Aviation Accident Summaries

Aviation Accident Summary CHI96LA210

LE SUEUR, MN, USA

Aircraft #1

N9274S

FARLAND GENESIS

Analysis

A witness reported the student pilot did a thorough preflight inspection and that the engine sounded good during run-up. The airplane climbed to about 100 feet AGL after takeoff and made a 180 degree turn. It then veered to the right and gradually lost altitude to 60 feet. The airplane suddenly nosed over and impacted the ground. Examination of the airplane revealed that the flight controls and engine exhibited continuity. Damage indicated the airplane impacted the ground in a nose low attitude. A toxicology test of the pilot's blood showed 0.493 mcg/ml Chlorpheniramine, and 0.324 mcg/ml Diphenhydramine. Chlorpheniramine and Diphenhydramine are antihistamines, which can result in drowsiness; the quantities found were many times the therapeutic levels. Also, an unspecified level of Diazepam (generic name for Valium) was detected in the pilot's blood and liver fluid. None of these drugs were approved for use while operating an aircraft. The student pilot had only about three hours of flight time in the make and model of airplane, and he had not been endorsed by a flight instructor to fly the airplane. The pilot had a history of obstructive sleep apnea, which was under evaluation. A witness reported the pilot had complained of a splitting headache on the night before the accident.

Factual Information

History of Flight On June 24, 1996, at 1030 central daylight time, an experimental Farland Genesis, N9274S, was destroyed when it impacted the ground after loss of control on downwind leg in the traffic pattern. The student pilot received fatal injuries. The 14 CFR 91 flight departed Le Sueur Airport, Le Sueur, Minnesota, on a local flight. Visual meteorological conditions prevailed and no flight plan was filed. A friend of the pilot, who was also in the process of building an experimental Genesis like the accident aircraft, had gone with the pilot to the airport. He reported that the preflight was normal and everything on the airplane was checked over thoroughly. He reported that the engine ran fine and it "sounded like a good airplane." He reported that the pilot did a high speed taxi to 50 mph. He reported the pilot then taxied back to the end of the runway for takeoff. He reported the pilot applied full throttle and the airplane "took off real nice." He reported that the pilot climbed to about 100 feet, but then the pilot did a 180 degree turn back to the south. Then the airplane started to veer off to the right and gradually lost altitude to about 60 feet. He reported that suddenly the airplane nosed straight over and went straight down. A witness who saw the airplane from his vehicle window reported that the airplane had banked right and then leveled out. He reported the airplane spiraled to the right and then, "...nosed just about straight in." The police report recorded that the same witness had reported to the police that the airplane had banked left and then spun into the ground. The witness reported that he arrived at the scene and determined that the pilot was still alive. Fuel was leaking from the fuel tank so he assisted the police in extricating the pilot from the cockpit. The pilot was taken to a hospital but died about two hours later. Personnel Information The pilot was a 68 year old male, student pilot. He had logged about 41 hours of flight time. He had been taking dual instruction in a Cessna 152. He had received about 20 hours of dual instruction, and had 20 hours of solo flight time. His flight instructor had not flown in the Genesis and the pilot was not endorsed to fly the Genesis. The pilot had flown about 3 total hours in the aircraft. Aircraft Information The airplane was an experimental Genesis. The airplane had been modified by the pilot to allow for the installation of a water cooled Subaru EA81 engine. The engine modification required considerable design changes which included cutting and removing the engine mount structure and creating an "engine box" which supported the larger engine. The original aft spar attach point was part of the original engine mount structure. To accommodate the larger engine, about 8 to 10 inches of the aft spar was cut. The new aft spar attach point was on the side of the "engine box." The original rear spar attach points were made of hardened aluminum alloy. The new attach points were made with a L-type bracket cut from 1/8 inch 6061-T6 aluminum angle stock, which is a softer aluminum than the original. Additionally, the rear wing spars were "pinned" to the bracket assemblies with 1/4 inch bolts that had been "ground" into a pin shape and center drilled to accommodate a cotter pin for safety. The cotter pins were missing from both bolts. The pilot had put a bag of sand weighing about 50 pounds in the cockpit. The aircraft designer and manufacturer reported that the ballast was not required in the aircraft as originally designed. The Subaru engine weighed more than the Rotax engine which the aircraft plan's called for. The friend of the pilot reported that the sandbag was well secured in the aircraft and could not shift during the flight. The weight and balance report calculated by the pilot indicated that the airplane was within center of gravity limits for flight. Wreckage and Impact Information The aircraft wreckage indicated that the airplane impacted the ground in about 60 to 70 degree nose down attitude. The left wing was buckled upward at the forward strut attach point. The left upper tailboom was deformed with a bulge in the direction of the left wing. The high mounted aft engine and wing crushed forward over the cockpit. The left wing rear spar attach point located on the engine box was crushed. The crush indicated that the engine's direction of movement at impact was toward the left rear spar. The right wing rear spar and rear spar attach point exhibited overload and separation failure. The right upper tailboom was cut when it impacted the propeller. One blade of the propeller was separated about 6 inches from the hub and the remaining part of the blade was found 108 feet from the wreckage. The remaining propeller blade was intact but had rotational scoring and gouges on the blade. It was still attached to the propeller hub. The right wing aileron control tube was struck by the propeller and was separated from the aileron control horn. The right wing had no apparent buckling. (See photographs) Medical and Pathological Information The autopsy was performed at the Hennepin County Medical Center, 730 South 7th Street, Minneapolis, Minnesota. A Forensic Toxicology Fatal Accident Report was prepared on the pilot by the Federal Aviation Administration's Civil Aeromedical Institute. The report indicated the following results: No Carboxyhemoglobin detected in blood. No Cyanide detected in blood. No Ethanol detected in vitreous fluid. Diazepam was detected in blood. Diazepam was detected in liver fluid. 0.31 (ug/ml, ug/g) Nordiazepam detected in liver fluid. 0.493 (ug/ml, ug/g) Chlorpheniramine detected in blood. 0.324 (ug/ml, ug/g) Diphenhydramine detected in blood. 1.26 (ug/ml, ug/g) Chlorpheniramine detected in liver fluid. 0.593 (ug/ml, ug/g) Diphenhydramine detected in liver fluid. The Diphenhydramine and Chlorpheniramine are drugs found in antihistamines. The pilot had 10 times the therapeutic blood levels of Diphenhydramine and 10 times the therapeutic blood levels of Chlorpheniramine in his blood. Drowsiness can result from using these over-the-counter drugs. They were not to be used when flying. The pilot also had a history of sleep apnea since 1989. He had received treatment for the condition. The pilot held a third class medical certificate issued on December 15, 1995. On April 11, 1996, the FAA sent the pilot a letter indicating that he was eligible for a third class certificate, and that the certificate he held was valid until its normal date of expiration. Between December 15, 1995, and April 11, 1996, the FAA had had questions concerning the pilot's high blood pressure, a carotid bruit, and sleep apnea. The friend of the pilot who was with him at the airport the day of the accident, reported that the pilot had indicated that he had had a "splitting headache" the night before the accident. Additional Information The parties to the investigation included the Federal Aviation Administration and Innovative Engineering. The aircraft was released to Robert Guentzel on November 11, 1996.

Probable Cause and Findings

the pilot's impairment of judgment and performance due to drugs, and his failure to maintain control of the airplane, which resulted in an uncontrolled descent and collision with terrain. Factors related to the accident were: the pilot's limited aeronautical experience and limited experience in the make and model of the accident airplane, which likely had different flying characteristics from the airplane in which he trained.

 

Source: NTSB Aviation Accident Database

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