Aviation Accident Summaries

Aviation Accident Summary WPR09LA032

Wallace, CA, USA

Aircraft #1

N80715

Universal Globe

Analysis

During the test flight of the experimental airplane, an on-board video camera recorded the takeoff and the pilot activating the landing gear retraction about 2 minutes after takeoff. Approximately 2 1/2 minutes later, the recording showed the pilot's hand slipping from the throttle and his head tilting forward. There were no subsequent coordinated movements made by the pilot, though the airplane remained airborne for about an hour. During this time, the video showed a series of descending and climbing turns varying in altitude between 1,900 feet and 3,800 feet mean sea level (msl). The test flight also included a second airplane, which was also videotaping the test flight. The recorded video from the second airplane verified the same flight path as the recording from the accident airplane. The airborne witnesses observed the accident airplane flying erratically for about an hour before they had to return to the airport due to fuel considerations. During the hour-long flight, the pilot of the second airplane attempted unsuccessfully several times to contact the accident pilot by radio. At one point, the second airplane was able to fly adjacent to the accident airplane. The airborne witnesses observed the accident pilot slumped over the flight controls and unresponsive. The airplane eventually collided with flat open terrain. Post accident examination of the engine found no evidence of a preimpact malfunction. The condition of the pilot's remains did not permit determination of whether the pilot was deceased prior to impact. Toxicology tests of post-mortem samples from the pilot detected alfuzosin, a prescription medication used for the treatment of prostate enlargement. Alfuzosin can rarely result in an unsafe drop in blood pressure, particularly with the first dose, or an increase in dose, but the medication typically does not have any adverse effects, and is routinely approved by the FAA.

Factual Information

HISTORY OF FLIGHT On November 6, 2008, about 1720 Pacific standard time, a Universal Globe GC-1A airplane, N80715, impacted flat terrain near Wallace, California. The pilot/owner operated the airplane under the provisions of 14 Code of Federal Regulations Part 91. The pilot, the sole occupant, was killed; the airplane was destroyed. The flight departed the Rancho Murieta Airport (RIU), Rancho Murieta, California, at 1610. Visual meteorological conditions prevailed for the local area test flight, and no flight plan had been filed. According to local law enforcement, the flight was to test a retractable tail wheel that had been installed on the airplane. It was a flight of two, with a friend of the accident pilot flying in the second airplane to observe the flight. The second pilot reported that nothing unusual was noted with the flight until he observed the accident airplane start to fly “erratically.” He attempted to raise the accident pilot on the radio, but received no response. The second pilot was able to catch up to the accident airplane and observed the accident pilot slumped over in the cockpit. The second pilot stayed with the accident airplane until his airplane became low on fuel; at which point he returned to the airport. The airplane was located near the campgrounds of the Comanche Lake Reservoir by the Calaveras County Sheriff's Department. WITNESS INFORMATION Friends of the pilot reported that the accident flight was the second flight since the airplane had been reassembled. The pilot had been working on the airplane for the past 2 years, which included painting, rebuilding the engine, and updating the instrument panel. The first flight was an engine break in, but lasted only 10 minutes due to a partially clogged fuel injector. The repair was made, and the second flight was planned. An airframe and power plant mechanic, who inspected the airplane in September 2008, reported that the airframe had been completed and assembled with the pilot still working on the instrument panel. During the inspection he found a few instances of incorrect hardware in the flight control system, that the pilot subsequently corrected. He was not able to perform the final inspection, but he did have several conversations with the pilot prior to and after the first flight. Witnesses reported seeing and interacting with the pilot prior to the flight. He appeared in good spirits, and his "usual cheerful, professional self." A ground witness reported that he and two other pilots watched the flight from its takeoff until they lost sight of the airplane. He reported hearing a strong engine on takeoff. The airplane made several stabilized climbing turns. After the chase airplane caught up with the accident airplane, the two airplanes continued to climb in a northeasterly direction for "several minutes." The group then observed the accident airplane start a series of diving and climbing maneuvers. In the chase airplane, along with the pilot, was a videographer. The videographer did not recall any of the communications, as he was focusing on his equipment. After takeoff, they caught up with the accident airplane. The chase pilot radioed the accident pilot that everything appeared good. They observed the accident pilot raise the landing gear, and about a minute later the airplane made an abrupt, steep nose dive. The airplane then recovered, and engaged in several more dives and climbs. The pilot of the chase plane attempted numerous times to contact the accident pilot. About an hour into the flight, the chase pilot indicated they were low on fuel and they decided to fly abreast of the accident airplane and signal to the pilot that they were returning to the airport. As they approached the accident airplane, they observed the pilot slumped over the flight controls. The chase pilot reported that the accident airplane's altitude varied between 1,000 and 3,000 feet mean sea level (msl). PERSONNEL INFORMATION The 67-year-old pilot held a commercial certificate with ratings for single and multiengine, instrument airplane, and rotorcraft. The pilot held a second-class medical issued on July 8, 2008; it held the restriction "Must wear corrective lenses." No pilot records were available for review. The flight hours listed in this report were obtained from the pilot's most recent medical application. The pilot listed his total flight time as 5,600 hours, with 20 hours in the past 6 months. AIRCRAFT INFORMATION The airplane was a 1946, four-seat, single engine Universal Globe CG-1A. A Lycoming IO-360-EXP, serial number L-51897-07 was installed. No logbooks were available for review by the Safety Board investigator-in-charge (IIC). An inspection of the engine showed no evidence of a preimpact malfunction. According to the manufacturer, there were no mechanical issues that would have precluded normal operation. MEDICAL AND PATHOLOGICAL INFORMATION The Calaveras County Office of the Coroner, Santa Clara, California, performed an autopsy of the pilot on November 10, 2008. In the "Comment" section of the autopsy report it was noted that "based on the examination of the remains, I cannot determine whether the deceased expired before the aviation accident or during the accident." The autopsy report noted that the body was "extensively disrupted." Examination of the heart documented, in part, that the coronary arteries were "patent at all levels," and that there was "no evidence of recent or remote myocardial infarction." Microscopic examination of the coronary arteries identified "diffuse atherosclerotic changes and in some areas the lumen appears to be narrowed up to 50 or 60[-percent] but in all the sections, the lumen appears patent and there is no evidence of thrombus." The FAA Forensic Toxicology Research Team CAMI, Oklahoma City, Oklahoma, performed a toxicological analysis from samples obtained during the autopsy. No blood, urine, or vitreous samples were available for testing. Ethanol was detected in the liver at 24 (mg/dL, mg/hg), and no ethanol was detected in the muscle. Alfuzosin was detected in the liver and kidney; there were no other positive findings. The pilot’s most recent application for second-class Airman Medical Certificate, dated July 8, 2008, indicated “Yes” in response to “Do You Currently Use Any Medication,” and noted only Zocor (simvastatin) and Protonix (pantoprazole). The application noted “No” to Visits to Health Professional Within Last 3 Years” and to all items under “Medical History,” except “Admission to hospital,” and indicated, under “Explanations,” “childhood tonsillectomy.” TESTS AND RESEARCH A video of the accident flight was obtained by the Safety Board IIC. It showed the pilot performing preflight of the airplane, along with the start-up and takeoff. There were no discrepancies noted with that portion of the flight. The video ends after the second airplane returns to the airport. The on-board video recorder remnants was recovered during the airplane reconstruction and shipped to the vehicle recorder laboratory in Washington, D.C., for review. The JVC mini-DV tape removed from the unit was smashed and the tape was broken into several pieces. The tape was spliced together and reloaded into a new case to facilitate a playback of the video. The video showed a 70 minute 40 second color recording with stereo sound. According to the accident pilot's brother, the camera was mounted in the rear seat area, which was confirmed by the view that the recording provides. The recording shows the back of the pilot, who was seated in the left seat of the airplane. The view generally showed the center portion of the instrument panel. The vertical field of view was from the lower throttle quadrant to the stand-by compass above the windshield. The horizontal field of view extended from the pilot's primary flight display on the left to about the right edge of the instrument panel on the right. This field of view did not change during the recording. According to the vehicle recorder specialist, the video showed the pilot in the left seat with his shoulder harness on, the engine running, taxi to the active runway, and the takeoff run. The airplane was airborne about 9 minutes into the recording, with an established climb rate of 500 feet per minute (fpm), to an altitude of 2,000 feet. The landing gear was retracted about 2 minutes later when the airplane leveled off at 2,000 feet. There were no discrepancies noted with the flight. At 13 minutes 28 seconds into the recording, the pilot adjusts the throttle and 2 seconds later, the pilot's hand slips off the throttle and his head tilts forward. No coordinated movement of the pilot's head or hand was observed during the remainder of the recording. The video also shows several descending and climbing turns. The descents are about 40 degrees pitch down with a 45-degree bank to an altitude of 1,900 feet. At that point, the airplane begins a 10-degree left climbing turn to about 3,800 feet. The video shows the airplane continuing that flight profile until the end of the recording.

Probable Cause and Findings

The pilot's incapacitation during cruise for unknown reasons that resulted in a loss of aircraft control.

 

Source: NTSB Aviation Accident Database

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