ERA15FA245

The pilot’s failure to maintain airplane control after the cockpit canopy opened during initial climb. Contributing to the accident was the pilot’s failure to securely lock the canopy before takeoff.

Earlier on the day of the accident, a condition inspection of the light-sport airplane had been completed, and the purpose of the flight was to relocate the airplane to its home base airport. About 1500, the pilot's wife dropped the pilot off at the airport. The temperature was in the "upper 90s," and, since the airplane was equipped with a clear cockpit canopy, it would have been hot inside of the airplane. According to the pilot's wife, it was the pilot's habit to leave the canopy up when it was hot until he was ready to depart. About 1530, the pilot called his wife from the airplane before he took off and advised her that it would take him 15 minutes to fly to the home base airport and that he would wait for her to pick him up in the air-conditioned office of the fixed-base operator (FBO) at the field. However, when she arrived at the FBO, he was not there. A search was initiated, and the airplane wreckage was found in a wooded area about 1.1 miles west of the departure airport. Recorded data downloaded from a portable GPS unit that was onboard the airplane revealed that the airplane was airborne about 1 minute before reaching a peak GPS altitude of 309 ft and a derived groundspeed of 104 knots. This was the final recorded position. Examination of the accident site and wreckage revealed that the airplane struck trees in a steep, nose-low attitude and that the pilot was ejected from the cockpit. Examination of the damage to the canopy, the cockpit sill, and the canopy locking mechanism indicated that the canopy was not closed and locked when the airplane impacted the trees. This most likely occurred due to the pilot delaying closing of the canopy due to the high temperature (as was his habit) and then forgetting to lock it. Although the airplane's Pilot's Operating Handbook advised that the canopy could not be closed in flight and that there would be no change of flight characteristics with the canopy open, it is likely that the pilot was attempting to close the canopy in flight and lost control of the airplane, which resulted in an uncontrolled descent into the trees. The pilot's four-point harness was intact and attached to its attachment fittings; however, the center buckle assembly was found unlatched. This may have been the result of the pilot forgetting to buckle the harness, or he may have unlatched it so he could reach the canopy sill and/or the latching mechanism in an attempt to close the canopy in flight. Other indicators that the pilot may have been in a hurry to get airborne due to the high temperature included his failure to arm the emergency locator transmitter, which was found in the "off" position, and to remove the ballistic recovery system activation handle safety pin with its "REMOVE BEFORE FLIGHT" flag, which was found in place. The pilot's autopsy revealed that his heart was mildly enlarged, and his coronary arteries were significantly narrowed by atherosclerotic plaques. Microscopic evaluation of heart tissue also demonstrated mild interstitial fibrosis. Toxicological testing revealed medications that were consistent with the pilot's heart disease. Although the pilot's heart disease put him at risk for physical symptoms, such as chest pain, shortness of breath, or a heart rhythm that could not produce enough blood pressure to stay awake, neither the heart disease nor his medications would have impaired his judgment or increased his risk of becoming distracted by the canopy issue. Thus, the pilot's medical conditions and medications most likely did not contribute to the cause of this accident.

The airplane was equipped with a Garmin GPSMAP 696 portable multifunction display that was mounted in a recess in the instrument panel. The unit consisted of a GPS receiver with a 7-inch diagonal high resolution liquid crystal display. The unit could store data including, date, time, latitude, longitude, and altitude information for multiple flights in non-volatile memory (NVM). Data recovered from the unit included track logs from June 5, 2011, through June 21, 2015. The last track log corresponded to the accident flight and contained data from 1525:57 to 1531:35. According to the data, the airplane began its takeoff roll on runway 21 at 1530:19 and became airborne about 1530:38. The airplane continued to climb while turning to the west until about 1 minute after the takeoff, and, at 15:31:35, the airplane reached a GPS altitude of 309 ft and a derived groundspeed of 104 knots. This was the final recorded position. 01NC was an uncontrolled, privately-owned airport, located 2 miles southwest of Holly Ridge, North Carolina. The field elevation was 65 ft above mean sea level. The airport had two runways oriented in a 18/36 and 3/21 configuration. Runway 21 was turf covered, in good condition, and measured 3,200 ft long and 75 ft wide. The airplane manufacturer's published Pilot's Operating Handbook (POH) for the airplane stated that "Before engine starting," the canopy should be "clean, closed, and locked" and that the pilot should "tighten" the safety harness. The POH also stated that "Before takeoff," the cockpit canopy should be "closed and locked," recommended to "manually check by pushing the canopy upwards," and again stated to "tighten" the safety harness. Review of Section 7 (Description of Airplane and Systems) in the POH revealed guidance regarding the canopy that stated, "make sure that the canopy is latched and mechanism is securely locked into position on both sides before operating the aircraft." Section 7 also provided guidance regarding the safety harness that stated, "adjust the buckle to a central position on the body." Supplement 03 to the POH, issued September 2010, advised that, if a canopy inadvertently opened on an airplane, it would not be possible to close the canopy, but the airplane would be fully functional. The supplement indicated the following: - During takeoff: the canopy would open about 2-inches. - During climb and descent (with the airspeed at 60-75 knots): the canopy would stay open 2-3.2 inches. - During horizontal flight (with airspeed at 60-80 knots): the canopy would stay open 2-3.2 inches. The supplement advised that in all of the above-mentioned cases, there would be no flight problems, no vibrations, good aircraft control, and no change of flight characteristics. It recommended that, before takeoff, the pilot should "manually check the canopy is locked by pushing on the canopy upwards," and cautioned that, with the canopy open in flight, "do not perform any slipping." The pilot was an 89-year-old male, who, as of his last FAA medical exam, was 68 inches tall and weighed 187 pounds. The pilot had first applied for a medical certificate in 2004 and reported to the FAA a medical history that included coronary artery disease treated with a stent in 2002 and coronary artery bypass grafting in 2004. In addition, he had hypertension and a history of a period of atrial fibrillation. After additional detailed information was reviewed, the pilot received a special issuance third-class medical certificate in 2005 with the limitation that it was valid for 1 year. The pilot continued to renew his special issuance medical certificate annually, providing detailed information requested by the FAA. He developed recurrent atrial fibrillation in 2008 when an atrial clot was also diagnosed. He was treated with rate control medication and blood thinners. With a few periods of being deferred because he needed to get better control of his rate or degree of blood thinning, the pilot generally continued to receive special issuance third-class medical certificates. At the time of his last exam, he reported using warfarin (a blood thinner), diltiazem (a blood pressure medicine also used to control the heart rate in patients with atrial fibrillation), and febuxostat (a medication to prevent attacks of gout) and received a special issuance third-class medical certificate limited by a requirement for corrective lenses and marked, "not valid for any class after 07/31/2014." At the time of the accident, the pilot was flying an airplane that met the definition of a light sport aircraft; thus, he was required only to hold a valid driver's license. According to the autopsy performed by the Brody School of Medicine at East Carolina University, Division of Forensic Pathology, the pilot's cause of death was multiple extreme injuries due to aircraft crash, and the manner of death was accident. The evaluation of natural disease was limited. The heart was described as "mildly enlarged" and weighed 430 grams (average for a 185-pound man is 358 grams with a range of 271-473 grams). The coronary arteries were significantly narrowed by atherosclerotic plaques including 80% stenosis of the left main and left anterior descending, 90% stenosis of the first diagonal, 70% stenosis of the circumflex, and 30% of the right coronary, which was fed by a patent coronary artery bypass graft. The septum was 1.5 centimeters thick (average is 1.3 centimeters). Microscopic evaluation of heart tissue demonstrated mild interstitial fibrosis. The FAA's Bioaeronautical Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing, but it and was limited by the absence of available blood. The evaluation for volatiles identified 79 mg/hg of ethanol in muscle and 19 mg/hg in liver as well as N-butanol and N-propanol in muscle. Ethanol may be ingested in beer, wine, and liquor but may also be produced by microbial action after death. The alcohols N-butanol and N-propanol are only produced by microbial action after death. In addition, atenolol, verapamil, its metabolite norverapamil, and warfarin were detected in liver, and verapamil and warfarin were detected in muscle. Atenolol and verapamil are prescription medications used to treat hypertension and control the heart rate in atrial fibrillation. Warfarin is a blood thinner used to prevent clot formation and resulting strokes in patients in atrial fibrillation. None of these medications are impairing. Examination of the accident site revealed that the airplane struck trees in a steep, nose-low attitude, and the pilot was ejected from the cockpit. The airplane then fell nose first to the forest floor below, impacted in a 90° nose-down attitude, nosed over, and came to rest inverted. Numerous areas of crush and compression damage to the fuselage and wings were noted, and there was evidence of fuel staining on the leading edges of the wings. There was no evidence of any inflight structural failure, inflight fire, or inflight explosion. Examination of the cockpit canopy revealed that it was detached from its mounting location and was lying underneath the aft portion of the inverted fuselage. The majority of its clear bubble was broken into multiple pieces; however, the pieces were not scattered around the accident site but were collocated with the canopy frame. One of the canopy lift struts was missing and was not recovered. The damage patterns observed on the canopy frame and cockpit sill did not match and could not be correlated with each other. The canopy latching mechanism hooks were found to be partially retracted, the canopy locking mechanism and activation handle were in the "OPEN" position, and the slots in the canopy frame that the hooks engaged when the canopy was closed and locked showed no evidence of tear-out. Both wing fuel tank caps were closed, both wing locker doors were closed and secured, all the inspection panels were closed and secured, and the pitot