CEN11FA629

The pilot’s improper decision to fly aerobatic maneuvers at low altitude, which resulted in a loss of control and impact with terrain. Contributing to the accident was the pilot’s impairment due to his recent use of multiple impairing drugs.

Several witnesses reported hearing a low-flying airplane. One witness stated that he heard the engine go silent three times and then rev back up twice and that he saw the airplane in about a 75-degree nose-low attitude. Another witness stated that he observed the airplane complete a 360-degree loop and then go into a "direct vertical climb, reach its pinnacle, and begin to fall tail first with a partial spin." He lost sight of the airplane behind trees. He then heard a "thud" and observed a black mushroom cloud appear above the tree line. Radar track data showed an airplane with a ground speed of 40 knots near the accident site at the time of the accident; the track was consistent with the performance of the aerobatic maneuver described by the witnesses. At the time of the accident, the sky was overcast with low clouds. The examination of the wreckage indicated that the airplane impacted the ground in about a 45-degree nose-low attitude. The examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Toxicological reports indicate that, at the time of the accident, the pilot had recently used at least five impairing drugs: diazepam, codeine, oxycodone, hydrocodone, and marijuana. All of these drugs work synergistically to create psychomotor slowing and interfere with judgment and executive functioning. It is very likely that the pilot was impaired by drug use at the time of the accident.

An autopsy of the pilot was performed at the Montgomery County Coroner's Office in Dayton, Ohio, on September 9, 2011. The "Cause of Death" was listed as multiple blunt force injuries. A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aerospace Medical Institute. The results were negative for carbon monoxide, cyanide, and ethanol. The following substances were identified in the toxicology report: 19.73 (ug/ml, ug/g) Acetaminophen detected in blood (cavity); codeine not detected in blood (cavity); 0.161 (ug/ml, ug/g) codeine detected in liver.; 0.152 (ug/ml, ug/g) diazepam detected in blood (cavity); 0.458 (ug/ml, ug/g) diazepam detected in liver; dihydrocodeine detected in blood (cavity); 0.201 (ug/ml, ug/g) dihydrocodeine detected in liver; 0.46 (ug/ml, ug/g) hydrocodone detected in liver; 0.091 (ug/ml, ug/g) hydrocodone detected in blood (cavity); 0.999 (ug/ml, ug/g) nardiazepam detected in liver; 0.21 (ug/ml, ug/g) nordiazepam detected in blood (cavity); 0.219 (ug/ml, ug/g) oxazepam detected in liver; 0.43 (ug/ml, ug/g) oxazepam detected in blood (cavity); oxycodone not detected in blood (cavity); oxycodone detected in liver; temazepam detected in liver; 0.094 (ug/ml, ug/g) temazepam detected in blood (cavity); 0.7593 (ug/ml, ug/g) tetrahydrocannabinol (marijuana) detected in heart; 6.3795 (ug/ml, ug/g) tetrahydrocannabinol detected in lung; 0.0959 (ug/ml, ug/g) tetrahydrocannabinol carboxylic acid (marijuana) detected in heart; and 0.1686 (ug/ml, ug/g) tetrahydrocannabinol carboxylic acid detected in lung. Acetaminophen is an analgesic marketed under the brand name Tylenol. It is available over the counter and by prescription in a number of combination medications. Diazepam is a Schedule IV controlled substance from the benzodiazepine class marketed under the brand name Valium. Nordiazepam is a metabolite of diazepam. Oxazepam and temazepam are psychoactive metabolites of diazepam and in addition are marketed separately as Schedule IV controlled substances under the brand names Serax and Restoril. Codeine, oxycodone, and hydrocodone are unique drugs and not metabolites of one another; all are opiate analgesics (narcotics). Codeine is a Schedule II controlled substance and is marketed in combination with acetaminophen under the brand names Tylenol #2, #3, and #4. Oxycodone is a Schedule II controlled substance and is marketed under brand names Percocet and Roxicet in combination with acetaminophen as well as OxyContin when in isolation. Hydrocodone is a Schedule III controlled substance and is marketed under the brand names Lortab, Vicodin, and Norco. Dihydrocodeine is an active metabolite of hydrocodone. Hydromorphone is an active metabolite of hydrocodone and is a Schedule II controlled substance marketed under the brand name Dilaudid. The NTSB's Vehicle Recorder Division inspected the PFD memory chips. The visual inspection of the units showed signs of extreme thermal damage to the chips packaging and some bent leads. One chip had a hairline fracture on the back-side of the chip packaging. X-ray imaging of the chips showed no signs of internal damage to either of the chips' die or bond wires. Readouts of the chips were attempted but were unsuccessful. No PFD data was recovered. The MFD memory card was found in good condition. The card was downloaded using the manufacturers' recommended procedures. The memory card contained 125 data files. One data file was identified as recording during the accident flight. The data file was about 7 minutes in duration. Three plots of the MFD data were produced by the Vehicle Recorder laboratory and are available with the docket material associated with this accident. The plots cover the time period from 11:14:20 EDT to 11:21:30 EDT. Plot one contains the basic engine parameters, including engine speed, oil pressure, oil temperature, and cylinder temperatures. Plot two contains electrical system and fuel used information. Plot three is a Google Earth image with the recorded flight path. The MFD did not record any altitude information. The MFD data indicated the airplane started to taxi for takeoff at 11:15:36 and started the takeoff roll at 11:17:54. The airplane departed from runway 7 and turned to a heading of about 170 degrees en route to Urbana, Ohio. The data indicated that the airplane stayed on this heading for about 6 nm until the MFD stopped recording engine data at 11:21:24. The accident site was located about 1.4 nm on a 167 degree heading from the last data point recorded. About 10 seconds before the MFD stopped recording data, the engine RPM dropped from 2,200 rpm to 1,900 rpm, the manifold air pressure (MAP) decreased from 22 MAP to 15 MAP, the fuel flow dropped from 16 to 9 gallons per hour, and the exhaust gas temperatures recorded a slight decrease in temperature. All engine parameters indicated that the engine was operating within the normal range during the flight up to the time when the MFD stopped recording data. Approach radar track data was obtained from the air traffic control tower at Port Columbus International Airport, Columbus, Ohio, located about 48 nm from EDJ on a 118 degree heading. The radar track data indicates that an aircraft using the visual flight rules transponder beacon code of 1200 departed runway 7 at EDJ about 11:18. After departure, the aircraft turned to a magnetic heading of about 168 degrees, flying at 2,000 feet about mean sea level (msl), +/- 200 feet. Radar contact was lost with the aircraft 3.4 nm to the south southeast of EDJ at 11:20:17. From 11:19:12 to 11:20:08, the aircraft had an average ground speed of 146 knots. The aircraft's altitude shows a descent from 2,000 feet at 11:15:54 to 1,800 feet at 11:20:08 with an average rate of 869 feet per minute. At 11:21:59, radar contact was regained on the aircraft for only four radar returns, 7 nm south of EDJ. Assuming a straight line flight track during the lost radar coverage (11:20:17 to 11:21:59), the aircraft had an average ground speed of 136 knots. The last three radar returns show an average ground speed of 40 knots. The last two radar returns (11:22:08 and 11:22:13) show a descent rate of 100 feet (+/- 99 feet) from 2,300 to 2,200 feet msl. The MFD is not equipped with an ON/OFF switch. To disconnect the MFD from electrical power, the MFD circuit breaker located on the Avionics Non-Essential bus would need to be pulled. The circuit breaker panel is located within the pilot's reach next to the central pedestal. Turning off the main avionics switch would disconnect the MFD from electrical power; however, all avionics equipment would be turned off as a result. The MFD generates new data files for each power-on cycle. The oldest record is dropped and replaced by a new recording once the storage limit has been reached. MFD data are sampled every six seconds, and are recorded to memory once every minute. If an interruption of power occurs during the minute between MFD memory-write cycles, data sampled during that portion of a minute are not recorded. The transponder is equipped with an ON/OFF switch. The transponder's circuit breaker is located on the Avionics Non-Essential bus. At 1120, the surface weather observation at EDJ, located about 7.3 nm north of the accident site, was: winds 360 degrees at 3 knots; visibility 3 miles; overcast ceiling at 600 feet; temperature 16 degrees Celsius (C), dew point 16 degrees C; altimeter 29.91 inches of mercury (Hg). The airport elevation at EDJ is 1,122 feet. The elevation at the Grimes Field Airport (I74), Urbana, Ohio, and located 15 nm south of EDJ is 1,068 feet. The accident site was located in a cornfield about one mile west of West Liberty, Ohio. The examination of the initial point-of-impact and the debris field revealed that the airplane impacted the terrain on a magnetic heading of about 110 degrees. The cut through the high corn made by the airplane's landing gear, fuselage, and wings indicated that it