the Champion Check-A-Plug AV-27 chart. Oil filters were opened and found free of debris.
Examination of both engines revealed no preimpact anomalies or malfunctions that would
have precluded normal operation.
Postaccident examination of the airplane’s heater assembly revealed that it was impact
damaged and exhibited deformation of the outer casing, heat exchanger and combustor
chamber sections as well as separation of some of the external accessories. The heater
assembly did not exhibit any external fire or thermal damage. Detailed examination revealed
that the welds and materials comprising the heater were intact and free of defects.
A panel mounted engine data monitor was recovered and examined. The device broke apart
during the accident sequence, and although data was recovered, it could not be determined
whether this session correlated to the accident event.
Additional Information
Page 8 of 13 ERA22FA114
FAA Carbon Monoxide and Exhaust System Guidance
On November 24, 1972, the FAA issued advisory circular (AC) 20-32B "Carbon Monoxide (CO)
Contamination in Aircraft—Detection and Prevention." The AC provided information on the
potential dangers of carbon monoxide contamination from faulty engine exhaust systems or
cabin heat exchangers. It also discussed means of detection and procedures to follow when
contamination is suspected.
In October 2009, the FAA issued report DOT/FAA/AR-09/49, "Detection and Prevention of
Carbon Monoxide Exposure in General Aviation Aircraft." The report documented research on
detection and prevention of CO exposure in general aviation aircraft, with the objective of
identifying exhaust system design issues related to CO exposure, evaluating inspection
methods and maintenance practices with respect to CO generation, and the identification of
protocols to quickly alert users to the presence of excessive CO in the cockpit and cabin. On
March 17, 2010, the FAA published Special Airworthiness Information Bulletin (SAIB) CE-10-19
R1. It recommended that owners and operators of general aviation aircraft consider the
information in the DOT/FAA/AR-09/49 report and use CO detectors while operating their
aircraft. The SAIB also recommended a cabin CO level check during every 100-hour or annual
inspection, along with continued inspection of the complete engine exhaust system during
100-hr or annual inspections and at inspection intervals recommended by the aircraft and
engine manufacturers in accordance with the applicable maintenance manual instructions.
On August 16, 2010, the FAA also published SAIB CE-10-33R1, which reiterated the
recommendation to use CO detectors as documented by SAIB CE-10-19R1. It recommended
the replacement of mufflers on reciprocating engine-powered airplanes that use an exhaust
system heat exchanger for cabin heat with more than 1,000 hours time-in-service (TIS) and at
intervals of 1,000 hours TIS. It further recommended following guidance for exhaust system
inspections and maintenance provided in SAIB CE-04-22, dated December 17, 2003, and AC 43-
16A, Aviation Maintenance Alert, issued October 2006. The FAA also recommended continuing
to inspect the complete exhaust system during annual inspections and at intervals
recommended by the aircraft and engine manufacturers.
SAIBs are for information only, their recommendations are not mandatory. Likewise,
compliance with manufacturer-issued service letters is not mandatory.
National Transportation Safety Board (NTSB) CO and Exhaust System Guidance
On December 20, 2021, the NTSB called on the FAA a second time to require carbon monoxide
detectors in general aviation aircraft. In June of 2004, the NTSB issued Safety
Recommendation A-04-28 to the FAA to require installation of CO detectors in all single-engine
airplanes with forward-mounted reciprocating engines. The FAA declined to require detectors
and instead recommended that general aviation airplane owners and operators install them on
a voluntary basis. The FAA also recommended exhaust system inspections and muffler
Page 9 of 13 ERA22FA114
replacements at intervals they believed would address equipment failures before they led to
CO poisoning. Because the FAA did not require installation of CO detectors, Safety
Recommendation A-04-28 was classified by the NTSB as "Closed – Unacceptable Action."
On January 20, 2022, NTSB Recommendation A-22-001 called on FAA to require that all
enclosed-cabin aircraft with reciprocating engines be equipped with a carbon monoxide
detector that complies with an aviation-specific minimum performance standard with active
aural or visual alerting. Additionally, Recommendation A-22-002 called on the Aircraft Owners
and Pilots Association and Experimental Aircraft Association to inform their members about
the dangers of CO poisoning in flight and encourage them to 1) install CO detectors with active
aural or visual alerting and 2) proactively ensure thorough exhaust inspection during regular
maintenance. The Recommendation identified 31 accidents between 1982 and 2020 attributed
to CO poisoning. Twenty-three of those accidents were fatal, killing 42 people and seriously
injuring four more. A CO detector was found in only one of the airplanes and it was not
designed to provide an active audible or visual alert to the pilot, features the NTSB
recommended in 2004.In each of these accidents, the pilot was not alerted to CO entering the
cabin in enough time to counteract the effects of CO poisoning.
Medical and Pathological Information
The Commonwealth of Virginia Office of the Chief Medical Examiner, Western District,
performed the pilot’s autopsy. According to the autopsy report, the cause of death was blunt
force trauma of the head, torso, and extremities, and the manner of death was accident.
The Virginia Department of Forensic Science (DFS) performed toxicological testing of
postmortem pooled cavity blood from the pilot. Ethanol was detected at 0.012 g/dL.
Carboxyhemoglobin, a marker of CO exposure, was elevated at 31%, as measured by
spectrophotometry with confirmation by microdiffusion.
The FAA Forensic Sciences Laboratory also performed toxicological testing of pooled cavity
blood from the pilot. Ethanol was not detected at a reporting threshold of 0.01 g/dL.
Carboxyhemoglobin testing was performed on five specimens using spectrophotometry. For
three of these specimens, carboxyhemoglobin was not detected at a reporting threshold of
10%. The remaining two specimens were unsuitable for measuring carboxyhemoglobin.
Postmortem ethanol production is made more likely by extensive traumatic injury and can
cause an affected toxicological specimen to test positive.
Page 10 of 13 ERA22FA114
Carboxyhemoglobin is formed when CO binds to hemoglobin in blood, impairing the blood’s
ability to deliver oxygen to body tissues (hypemic hypoxia). CO is an odorless, tasteless,
colorless, nonirritating gas that can be produced during hydrocarbon combustion. Exposure to
CO usually occurs by inhalation of smoke or exhaust fumes. Symptoms of low-level CO
exposure are nonspecific and variable, and may include headache, nausea, and tiredness.
Increasing levels of exposure may become impairing or incapacitating, causing more serious
neurocognitive, cardiac, and/or vision problems, progressing to death above
carboxyhemoglobin levels of about 50% (or lower if other serious medical conditions co-exist),
although symptoms are not simply predictable from carboxyhemoglobin levels. Nonsmokers
normally have carboxyhemoglobin levels of less than 1-3%, while heavy smokers may have
levels as high as 10-15%. As with other causes of tissue hypoxia, CO poisoning may be
insidious and difficult for an exposed person to recognize; there is no reliable physical sign of
exposure.
Tests and Research
After the accident, electronic CO detectors were installed in the operator’s fleet. Research was
conducted by the operator at the investigator’s request to determine if the engine exhaust
could penetrate the cockpit under the specific conditions that were present on the day of the
accident. The goal of the research was to determine the ability of CO to enter the cockpit from
the engine exhaust during taxi and engine run-up in similar wind conditions and relative wind.
On the day of the of the accident, the reported wind was from 060° true at 7 kts, and the
airplane’s engines were started on the ramp, where the airplane then taxied to the run-up area
of runway 2 for run-up and surveying computer start-up. During this taxi and subsequent run-
up, the accident airplane was heading 196º true (205° magnetic), and the relative wind to the
airplane was a 44º left quartering tailwind, which would have blown the exhaust from the left
engine toward the cockpit and heater air intake at the nose of the airplane. The airplane was on
this heading for about 8-10 minutes according to the statement of another company pilot who
taxied out in front of the accident airplane and conducted the run-up at the approach end of
runway 2 while turned into the wind.
During the test, the exemplar airplane (the same make/model as the accident airplane) was
positioned so that the relative wind was also a quartering tailwind. The airplane was equipped
with an electronic audible CO detector and the pilot video-recorded the test. The following is an
excerpt from the pilot’s report:
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My startup and taxi time was "average". I taxied to runway 18 with the door cracked open
and window open due to the heat that day. The heater was left off, including the fan.
Neither were turned on. During the taxi, the electronic CO detector read "0" PPM the whole
time. As I approached the run-up area, I closed the door and window. Once I got to the
run-up area I angled, the airplane close to an east-northeast orientation to put the breeze
off my right quartering tail based on the grass and other indicators. Almost immediately, I
noticed the audible alarm on the CO detector going off. I looked over and could see the
number on the CO detector rising through the 50-60 PPM range. . . it quickly rose above
100 PPM within the 17 second video. At the time, I was unsure what level would be
harmful . . . I shut the video off so I could focus on clearing the cabin air. The number
eventually climbed up to around 150-160 PPM before finally coming back down. There
were very minor exhaust odors present during the high readings.
Following this research, the operator noted that if the cabin heater had been on the day of the
accident, when outside temperatures were 33° F, the heater fan would have drawn in air at the
ventilation inlet on the front of the nose. This would have “pushed” the exhaust into the cabin.
Administrative Information
Investigator In Charge (IIC): Spencer, Lynn
Additional Participating Persons: Steve Harness; FAA FSDO; Richmond, VA
Rick Roper; RAM Aircraft; Waco, TX
Peter Basile; Textron Aviation; Wichita, KS
Peter Makredes; Sol Aerial Surveys LLC; Las Vegas, NV
Original Publish Date: October 5, 2023 Investigation Class: 3
Note:
Investigation Docket: https://data.ntsb.gov/Docket?ProjectID=104587
Page 12 of 13 ERA22FA114
The National Transportation Safety Board (NTSB), established in 1967, is an
independent federal agency mandated by Congress through the
Independent Safety Board Act of 1974 to investigate transportation
accidents, determine the probable causes of the accidents, issue safety
recommendations, study transportation safety issues, and evaluate the
safety effectiveness of government agencies involved in transportation. The
NTSB makes public its actions and decisions through accident reports,
safety studies, special investigation reports, safety recommendations, and
statistical reviews.
The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b),
precludes the admission into evidence or use of any part of an NTSB report
related to an incident or accident in a civil action for damages resulting
from a matter mentioned in the report. A factual report that may be
admissible under 49 U.S.C. § 1154(b) is available here.
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