ERA18FA064

The pilot's unsafe maneuvering and exceedance of the airplane's operating limitations, which resulted in an in-flight failure of the left wing. Contributing to the accident was the pilot's underlying physiologic or psychiatric disease.

The sport pilot departed on the visual flight rules (VFR) cross-country flight under day visual meteorological conditions and climbed the airplane to 2,500 ft. While on the ground and during the climb and cruise portions of the flight, the pilot missed or did not respond to numerous radio calls from air traffic controllers, deviated from assigned altitudes, and used improper radio terminology. Data from onboard the airplane indicated that, throughout the flight, the pilot operated the airplane within the yellow airspeed caution range in excess of its maximum structural cruise speed of 108 knots. About 4 minutes before the accident, he began a descent toward the destination airport. When the controller advised the pilot of nearby traffic, the pilot responded that he was looking. The airplane's pitch then increased slightly nose-up, followed by a significant pitch change to 45° nose-down and a right roll of 37°. The pilot transmitted "mayday, mayday." The roll continued through inverted and the airspeed eventually increased to 169 knots, which was 33 knots in excess of the airplane's never-exceed (redline) speed. During the final 10 seconds of recorded data, the engine speed varied between 4,550 and 5,950 rpm (redline rpm was 5,800). The wreckage debris path and fracture signatures on the left wing indicated that it failed in-flight in a positive (wing up) direction, striking the airplane's canopy while departing the airplane. The wing spar fracture surfaces were consistent with overload with no evidence of preexisting corrosion or fatigue. It is likely that the wing failure occurred as the airplane descended and exceeded its redline speed. Although the airplane did not have a current condition inspection, there was no evidence of any preexisting mechanical malfunction or anomaly with the airplane or engine. The pilot did not possess a Federal Aviation Administration (FAA) medical certificate, nor was he required to in order to exercise the privileges of a sport pilot. According to personal medical records, he had been diagnosed with hypertension, high cholesterol, obstructive sleep apnea, neurogenic bladder, cataracts, peripheral neuropathy, depression, and post-traumatic stress disorder. It would have been the pilot's responsibility to report any medical deficiency that would interfere with the safe performance of sport pilot operations to the FAA; however, he did not do so. An autopsy of the pilot revealed an enlarged and thickened heart and significant coronary artery disease with about 50% to 75% narrowing of both the left main and left anterior descending coronary arteries. While possible, it could not be determined if the pilot experienced an acute cardiac event that may have affected his ability to control the airplane. Toxicology testing identified three different potentially impairing psychoactive medications in specimens of the pilot. What effects the pilot may have experienced from the use of this combination of medications could not be determined; additionally, the pilot's mental state at the time of the accident could not be established. Overall, the pilot's coronary artery and significant psychiatric disease put him at risk for distraction and inattention that could have led to the accident circumstances. His unreported psychiatric disease, if not well-controlled, could have led to intentionally unsafe maneuvering. Whether the effects from multiple psychoactive medications contributed to the accident could not be determined, but it was evident that, based on his interaction with air traffic controllers, the pilot was not performing at a competent level. While the exact cause of the pilot's behavior could not be determined, given the lack of mechanical anomalies or weather phenomena that could explain the accident sequence, it is likely that his underlying physiologic or psychiatric disease resulted in his exceedance of the airplane's operating limitations, which led to an in-flight failure of the left wing while maneuvering.

The Office of the State of Florida, District 21 Medical Examiner performed the autopsy of the pilot. The cause of death was multiple blunt force injuries. The heart was enlarged and thickened; it weighed about 60 grams more than that of an average man of his weight. There was significant coronary artery disease with about 50% to 75% narrowing of both the left main and left anterior descending coronary arteries. The FAA Forensic Sciences Laboratory performed toxicology testing on specimens from the pilot. Testing was negative for carbon monoxide and ethanol. Naproxen was identified in the urine. Atenolol was identified in the liver. Citalopram, its metabolite N-desmethylcitalopram, mirtazapine, and trazodone were detected in cavity blood and in the urine. Naproxen is an analgesic available over-the-counter or by prescription, often with the names Aleve® and Naprosyn®. Atenolol is a blood pressure medication that may also be used to reduce the risk of recurrent heart attacks. Neither of these are considered impairing. Citalopram is an antidepressant often sold under the name Celexa® that carries a precaution for patients that it impairs mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). It has not been shown to degrade performance in psychological testing experiments using healthy volunteers. Mirtazapine is another prescription antidepressant commonly marketed with the name Remeron®. It is well known to cause somnolence (sleepiness) in the majority of people using it and carries the precaution, "Mirtazapine may impair judgment, thinking and particularly, motor skills, because of its prominent sedative effect. The drowsiness associated with mirtazapine use may impair a patient's ability to drive, use machines, or perform tasks that require alertness. Thus, patients should be cautioned about engaging in hazardous activities until they are reasonably certain that mirtazapine therapy does not adversely affect their ability to engage in such activities." Trazodone is another antidepressant that is sedating enough that it is often prescribed as a sleep aid. It carries this information for prescribers: "Antidepressants may impair the mental and/or physical ability required for the performance of potentially hazardous tasks, such as operating an automobile or machinery; the patient should be cautioned accordingly. Trazodone hydrochloride may enhance the response to alcohol, barbiturates, and other central nervous system depressants." Major depression itself is associated with significant cognitive degradation, particularly in executive functioning. The cognitive degradation may not improve even with remission of the depressed episode, and patients with severe disease are more significantly affected than those with fewer symptoms or episodes. Thus, depression is a disqualifying condition for pilot medical certification. According to the Guide for Aviation Medical Examiners, an aviation medical examiner should not issue a medical certificate to a depressed pilot. The FAA will consider a special issuance of a medical certificate for depression after six months of treatment if the applicant is clinically stable on one of four approved medications. Records from the pilot's usual source of care, the Veterans Administration, for the period between January 2015 and the accident date were obtained and reviewed. The records documented that the pilot had hypertension, high cholesterol, obstructive sleep apnea, neurogenic bladder, cataracts, peripheral neuropathy, depression, and post-traumatic stress disorder (PTSD). At the time of his last annual exam (March 2017), he was prescribed atenolol and lisinopril to treat his blood pressure, simvastatin for his cholesterol, use of a continuous positive airway pressure (CPAP) machine for his sleep apnea, and citalopram and trazodone for his psychiatric disease. Records indicated that the pilot complained of worsening symptoms from PTSD, including nightmares and intrusive thoughts, during the end of 2016 and early 2017. This was apparently brought on by legal issues. The underlying issue was that the pilot had been discovered misrepresenting his military service, which had been revealed on the internet by a group he considered "terrorists." The pilot was facing charges for repeatedly breaking the conditions of a restraining order regarding threatening the wife of the individual who revealed his misrepresentation. The pilot's wife told investigators that she was unaware that her husband was being treated for mental health issues. FMY was located about 18 nautical miles (nm) northwest of the accident site. The FMY weather at 1153 included wind from 140º at 9 knots, 8 statute miles visibility, clear sky, temperature 26°C, dew point 18°C, and altimeter setting of 30.11 inches of mercury. The pilot, age 68, held a sport pilot certificate with airplane single-engine land privileges. According to the FAA, the pilot never held an FAA medical certificate, nor was he required to as a sport pilot. The pilot's logbook contained entries from February 12, 2015, through January 10, 2017. No flight times were forwarded from a previous logbook. There was an endorsement for a flight review dated January 6, 2017. According to information provided by the pilot's insurer, the pilot reported, as of January 12, 2018, 530 total hours flight experience, including 130 hours in the RV-12, and 10 hours in the preceding 12 months. The airplane impacted a forested area about 33 nm northwest of X01. There was no fire. The wreckage debris field was oriented in a south-to-southwest direction and measured about 715 ft long and about 100 ft wide. All components of the airplane were accounted within the wreckage debris field. The first piece of wreckage found along the debris path was the left wing. Adjacent to the left wing were fragments of the cockpit canopy. The left wing was located about 670 ft north-northeast of the main wreckage. The flaperon separated into three sections. The inboard section remained attached to the wing. The center and outboard sections were found in close proximity to each other, about 410 ft south-southeast of the left wing. The main wing spar was fractured at the wing root. The spar was bent in an upward direction at the area of fracture. All fracture surfaces of the left wing spar exhibited characteristics of overload. No areas of corrosion were found on or near the fracture surfaces. The main wreckage consisted of the fuselage, the inboard half of the right wing, and the empennage. These sections came to rest against trees and were highly fragmented. The engine and propeller were separated and found within the fuselage debris. The empennage was adjacent to the fuselage and the vertical stabilizer was still partially attached. The rudder was separated and found adjacent to the vertical stabilizer. The outboard section of the right wing was found about 55 ft northeast of the fuselage. The aft section exhibited impact signatures consistent with tree contact. The right stabilator was impact-separated and found about 137 ft northeast of the main wreckage. The left stabilator was impact-separated and found about 83 ft northeast of the main wreckage. The painted surfaces of the right stabilator exhibited brown transfer marks consistent with tree impact. The wreckage was recovered to a storage facility for additional examination. Flight control continuity was confirmed from all flight control surfaces to the cockpit controls. All separations and fractures to cables and control rods exhibited overload signatures or were cut by recovery personnel. The flap handle was found in the retracted position. The autopilot pitch servo was located intact in its mount beneath the right seat pan. The servo arm remained connected to the control column, with no deformation of bolts or rod end bearings at either the ser