ERA16FA194

The pilots' loss of control that necessitated the activation of the parachute system and the airplane manufacturer's inadequate design of the front parachute anchor attachment structure, which resulted in a failure of the parachute after it was deployed in flight and precluded the pilots from safely recovering from the spin.

The sport pilot had recently purchased the airframe-parachute-equipped light sport airplane and was receiving instruction in it to satisfy insurance requirements. Radar data indicated that, during the flight, the airplane's groundspeed decreased from 94 to 62 knots, consistent with airwork including slow flight and stall practice. Subsequently, several witnesses observed the airplane descending nose-down with the parachute still attached, but with the canopy only partially inflated, before the airplane impacted terrain. The parachute handle was located on the left side of the instrument panel, and the sport pilot likely activated the parachute due to inadvertent spin entry. The previous owner of the airplane stated that he had to be vigilant during stall practice because the airplane always seemed to yaw abruptly right and into a spin, more so than any other airplane he had flown. The parachute attached to the airframe via four risers. Two of the risers shared a front anchor attached to the aluminum bulkhead behind the seats. The other two risers attached to a rear anchor located at each wing root. Examination of the wreckage revealed that the two front risers remained attached to the shared front anchor but that the anchor had separated from the airframe. The two rear risers had separated in overstress. The front anchor was designed to carry the majority load. The remaining two rear risers were designed to stabilize the airplane in an optimal descent attitude and could not carry the full load if the front anchor failed. Metallurgical examination of the separated front anchor revealed that it had been bolted into aluminum bulkhead skin that was about 0.022-inch thick. Although the anchor and seven of its eight bolts remained intact, the surrounding aluminum skin of the airplane had separated from the airplane in overstress. Without any additional supporting structure such as longerons, stringers, or bathtub fittings, it is likely the thin aluminum skin could not withstand the force applied to the front anchor during parachute deployment. The investigation noted that the first in-flight deployment of the parachute on the make and model airplane was on the accident airplane during the accident flight. During certification, one test deployment was performed on the ground. Further, the airplane manufacturer was unable to provide any data or testing of the amount of shock force the surrounding aluminum skin could withstand during deployment. The airplane's maximum takeoff weight was 1,279 lbs. According to the parachute manufacturer, the parachute could be deployed at a maximum weight of 1,350 lbs and a maximum speed of 138 mph. A representative of the parachute manufacturer stated that, although the engine should be off during parachute deployment, it did not have as significant an effect on deployment as airplane speed and weight. Although the airplane was about 50 lbs over its maximum takeoff weight at the time of deployment, it was under the parachute manufacturer maximum weight of 1,350 lbs. Additionally, the pilot likely activated the parachute in the early stages of a spin and closer to stall speed, significantly slower than the 138-mph parachute limit. The sport pilot had chronic pain treated with multiple medications, including Methadone, an impairing opioid medication, which was detected in blood at levels consistent with chronic use. Further, the sport pilot had insomnia and depression treated with quetiapine and doxepin, both of which are sedating medications. The pilot's recent use of the combination of two potentially impairing medications likely impaired his cognitive and psychomotor function to some degree. However, the investigation could not determine if the pilot's impairment led to a situation that required activation of the parachute. Additionally, there was no evidence that the decision to activate the parachute was inappropriate. Therefore, it is likely that the pilot was impaired by the combination of medications, but there is no evidence that his impairment contributed to the cause of the accident.

According to the manufacturer, the airplane's basic empty weight was 819.82 lbs. Review of fueling records revealed that on the day of the accident, 9.1 gallons of fuel were added to the airplane, and its total fuel capacity was 16.9 gallons (101.4 lbs). Review of autopsy reports revealed that the pilot weighed 270 lbs and that the flight instructor weighed 170 lbs, which resulted in a total airplane weight of 1,361.22 lbs, or 82.22 lbs above the airplane's maximum takeoff weight of 1,279 lbs. The airplane had flown about 1 hour before parachute deployment, and a fuel consumption rate of 5 gallons per hour corresponded to an airplane weight about 50 lbs above its maximum takeoff weight of 1,279 lbs at the time of parachute deployment. The airplane manufacturer and FAA Office of Accident Investigation, Recommendation and Analysis Division were notified about the overstress failure of the airplane structure to which the front anchor attached. A search of FAA data revealed fifteen other U.S.-registered Skyleader 500 airplanes. Orange County Airport (OMH), Orange, Virginia, was located about 9 miles west of the accident site. The 1635 recorded weather at OMH included calm wind, visibility 10 miles, and scattered clouds at 11,000 ft. The State of Virginia Office of Chief Medical Examiner, Manassas, Virginia, conducted autopsies on the pilot and flight instructor. The autopsy reports noted the cause of death for both pilots as "blunt force trauma." The FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of specimens from the pilot and flight instructor. The results for the flight instructor were negative for alcohol and drugs. The results for the pilot were as follows: "Carvedilol detected in Liver Carvedilol detected in Blood Doxazosin detected in Liver Doxazosin detected in Blood 2.099 (ug/mL, ug/g) Doxepin detected in Liver 0.451 (ug/mL, ug/g) Doxepin detected in Blood Methadone detected in Liver Nordoxepin detected in Liver Nordoxepin detected in Blood 0.592 (ug/mL, ug/g) Quetiapine detected in Liver Quetiapine NOT detected in Blood Blood unsuitable for analysis of Methadone." According to the pilot's personal medical records, his chronic medical conditions included obstructive sleep apnea, high blood pressure, elevated cholesterol, heart disease, chronic obstructive pulmonary disease, and benign prostatic hypertrophy; these were all reportedly controlled, and the treatments are generally considered not to be impairing. In addition, he had an unspecified clotting disorder treated and controlled with apixaban. Because of the clotting disorder and bleeding into his muscles, he had severe myositis ossificans (bone formation in the muscle tissue), which resulted in limited range of motion and chronic pain treated with the impairing opioid medications methadone and oxycodone. The pilot had a remote history of strokes and heart disease, but no abnormal findings were documented on recent neurological and cardiac examinations. Further, the autopsy did not identify any significant natural disease in the heart or brain. Finally, he had a history of insomnia and depression treated with the impairing medications seroquel and doxepin. Although there was no evidence of depression on recent examinations, both psychoactive medications had been prescribed specifically for their sedating effects. Title 14 CFR Part 61.23(c)(1) allows sport pilots to use a valid and current U.S. driver's license in lieu of a medical certificate. However, further review of 61.23(c)(2)(iv) revealed that the sport pilot must "Not know or have reason to know of any medical condition that would make that person unable to operate a light-sport aircraft in a safe manner." The pilot, age 57, held a sport pilot certificate with endorsements for airplane single-engine land and powered-parachute land. He did not possess an FAA medical certificate nor was he required to. Review of the pilot's logbook revealed that he had accumulated a total flight experience of about 121 hours, of which 2.5 hours were in the accident airplane. The pilot had flown 4.5 and 0 hours during the 90- and 30-day periods preceding the accident, respectively. Further review of his logbook revealed that the 2.5 hours of experience in the accident airplane consisted of two flights on March 20, 2016, and March 22, 2016, in California. The pilot recorded those flights in his logbook as prebuy flights. During the second prebuy flight, the pilot also recorded "Slowflight Stalls" in his logbook. Additionally, the pilot recorded those two flights as dual instruction received; however, there were no accompanying endorsements from a flight instructor. Other than the 2.5 hours in the accident airplane, the pilot did not have any prior experience in the accident airplane make and model. The flight instructor, age 81, held an airline transport pilot certificate with a rating for airplane multiengine land. He also held a commercial pilot certificate with ratings for airplane single-engine land and airplane single-engine sea. Additionally, he held a flight instructor certificate with ratings for airplane single-engine and instrument airplane. His most recent FAA second-class medical certificate was issued on March 1, 2016. Review of the flight instructor's logbook revealed that he had accumulated a total flight experience of about 32,840 hours, of which 100 and 43 hours were flown during the 90- and 30-day periods preceding the accident, respectively. There was no record of the flight instructor having any prior experience in the accident airplane make and model. The two-seat, low-wing, retractable tricycle landing gear-equipped airplane, serial number 5141163M, was manufactured in 2007. It was powered by a Rotax 914 UL, 115-horsepower engine, equipped with a DUC Swirl ground-adjustable three-blade propeller. The airplane was issued an FAA special light sport aircraft (S-LSA) airworthiness certificate in 2008, which was superseded by an FAA experimental light sport aircraft (E-LSA) airworthiness certificate in 2010. According to the previous owner of the airplane, he chose to have the airplane subsequently recertified as an E-LSA, rather than an S-LSA because he could perform more of the maintenance work himself under the E-LSA certification. The previous owner further stated that he had to be vigilant during stall practice because the airplane always seemed to yaw abruptly right and into a spin, more so than any other airplane he had ever flown. The airplane's maximum gross takeoff weight was 1,279 lbs. Review of the airplane's logbook revealed that its most recent annual condition inspection was completed on May 6, 2016. At that time, the airframe and engine had accumulated 534 hours since new. Review of the airplane's Pilot's Operating Handbook revealed, "Acrobatic, intentionally driven stalls and spins are prohibited!" The airplane was equipped with a Galaxy Rescue Systems (GRS) ballistic parachute. According to the manufacturer label, the model parachute could be deployed at a maximum weight of 1,350 lbs and maximum speed of 138 mph. Review of the parachute manual revealed instructions for the engine to be turned off before activation. The parachute attached to the airframe via four risers (cables) and three anchors. Two of the risers shared an anchor (front) attached by eight bolts with nuts to the aluminum bulkhead behind the seats. The other two risers (rear) attached to an anchor located at each wing root near the trailing edge of the wing. According to a representative of the parachute manufacturer, the double-riser front anchor was designed to carry the majority load. The remaining two rear risers were designed to stabilize the airplane in an optimal descending attitude and could not carry the full load if the double-riser front anchor failed. Specifically, the double-riser front anchor could withstand a maximum shock/load of 40.1 kiloNew