National Transportation Safety Board - Aircraft Accident/Incident Database

Transcription

1 Accident Rpt# WPR15CA093 01/25/ PST Regis# N559KC Hanford, CA Acft Mk/Mdl FLIGHT DESIGN GMBH CTLS Acft Dmg: Rpt Status: Prelim Prob Caus: Pending Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: Aircraft Fire: Page 1 Copyright 1999, 2015,

2 Accident Rpt# WPR15LA092 01/26/ PST Regis# N747BA Seabeck, WA Apt: N/a Acft Mk/Mdl ALEXANDER RV-7-UNDESIGNAT Acft SN Acft Dmg: DESTROYED Rpt Status: Prelim Prob Caus: Pending Eng Mk/Mdl AEROSPORT IO-360 Fatal 1 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: ALEXANDER ROBERT K JR Aircraft Fire: NONE AW Cert: SPE 1. Maneuvering - Part(s) separation from AC On January 26, 2015, about 1250 Pacific standard time, an amateur built experimental Alexander RV7 airplane, N747BA, impacted the water of the Hood Canal near Seabeck, Washington. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The airline transport rated pilot, sole occupant of the airplane, is missing and is presumed to be fatally injured. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The local flight originated from the Tacoma Narrows airport, Gig Harbor, Washington, at Witnesses located near the accident site reported hearing an airplane fly over their position and the engine sounded erratic. One witness reported that when she looked up, she saw a 3 to 4 foot portions of the airplane separate before it descended below a tree line out of her view. Additional witnesses reported observing debris and oil slick about one-half mile from the eastern shoreline of Hood Canal. Wreckage debris consistent with the accident airplane was located floating on the water surface and was recovered by the United States Coast Guard. The main wreckage has not been located. Reported water depths in the vicinity of the accident site range between 500 to 600 feet. Page 2 Copyright 1999, 2015,

3 Accident Rpt# CEN14LA492 09/04/ EDT Regis# CFBCA Sault Ste Marie, MI Apt: N/a Acft Mk/Mdl CAMPBELL SUPER BEARHAWK Acft SN RNC 469 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl CONTINENTAL IO-470E Acft TT 43 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: PILOT Aircraft Fire: NONE 1. Landing - Loss of control on ground On September 4, 2014, about 1230 eastern daylight time, an experimental amateur-built Campbell Super Bearhawk, CFBCA, nosed over during landing on Lake George near Sault Ste Marie, Michigan. The recreational pilot was uninjured. The airplane sustained substantial damage to the wing. The airplane was registered to and operated by the pilot under the provisions of 14 CFR Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight that was not operating on a flight plan. The flight departed from the Ste Marie River at 1145, and was destined for Lake George near Sault Ste Marie, Michigan. The pilot reported that he was attempting a landing on Lake George when he misjudged the height of the airplane above the water, which he described as glassy. During the touchdown, the left float "dug in" and the airplane nosed over. Page 3 Copyright 1999, 2015,

4 Accident Rpt# CEN13LA428 07/21/ EDT Regis# N1519 Mill Creek, IN Apt: N/a Acft Mk/Mdl COOPER, DAVID W. CHALLENGER II Acft SN C Acft Dmg: DESTROYED Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl ROTAX 447 Fatal 1 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: BENJAMIN T. HUBBARD Aircraft Fire: NONE 1. Enroute-cruise - Fuel exhaustion On July 21, 2013, about 0700 eastern daylight time, an amateur-built Cooper Challenger II airplane, N1519, impacted terrain near Mill Creek, Indiana. The non-certificated pilot was fatally injured and the airplane was substantially damaged. The aircraft was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which operated without a flight plan. The flight originated from the Jerry Tyler Memorial Airport (3TR), Niles, Michigan, about 0630 and was en route to the Plymouth Municipal Airport (C65), Plymouth, Indiana. The airplane departed 3TR along with another airplane en route to C65. When the accident airplane did not arrive at C65, a search was conducted and the airplane was found in a corn field near Mill Creek Indiana. There were no known witnesses to the accident. Postaccident examination of the airplane revealed that there was no fuel in the fuel tank and no fuel was found in the carburetor bowl. No evidence of a fuel spill was detected at the accident site. Further examination of the airplane did not reveal any pre-impact anomalies. The pilot held a second class medical certificate issue on March 27, The limitations section of the medical certificate noted that the pilot must wear corrective lenses. There was no record of the pilot having been issued a pilot certificate by the Federal Aviation Administration. A pilot flight logbook was recovered and indicated that the pilot had received flight training in Cessna 172 airplanes between March 14, 2013 and April 27, During that time the pilot had accumulated 14.1 hours of flight time in Cessna 172 airplanes and had soloed a Cessna 172 airplane on March 30, The logbook also indicated that the pilot had flown the accident airplane about 11 hours between May 5, 2013, and May 25, The May 25, 2013 entry was the most recent completed entry in the logbook. The logbook contained an instructor's endorsement for solo operations in Cessna 172 airplanes, but no endorsement for solo operation in the accident airplane was found. There were no logged flights indicating that the pilot had received any flight training in the accident airplane or in a like model airplane. Page 4 Copyright 1999, 2015,

5 Accident Rpt# ERA13FA219 04/29/ EDT Regis# N85KY Valkaria, FL Apt: Valkaria Airport X59 Acft Mk/Mdl DANIELS DOMINATOR Acft SN 001 Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl ROTAX 582 Acft TT 50 Fatal 1 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: WILLIAM SCOTT ADAIR Aircraft Fire: NONE Summary The pilot purchased the single-seat gyroplane and then took flying lessons in a gyroplane with a tandem-seating configuration. The pilot recorded about 7.8 hours in two-seat gyroplanes and had no experience in single-seat gyroplanes. On the day of the accident flight, the pilot was anxious to fly the gyroplane before traveling to the northeast for the summer. During his first flight in the single-seat gyroplane, the pilot had just crossed the approach end of runway 14 when the gyroplane pitched down 30 degrees, then pitched up 45 degrees, and subsequently descended to the ground. Witnesses, who were personal friends of the accident pilot, noted that, in their opinion, the pilot was not experienced enough to fly his gyroplane solo. One witness also stated that he was going to test fly the gyroplane for the owner2 days before the accident flight but was unable due to inclement weather. According to the inventor of the gyroplane, and based on his analysis of the accident flight details, the engine power was reduced with the control stick positioned slightly aft of center and that it appeared that the pilot decreased power and airspeed just before entering a vertical descent to the ground. Toxicological testing revealed therapeutic levels of diphenhydramine (for example, Benadryl) in the pilot's blood samples. Diphenhydramine is a sedating antihistamine that could impair a pilot's cognitive and psychomotor performance. The diphenhydramine in cavity blood (0.038 ug/ml) was slightly above the lower limit of the normal therapeutic range ( to ug/ml). Diphenhydramine undergoes significant postmortem redistribution; as a result, it is likely that the pilot's diphenhydramine level was most likely at or below the lower therapeutic level about the time of the accident. Therefore, it is unlikely that impairment from diphenhydramine degraded the pilot's ability to safely operate the gyroplane. The clinical findings of an elevated hemoglobin A1C (9.2%) and elevated glucose in the urine is consistent with poorly controlled diabetes. The hemoglobin A1C of 9.2% correlates with an average blood sugar level of about 250 mg/ml (below 140 mg/ml is normal). Blood sugar elevated into this range causes few identified symptoms other than increased urination and is not acutely impairing. However, long-term diabetes can cause loss of vision, neuropathy in the lower limbs, and kidney disease. The investigation could not determine if the pilot had any symptoms from diabetes or its long-term complications. Examination of the airframe, engine, and flight control system components revealed no evidence of preimpact mechanical malfunctions or anomalies that would have precluded normal operation. Cause THE NATIONAL TRANSPORTATION SAFETY BOARD DETERMINED THAT THE CAUSE OF THIS OCCURRENCE WAS: The pilot's failure to maintain adequate power and airspeed, which resulted in a loss of control, abrupt descent, and impact with terrain. Contributing to the accident was the pilot's failure to obtain adequate experience in the gyroplane before making the flight. 1. Approach-VFR pattern final - Loss of control in flight 2. Uncontrolled descent - Collision with terr/obj (non-cfit) Findings - Cause/Factor 1. Aircraft-Aircraft oper/perf/capability-performance/control parameters-(general)-not attained/maintained - C 2. Personnel issues-action/decision-action-lack of action-pilot - C 3. Personnel issues-experience/knowledge-experience/qualifications-total experience w/ equipment-pilot - F HISTORY OF FLIGHT On April 29, 2013, about 0744 eastern daylight time, a Daniel J. Danies Dominator gyroplane incurred substantial damage after impacting terrain while in the local traffic pattern at Valkaria Airport (X59), Valkaria, Florida. The light sport pilot sustained fatal injuries. The gyroplane was registered to and operated by a private individual as a 14 Code of Federal Regulations (CFR) Part 91 personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the local flight that departed X59 about In an interview with a National Transportation Safety Board (NTSB) investigator, a certified flight instructor who witnessed and videotaped the flight stated that on the morning of the flight, the pilot ran up the engine and did his preflight checks at the approach end of runway 10, which was a closed runway. During this procedure, the pilot turned the engine off and then back on again for an unknown reason. The pilot then started a takeoff roll, engaged the rotor head pre-rotator, the gyroplane jerked to the left, and the pilot aborted the takeoff attempt. On taxi back, the pilot told the witness that the pre-rotator system was slipping. The pilot reached the approach end of runway 10, reengaged the pre-rotor and started a second takeoff roll. The witness stated that the takeoff roll was about 1,500 feet in length, and was an unusually long takeoff roll compared to the other gyroplane takeoffs that he had witnessed in the past. Page 5 Copyright 1999, 2015,

6 The witness stated that the rotor blades slowly accelerated and the pilot lifted the aircraft off the runway to about 300 to 400 feet above ground level (agl). The witness added that the rotor blades were not "coning" as the pilot lifted off of the runway. The pilot made a left downwind in the local pattern and then flew over runway 10 at about 50 feet agl. The pilot then overflew the aircraft apron where several aircraft were parked and, as he approached runway 14, he made a left turn for a right downwind and right base turn for runway 14. After crossing the approach end of runway 14, the gyroplane entered a 30 degree pitch down attitude followed by an abrupt 45 degree pitch up attitude. As the gyroplane reached the top of the upward arc, it appeared to have lost much of its airspeed and subsequently began a downward descent. The gyroplane assumed a left wing down attitude just prior to impact with the apron on the east side of runway 14. The same witness also stated that the pilot had acquired most of his flying experience in powered parachutes. The accident pilot had purchased the gyroplane about 5 months prior to the accident flight. The accident pilot was receiving instruction in dual seat gyroplanes at an off-site location. About two weeks before the accident, the pilot told friends that he had been "signed off" to solo in his single seat gyro. A NTSB investigator asked the witness "in his opinion, was the accident pilot ready to solo?" The witness stated "no." A personal friend of the accident pilot, with about 160 hours of flight experience in gyroplanes, performed an uneventful preflight inspection on the accident gyroplane two days prior to the accident. The preflight was conducted so that the witness could conduct an initial test flight of the gyroplane before the accident pilot flew it for the first time; however, he was unable to test fly the gyroplane due to inclement weather at the airport. Prior to his first flight, the accident pilot practiced taxiing the gyroplane around the airport without the rotor blades attached to get a feel for the differential braking. According to the witness, the accident pilot was due to travel to his summer home in the northeastern United States on or about April 30, 2013, and wanted to see it fly before he left. The pilot planned to return to X59 two weeks later to trailer the gyroplane at his summer home. The witness also added that he would not have test flown the gyroplane on the morning of the accident because of the approximate 10 knot winds that were present at the airfield when he arrived at about The witness stated that the more experience that you have with a gyroplane increases your proficiency of flying in higher winds, and "if you are learning how to fly gyroplanes, you should be doing so with no wind." A NTSB investigator asked the witness "in his opinion, was the accident pilot ready to solo?" The witness stated "no." PERSONNEL INFORMATION The pilot, age 58 held a sport pilot certificate and a light sport aircraft repairman certificate with a rating for powered parachutes. Both certificates were issued on November 30, The limitation on the sport pilot certificate included, "holder does not meet International Civil Aviation Organization requirements." The limitation on the repairman certificate was for powered parachute only. A review of the pilot's logbooks revealed that the pilot had recorded 90.5 hours total flight time in powered parachutes, and he recorded 7.8 hours total flight time in two-seat gyroplanes, of which, 6.8 of those hours were logged as pilot-in-command. No time was recorded for single seat gyroplanes. The first endorsement in the pilot's logbook covered Federal Aviation Regulations Part and on April 6, The pilot received a signed but undated endorsement for FAR Part , , and in his logbook by a flight instructor. AIRCRAFT INFORMATION The experimental, amateur-built, single-seat gyroplane, serial number 001, was manufactured in 2009, and was equipped with a fixed-pitched, semi-rigid, teetering, two-blade rotor system. It was powered by an uncertified 65-horsepower Rotax two-cycle engine, serial number An uncertificated three bladed composite propeller was attached to the engine. A review of the engine logbooks revealed that a complete overhaul was performed on December 29, The last condition inspection of the engine was completed on April 1, 2013 at a tachometer time of 49.5 hours. There was no record of the engine total time prior to the engine overhaul. The airframe logbook was not located. METEOROLOGICAL INFORMATION The Melbourne International Airport (MLB), Florida 1153 recorded weather observation, located 10 nautical miles to the northwest, reported wind from 160 degrees at 06 knots, visibility 10 statute miles, few clouds at 3,800 feet, temperature 24øC, dew point 18øC, and an altimeter setting of inches of mercury. WRECKAGE AND IMPACT INFORMATION Page 6 Copyright 1999, 2015,

7 The gyroplane came to rest about 400 feet inside the approach end of runway 14 on the north side apron, against a Cessna 172 parked on the ramp. The debris path bore 117 degrees magnetic at a width of 60 feet and a length of 80 feet. Initial examination of the gyroplane by a Federal Aviation Administration (FAA) inspector and a National Transportation Safety Board (NTSB) investigator revealed that the gyroplane incurred substantial damage to the rotor blades, fracturing of the keel, and bending damage to the frame. Pitch, roll, and yaw control continuity was verified on all control surfaces. The left rotor pitch control tube was severed by the propeller. The right rotor pitch control tube failed due to bending overload. The rudder and horizontal surfaces remained attached to each other, departed the airframe, and were cracked about 8 inches upward from the bottom of the vertical stabilizer. Suction and compression were verified on both engine cylinders and crankshaft continuity was verified through the engine to the accessory drive ring gear by rotating the propeller blades manually. Examination of the recovered airframe, engine, and flight control system components revealed no evidence of pre-impact mechanical malfunctions or anomalies that would have precluded normal operation. A detailed summary of the airframe and engine examination is contained in the public docket. MEDICAL AND PATHOLOGICAL INFORMATION A postmortem examination was conducted by the Brevard County Medical Examiner's office. The cause of death was reported as blunt force injuries. The FAA's Civil Aerospace Institute (CAMI) performed forensic toxicology on specimens from the pilot. The report stated that there was no carbon monoxide or ethanol detected in the specimens provided. The report also stated that (ug/ml, ug/g) of diphenhydramine was detected in the blood and urine. Diphenhydramine (commonly known by the trade name Benadryl) is an over-the-counter antihistamine with sedative effects, often used to treat allergy symptoms or as a nighttime sedative." The therapeutic range is considered to ug/ml according to the FAA Civil Aeronautical Institute. There was 484 (mg/dl) of glucose detected in the urine. Urine levels above 100 mg/dl are considered abnormal. 9.2 % of hemoglobin A1C was detected in the blood (Cavity). Hemoglobin A1C blood levels above 6% are considered abnormal. These findings are consistent with a pilot who has diabetes. According to the National Highway Traffic Safety Administration report, Drugs and Human Performance Fact Sheets: Diphenhydramine: Diphenhydramine clearly impairs driving performance, and may have an even greater impact than does alcohol on the complex task of operating a motor vehicle. Laboratory studies have shown diphenhydramine to decrease alertness, decrease reaction time, induce somnolence, impair concentration, impair time estimation, impair tracking, decrease learning ability, and impair attention and memory within the first 2-3 hours post dose. Significant adverse effects on vigilance, divided attention, working memory, and psychomotor performance have been demonstrated. ADDITIONAL INFORMATION In a personal interview with the inventor of this gyroplane, he stated that the Dominator gyroplane is an inherently stabile machine. During flight, the gyroplane is designed to use the rotor speed to safely descend to the ground with little or no power. In reviewing the accident sequence, the inventor stated that the initial approach to runway 14 appeared normal. He stated that it appeared that the pilot seemed to "check" (decrease) his speed just prior to entering a vertical descent to the ground. He stated that the only way to get the gyroplane into this configuration is to have reduced power and the control stick slightly aft of center. The pilot received instruction on dual seat gyroplanes with a tandem configuration. According to FAA records, the pilot had previously met the 14 CFR Part 61 requirements for a light sport aircraft certification. Per 14 CFR Part , the pilot was adding an additional category or class of aircraft to his existing light sport certification. According to 14CFR Part , a sport pilot certificate does not list aircraft category and class ratings. When a candidate successfully passes the practical test for a sport pilot certificate, regardless of the light sport aircraft privileges sought, the FAA will issue a sport pilot certificate without any category and class ratings. The qualified instructor pilot will provide the pilot with a logbook endorsement for the category and class of aircraft in which the pilot is authorized to act as pilot in command. In this case, the pilot received training in a gyroplane with two seats and was not required to solo in order to receive the two logbook endorsements required by 14 CFR Part The pilot had no recorded experience flying fixed-wing aircraft, rotary-wing aircraft, or single seat gyroplanes; nor was he required by the FARs to demonstrate a satisfactory solo flight upon completion of an approved training program. Page 7 Copyright 1999, 2015,

8 Accident Rpt# CEN13LA377 06/27/ CDT Regis# N445RV Marion, TX Apt: Zuehl 1TE4 Acft Mk/Mdl DANKELMAN PETER G RV-7A Acft SN Acft Dmg: DESTROYED Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl LYCOMING O-360-A2A Fatal 1 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: DANKELMAN PETER G Aircraft Fire: GRD 1. Maneuvering-low-alt flying - Cabin safety event HISTORY OF FLIGHT On June 27, 2013, about 2116 central daylight time, a Dankelman Vans RV-7A, N445RV, collided with power lines and trees 0.9 miles northwest of Zuehl Airport (1TE4), Marion, Texas. The pilot, the sole occupant on board, was fatally injured. The airplane was destroyed. A post-impact fire ensued. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The flight originated from Huber Airpark (E70), Sequin, Texas, at 2104, and was en route to 1TE4, about 12 miles southwest of E70. A Federal Aviation Administration (FAA) inspector interviewed several witnesses. The following is a summation of those interviews and written statements submitted: Prior to departing E70, the pilot refueled his airplane and appeared to have normal cognitive abilities. "He seemed his same old self," said one witness. During the takeoff from E70, the engine sounded normal. It was dark when the pilot made two attempts to land on 1TE4's runway 17. The runway was not equipped with runway lights, and the airplane's landing lights were not on. Each attempt was followed by a departure from the traffic pattern by turning left to the south and then turning east. The accident occurred on the pilot's third attempt to land. The airplane struck two 14,400-volt electric power lines and impacted the ground 100 feet from a tree line on the edge of a farmer's field. The accident site was 750 feet south of Interstate Highway 10, and 0.9 nm northwest of the airport, on airport property. The following are excerpts from the Federal Aviation Administration (FAA) inspector's report: At 2106, San Antonio, Texas, Approach Control displayed a target squawking mode C VFR (visual flight rules) transponder code 1200 about 3 miles west of E70. The pilot was not in radio contact with approach control. The target was on a straight line track of 240ø to 1TE4. Altitude and ground speed varied between 1,300 and 1,600 feet msl (mean sea level) and 125 and 130 knots. The target lined up with runway 17 and began a descent. The target disappeared from radar at 2110 at an altitude of 1,000 feet msl and on a heading of 244ø. Ground speed was 100 knots. The target reappeared on radar at 2112 at an altitude of 900 feet msl, heading 125ø, and at a ground speed of 50 knots. The target turned to a north-northwest heading. Altitude varied between 900 to 1,000 feet msl (300 to 400 feet above ground level), and accelerated to 131 knots ground speed. The target disappeared again from radar at 2113, at an altitude of 1,000 feet msl, a heading of 343ø, and a ground speed of 131 knots. Between 2115 and 2116, the target appeared and disappeared intermittently from radar at altitudes between 800 and 900 feet msl (200 to 300 feet agl). The last radar contact was at 2116 when the target was northwest of 1TE4 in the vicinity of the crash site. The radar data was consistent with what witnesses reported. PERSONNEL INFORMATION The 74 year old pilot held a commercial pilot certificate with airplane single/multiengine land and instrument ratings. He also held a flight instructor certificate with airplane single engine and instrument ratings. His third class airman medical certificate, dated September 28, 2011, contained the restrictions: "Not valid for any class after 9/30/2012. Must were corrective lenses." This medical certificate had expired. When the pilot completed his application for medical certification in 2011, he estimated his total flight time to be 1,361 hours. AIRCRAFT INFORMATION N445RV (serial number 71938), a model RV-7A, was built by the owner-pilot and was issued an Experimental Certificate of Airworthiness by the FAA in The airplane's maintenance records were not located. As a result, inspection dates and times; engine make, model, and horsepower, and propeller make and model could not be determined. Page 8 Copyright 1999, 2015,

9 METEOROLOGICAL INFORMATION The following METAR (Meteorological Terminal Aviation Routine Weather Report) was recorded at the New Braunfels Regional Airport (KBAZ) Automated Surface Observing System (ASOS), New Braunfels, Texas, located 14 miles northeast of the accident site: KBAZ 2051: Wind, 120 degrees at 4 knots; visibility, 10 miles; sky condition, clear; temperature, 31 degrees Celsius (C.); dew point, 16 degrees C.; altimeter, inches of mercury. KBAZ 2151: Wing, 160 degrees at 09 knots; visibility, 10 miles; sky condition, clear; temperature, 29 degrees C.; dew point, 16 degrees C.; altimeter, inches of mercury. AERODROME INFORMATION Zuehl Airport (1TE4) is a privately owned airport, located 4 miles south of Marion, Texas, and situated 592 feet msl. It is equipped with one runway, 17-35, 3,000 feet x 200 feet, turf. There are no runway lights, and the airport does not have a rotating beacon. WRECKAGE AND IMPACT INFORMATION According to the FAA inspector, the left wing leading edge and left horizontal stabilizer struck and severed two power lines, but only one power line bore a contact point. About 100 feet of power line was wrapped around the airplane's empennage and trailed through the tree tops. The right wing struck a large tree branch and was torn off, spilling fuel that fed a post-crash fire. The fire destroyed the cockpit and instrument panel, precluding a definitive establishment of flight control continuity, and engine controls and cockpit switch positions. Chop marks on the tree branches and scrape marks on the propeller were consistent the propeller turning at impact. The airplane came to rest 100 feet beyond the trees and power lines on a magnetic heading of 200 degrees. The power company recorded a 380-amp fault about the time of the accident. A power company spokesman said the fault could have been triggered when the airplane struck the power lines or when the lines contacted the ground. MEDICAL AND PATHOLOGICAL INFORMATION According to the FAA inspector who interviewed the pilot's wife, she said her husband was in good health, that he had had a good night's sleep the night before, and he was in an upbeat mood on the day of the accident. She stated that he had been eating and sleeping well for at least 3 days prior to the accident. She stated that he had not flown the airplane for 2 or 3 months and, to the best of her knowledge, had landed only once after sunset at 1TE4. On that particular occasion, it was not completely dark. She thought the pilot and aircraft logbooks were on board the airplane. A search of pilot's hangar failed to locate any of the logbooks. A review of FAA medical records revealed the pilot was issued a special issuance third class airman medical certificate with the restriction that he must wear corrective lenses. Eyeglasses were found in the aircraft wreckage. The medical certificate was also invalid after September 30, The pilot had a history of heart disease. According to the forensic pathologist's autopsy report, death was attributed to "complications of hypertensive and arteriosclerotic cardiovascular disease....no antemortem traumatic injuries were found that contributed to his death." No soot was detected in the airways or lungs. It was the pathologist's opinion that "the decedent suffered and succumbed to a complication of his cardiac disease." Toxicology protocol by NMS Laboratories detected 11% carboxyhemoglobin in femoral blood. Toxicology protocol by FAA's Civil Aerospace Medical Institute detected Losartan, a prescription medication and an angiotensin II receptor (type AT1) antagonist, used in the treatment of high blood pressure, in (heart) blood. No carbon monoxide was detected. Page 9 Copyright 1999, 2015,

10 This case was reviewed by the National Transportation Safety Board's medical officer. According to his report, the 74 year old pilot "had a history of treated high blood pressure, hypothyroid disease, and prostate cancer resected in 2009." He reported taking losartan, triamterene, and hydrochlorothiazide to treat his high blood pressure, and levothyroxine to treat hypothyroidism. The pilot was required to have a valid third class airman medical certificate while operating an aircraft. His last medical certificate expired September 30, 2012, 9 months before the accident. Page 10 Copyright 1999, 2015,

11 Accident Rpt# ANC14CA059 08/02/ AKD Regis# N821AK Palmer, AK Apt: Butte Muni AK1 Acft Mk/Mdl STEVEN R MCNEESE AIRBORNE EDGE Acft SN Acft Dmg: SUBSTANTIAL Rpt Status: Factual Prob Caus: Pending Eng Mk/Mdl ROTAX 582 Acft TT 206 Fatal 0 Ser Inj 0 Flt Conducted Under: FAR 091 Opr Name: MCNEESE STEVEN R Aircraft Fire: NONE AW Cert: NON 1. Takeoff - Loss of control in flight The non-certificated pilot was performing a high speed taxi test at a privately-owned, dirt and gravel-covered airport, in his tricycle-gear equipped weight-shift-control airplane. He reported that after arriving at the airport, he assembled the airplane, and then did a thorough preflight, which included checking wind conditions aloft by releasing helium balloons. He stated that the airplane had recently undergone an extensive rebuild, and he intended to do series postmaintenance taxi tests before flying the airplane. During the first high speed taxi test, as the airplane reached a takeoff speed, the pilot pushed the control bar forward, and the airplane became airborne. In an attempt to land the airplane and gain additional airspeed, the pilot pulled back on the control bar, but the airplane began to roll to the left. The pilot then applied full right control bar input, but the airplane continued to the left, and it subsequently collided with a stand of trees, sustaining substantial damage to the wings. The pilot stated that there were no preaccident mechanical anomalies with the airplane that would have precluded normal operation. In the recommendation section of the NTSB Accident/Incident Reporting Form , the pilot stated that the accident may have been prevented if he would have been more familiar with the airplane. Page 11 Copyright 1999, 2015,