ERA22FA422

The pilot’s exceedance of the airplane’s critical angle of attack and failure to maintain airspeed while recovering from an aerobatic maneuver, which resulted in an aerodynamic stall and loss of control. Contributing to the accident was the pilot’s use of ethanol and other depressant medications, and his decision to operate the airplane outside of the published weight limitations.

The pilot and passenger departed a private airport in an experimental amateur-built airplane. A witness who knew the pilot described the pilot as flying “aggressively” and observed the airplane complete a barrel roll, and then enter into an aerodynamic stall and spin into a swamp. The witness also advised that it sounded as if the engine was brought back or went back to idle power. Postaccident examination of the accident site and wreckage revealed that there was no debris path, the wreckage was partially submerged, and the odor of fuel was present, along with a fuel sheen on the surface of the water. Flight control continuity was established. The throttle control was in the closed (idle) position and damage to two of the three propeller blades showed no leading-edge gouges or chordwise scratches that would indicate that the propellers were operating under high power at impact. The third propeller blade was submerged in the swamp and could not be examined. The engine was also submerged in the swamp, was not recovered, and could not be examined. Review of weight and balance information indicated that the airplane was likely being operated in excess of the kit manufacturer’s published gross weight. The weight would have resulted in a higher stalling speed, which would have made the airplane more difficult to control in the barrel roll and more difficult to recover once the stall and spin had begun. The pilot was employed as an airline pilot. He was on medical leave for depression, anxiety, and a head injury. The pilot’s toxicology was positive for ethanol. The consistency of ethanol levels across multiple postmortem specimens, including vitreous fluid, indicated that the pilot likely had consumed ethanol before the accident. Based on the ethanol concentrations he likely experienced degradation of judgment and deficits in coordination, psychomotor skills, perception, and attention. In addition, the pilot’s toxicology results detected delta-9-THC and its metabolites 11-hydroxy-THC and carboxy-delta-9-THC. Research shows poor and inconsistent correlation between the degree of impairment and delta-9-THC blood levels in living persons. Interpretation of levels in postmortem cavity blood is further complicated by cavity blood’s potential for contamination. Thus, the pilot’s delta-9-THC results could not be used to determine if specific impairing effects were present. In addition, the pilot’s toxicology results detected other central nervous system depressant medications including quetiapine and gabapentin, both of which can adversely interact with one another, in addition to ethanol, to worsen impairment—most commonly in the form of drowsiness, difficulty concentrating, and confusion. According to the Federal Aviation Administration (FAA) medical case review, the pilot had a significant history of depression and anxiety. Depression can impact risk perception; specifically, some depressed persons will avoid risk to avoid anxiety, while others may engage in risky behavior without consideration of the consequences. One month before the accident, a psychologist assessed the pilot via formal neurocognitive testing and recommended him for consideration of Special Issuance medical certification. The pilot’s psychiatrist assessed the pilot’s condition to be “stable.” Thus, whether the pilot’s psychiatric condition contributed to the accident could not be determined. The pilot’s autopsy detected mild coronary artery disease with low grade stenoses and a flabby myocardium. Due to his mild heart disease, the pilot was at a slightly increased risk of a sudden distracting, impairing, or incapacitating cardiac event, including angina, arrhythmia, or heart attack; however, there is no forensic evidence that such an event occurred. The circumstances of the accident with the pilot actively controlling the airplane through an aerobatic maneuver is generally inconsistent with a sudden incapacitating event. Thus, it is unlikely that the pilot’s heart disease contributed to the accident. In summary, the airplane’s overweight condition, and the pilot’s use of ethanol, delta-9-THC, gabapentin, and quetiapine before the accident, likely contributed to the accident. The contribution of the pilot’s mental health to the accident could not be determined.

The pilot had served as a naval aviator for 18 years. After retiring from the United States Navy, he was employed as an airline pilot for about 23 years. According to FAA records, the pilot held an airline transport pilot certificate, with a rating for airplane multi-engine land, with commercial privileges for airplane single-engine land, and glider. He possessed type ratings for B-737, B-757, B-767, BD500, and DC-9, and a flight engineer certificate with a rating for turbojet-powered aircraft. He also held sport pilot endorsements for airplane single-engine sea and weight-shift-control land. The pilot also held a flight instructor certificate for multi-engine and instrument airplanes, a flight instructor sport endorsement for weight-shift-control aircraft, and possessed a repairman certificate for weight-shift-control aircraft. At the time of the accident, he was on medical leave and did not possess a medical certificate. No pilot logbooks were recovered or provided. According to FAA records, as of August of 2022, he had accrued about 12,100 total flight hours, of which about 36 hours were in the previous 6 months. The accident aircraft was a high-wing experimental amateur-built airplane that was assembled from a kit. According to FAA records, the airplane was issued a special airworthiness certificate on October 26, 2006. During the investigation, no maintenance records were recovered or provided. According to FAA records, the 64-year-old pilot’s last aviation medical examination was on August 25, 2022. At that time, he reported a medical history including depression and generalized anxiety as well as high blood pressure. He reported using the medications quetiapine, lisinopril, escitalopram, and gabapentin. In February of 2022, the pilot sustained a fall and a mild closed head injury resulting in headaches, neck pain, vision problems, and mood liability. At the time of his last aviation medical examination, the pilot was still in therapy for complications from his head injury. The aviation medical examiner (AME) deferred his medical certification decision to the FAA due to the pilot’s ongoing therapy and his use of quetiapine and gabapentin. Before his last aviation medical examination, the pilot underwent formal neurocognitive testing. Based on the results, the psychologist recommended re-authorization of his special issuance medical certification. In addition, the pilot had a psychiatric visit and the psychiatrist reported the pilot was psychiatrically stable. At the time of the accident, FAA review of the pilot’s application for medical certification was pending. According to the pilot’s autopsy report, his cause of death was multiple blunt force injuries, and his manner of death was accident. He was noted to have mild coronary artery disease with 30-40% stenosis of the distal left anterior descending coronary artery and the mid-portion of the right coronary artery as well as moderate atherosclerotic disease of the abdominal aorta. A flabby myocardium was also noted. The remainder of the autopsy examination did not identify other significant natural disease. Postmortem toxicological testing of one cavity blood specimen detected delta-9-THC at 38 ng/mL, carboxy-delta-9-THC at more than 500 ng/mL, and 11-hydroxy-THC at more than 100 ng/mL. In additional specimens, delta-9-THC was detected in cavity blood at 22.1 ng/mL and in urine at 15.8 ng/mL. Carboxy-delta-9-THC was detected in cavity blood at 87.8 ng/mL and in urine at 277 ng/mL. 11-hydroxy-THC was detected in cavity blood at 8.9 ng/mL and in urine at 739.4 ng/mL. Ethanol was detected in a cavity blood specimen at 0.055 g/dL, in vitreous fluid at 0.063 g/dL, and in urine at 0.069 g/dL. Citalopram was detected in cavity blood at 79 ng/mL and was not detected in urine. N-desmethylcitalopram was detected in cavity blood at 51 ng/mL and was not detected in urine. Quetiapine was detected in cavity blood at 13 ng/mL and urine at 17 ng/mL. Norquetiapine was detected in cavity blood at 13 ng/mL and urine at 421 ng/mL. Gabapentin was detected in cavity blood at 1835 ng/mL and urine at 88,944 ng/mL. Examination of the accident site revealed that the airplane struck trees and came to rest inverted in a swamp within a heavily wooded area on a magnetic heading of about 270°. Further examination revealed that there was no debris path, the wreckage was partially submerged, and the odor of fuel was present along with a fuel sheen on the surface of the water. Examination of the airplane revealed that most of the airplane’s structure was on site. The tail boom was twisted and displayed a fracture around its circumference near the attach point on the fuselage. The wings were partially separated from the fuselage. Control continuity was established from the flight control surfaces to the breaks in the system, and from the breaks in the system to the flight controls in the cockpit. The throttle control was in the closed (idle) position, the cabin door locking mechanism was in the closed position. The fuel filter was free of debris and both it and the fuel line from the fuel tank contained fuel that was clear and bright. Examination of the 3-blade pusher-type propeller revealed that one blade was separated from the hub near the blade root consistent with damage from the impact sequence. Examination of the separated blade did not reveal any evidence of leading-edge gouging or chordwise scratching. Examination of one blade that was visible above the water and had remined attached to the hub also did not reveal the presence of leading-edge gouging or chordwise scratching. The remaining blade was unable to be examined as it was buried in muck below the surface of the water. The engine was also unable to be examined as it was buried in muck below the surface of the water. The wreckage was not recovered. On September 17, 2022, about 1847 eastern daylight time, an experimental amateur-built Titan Tornado II airplane, N709RD, was substantially damaged when it was involved in an accident near Citra, Florida. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. On the day of the accident, the pilot and passenger departed Patch O Blue Airport (FD02), Orange Springs, Florida about 1835. According to ADS-B track data provided by the FAA, the airplane made a left turn after takeoff and climbed to about 900 ft above mean sea level while circling back towards FD02, where it appeared to make an approach to the airport. Track data was lost briefly, but then reappeared on the other side of the airport, with the airplane making a left climbing turn and circling back toward the point of departure as it continued to climb. As the airplane climbed and circled to the left within about a 1-mile area, it reached an altitude of just over 3,000 ft. The airplane then began to descend with varying ground speeds until the last track data showed a more significant descent rate. Track data was lost at 1846:47 when the airplane was at 2,200 ft, traveling at a groundspeed of 67 kts on a heading of 227°, about 2.0 miles south of the point of departure. Weight and Balance According to the kit manufacturer, the airplane was designed to a +6g /-4g load limit at 1,000 pounds gross weight. A review of the kit manufacturer’s weight and balance data and the accident airplane’s weight and balance data submitted to the FAA by the original builder indicated that the accident aircraft’s empty weight of 624 pounds was higher than the published kit manufacturer’s standard empty weight of 440 pounds, which would have resulted in a reduction of useful load by 184 pounds. Further review also indicated that the kit manufacturer’s acceptable Center of Gravity (CG) forward limit was 73” aft of datum and the acceptable CG aft limit was 79” aft of datum. Calculations using the kit manufacturer’s published weight and balance dat