WPR16FA157

The pilot's loss of airplane control due to an exceedance of the airplane's critical angle of attack, which resulted in an accelerated stall and subsequent impact with a building. Contributing to the accident was the pilot's unreported physiological impairment from traumatic brain injury, which impaired his ability to safety operate the airplane.

The pilot of the light sport airplane contacted the tower controller at his destination airport, where he planned to complete several touch-and-go maneuvers. The airplane touched down hard on the runway, and during the subsequent takeoff, the pilot reported to the controller that he heard a "banging" sound. The controller observed the left main landing gear "dangling" from the airplane. The pilot advised the controller that he planned to return to the airport for landing; however, as the airplane reached the airport boundary, it began a left turn that gradually progressed into a 70° bank angle. The airplane's bank angle increased further before the airplane entered a nose-down attitude and impacted a building, consistent with an aerodynamic stall. A normal standard-rate turn would have allowed the pilot to rejoin the downwind leg of the traffic pattern and provided additional time to configure the airplane for a normal landing. However, the aggressive bank angle increased the airplane's stall speed and likely contributed to the pilot's exceedance of the airplane's critical angle of attack. Examinations of the airframe and engine did not reveal any mechanical malfunctions or anomalies that would have precluded normal operation, although the engine ran about 200 rpm below its maximum power output during the engine run. Although the source of this power loss could not be confirmed, it may have been the result of a reduction in fuel flow from a torn carburetor diaphragm and bent float. Data obtained from the airplane's engine monitor revealed that the engine achieved rated power throughout the accident flight, which suggested that the damage observed to the carburetor was the result of impact. A witness reported hearing the engine sputtering seconds before the airplane impacted the ground, and recorded engine data showed a corresponding decrease to idle power. It could not be determined why the pilot may have retarded the throttle to idle power. The pilot allowed his Federal Aviation Administration (FAA) medical certificate to expire about 2 years before the accident, a few months after he sustained traumatic injuries, including a traumatic brain injury, in a car accident. Although his personal medical records did not show any permanent neurocognitive or physiological defects, formal testing was not documented. However, acquaintances and flight instructors who flew with the pilot stated that his ability to control the airplane and his decision-making capacity were affected by his injuries.  The pilot continued to fly and was involved in three incidents that resulted in damage to the accident airplane; evidence suggested the pilot's physiological condition remained unchanged until the day of the accident. Thus, it is likely that the pilot's injuries impaired his ability to safely operate the airplane and directly contributed to the accident. Furthermore, the pilot ignored recommendations from other pilots to stop flying and continued to operate the airplane with a known physiological impairment.

The airplane was equipped with a Dynon SV-D1000T primary flight display designed for experimental and light sport aircraft, which captured airplane and engine performance data. According to the recovered data, the airplane began its takeoff roll from SMO about 1308:53 and entered a climb to the southwest. The airplane then changed course to a northern heading and crossed the Santa Monica Mountains toward VNY. Following the airplane's touch-and-go landing on runway 16L about 1321:32, the data showed that the airplane maintained a slow climb on runway heading. The airplane began a slight left turn as it reached the southern end of the airport. At 1322:34, the airplane slowed as its left turn bank angle increased to about 70°. In the 3 seconds that followed, the airplane entered a steep left turn with a maximum recorded left roll of 95° and a 55º nose-down pitch attitude. The engine rpm, exhaust gas temperature (EGT), and fuel flow were steady during the airplane's climb out. As the airplane's bank angle increased, the engine power decreased from about 2,200 rpm to about 1,200 rpm. It momentarily returned to 2,000 rpm before decreasing to about 1,100 rpm at 1322:43, when the air and position data stopped recording. During this time, the fuel flow and EGT values decreased slightly. According to 14 CFR Part 61.53(b), for operations that do not require a medical certificate: …a person shall not act as pilot in command, or in any other capacity as a required pilot flight crewmember, while that person knows or has reason to know of any medical condition that would make the person unable to operator the aircraft in a safe manner. The 1351 recorded weather observation at VNY included wind from 120° true at 8 knots, visibility 10 statute miles, clear skies, temperature 32°C, dew point 11°C, and an altimeter setting of 29.96 inches of mercury. The County of Los Angeles, Department of Medical Examiner-Coroner, Los Angeles, California, conducted an autopsy on the pilot. The cause of death was listed as "multiple traumatic injuries." The pilot's autopsy documented 60-70% narrowing of the left anterior descending coronary artery, but there was no evidence of new or old ischemic damage to the heart muscle. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens of the pilot. Testing identified amlodipine and gabapentin in samples of urine and cavity blood. Amlodipine is a blood pressure control medication that is not generally considered impairing. Gabapentin is a central nervous system (CNS) depressant anti-seizure medication that is also used to treat peripheral neuropathy. The medication carries the precaution, "patients should be advised that [gabapentin] may cause dizziness, somnolence and other symptoms and signs to CNS depression. Accordingly, they should be advised neither to drive a car nor to operate other complex machinery until they have gained sufficient experience on [gabapentin] to gauge whether or not it affects their mental and/or motor performance adversely." Personal medical records showed a history of high blood pressure, elevated lipids, a clotting disorder with a history of deep vein thrombosis and placement of an inferior vena cava filter, asthma, hypothyroidism, and borderline diabetes. Additionally, the pilot was involved in a car accident in May 2014 that resulted in a traumatic brain injury and a spinal cord injury. The traumatic brain injury did not result in any documented significant loss of cognitive function, with the exception of some memory loss around the time of the accident. However, the spinal cord injury resulted in arm pain and weakness that had reportedly resolved by the pilot's September 2015 personal medical examination. The pilot, age 78, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent third-class medical certificate was issued on September 12, 2012, with no limitations. During the exam, the pilot reported that he had accumulated 908 total hours of flight experience, 60 hours of which were in the previous 6 months. The pilot's medical certificate was not valid after September 30, 2014. The pilot's most recent logbook records showed that he had accumulated a total of 19.6 hours from October 14, 2015 to February 2, 2016. His flight experience before 2015 was captured in a logbook that spanned from 2005 to 2008. His most recent flight review was completed on February 15, 2016. According to an acquaintance, in 2014, the pilot was involved in a car accident that resulted in serious injuries and required intensive care treatment for about 5 months. Another witness reported that the pilot took several months to recuperate but was not the same person physically after the car accident. The witness stated that when the pilot returned to flying, he was unable to hold his head straight. He was frequently hunched over and was only capable of using about 10% of his right arm and hand strength. When driving, the pilot frequently used his left hand to pick up his right arm and place it on the gear shift. The witness reported that the pilot's physical condition was the same the day before the accident. The witness further stated that several instructors refused to fly with him; eventually, the pilot found one instructor who agreed to sign him off for a flight review. The witness stated that several of the pilot's peers had encouraged him to stop flying. Flight Review The instructor who endorsed the accident pilot for his flight review reported that they started flying together in September 2015 and accumulated 23 hours of flight instruction before the instructor would endorse the pilot for a flight review. The instructor stated that the pilot had difficulty with turn coordination and airplane control in the airport traffic pattern and found landing the airplane to be challenging. The flight instructor informed the pilot that he would not endorse him for the completion of a flight review until he demonstrated consistency in the airplane, which took about 5 months. Recent Flight History An acquaintance reported that the pilot had a total of three incidents in the airplane following the car accident, not including the accident flight. The first incident occurred in March 2015 during a landing attempt. The flight instructor who was in the airplane with the pilot during the incident reported that he stopped flying with the pilot due to safety concerns. According to the instructor, the pilot had difficulty entering and exiting the airplane and did not seem mentally "sharp," as he did not look for or listen for other air traffic. During flight, the pilot consistently overcontrolled the airplane and was unable to hold altitude, particularly in the airport traffic pattern. During landing attempts, the pilot would either touch the airplane down early and bounce the airplane or hold the airplane in a nose-high attitude to bleed off airspeed then let the nose drop aggressively. The instructor recounted that during their landing attempt, the airplane touched down on the main landing gear and then floated, but the pilot pushed the control stick forward hard. The nose landing gear subsequently impacted the ground and separated. The instructor discontinued flight instruction with the pilot shortly after the incident. The second incident occurred in May 2016 during a landing attempt that resulted in damage to the nose landing gear. According to an airport representative who responded to the incident, the pilot stated that the airplane bounced once then impacted the runway in a slight nose-low attitude, which caused the nose landing gear to collapse. The pilot did not want to report the incident and argued that he did not require a medical certificate because the airplane met the requirements of a light sport aircraft that only required a driver's license to fly. The pilot was