WPR17FA074

The pilot's failure to identify and correct his construction error of a critical structural component, which resulted in a loss of airplane control during takeoff. Contributing to the accident was the pilot's impairment due to his combined use of multiple medications and illicit drugs, which led to his improper decision to attempt the flight despite evidence indicating that the error had not been addressed.

The pilot, who did not hold a pilot or medical certificate, had been performing multiple high-speed taxi tests in the experimental amateur-built airplane since he had completed construction of it about 2 months before the accident. During those tests, the airplane had been pulling to the left. About 1 month before the accident, the pilot performed the first flight test; however, shortly after getting airborne, the airplane rolled left, departed the runway, struck a hangar, and sustained substantial damage. He spent the next month repairing the damage sustained in that accident and performing more high-speed taxi tests. Onboard video footage revealed that, during the days leading up to the final accident, the pilot performed multiple high-speed taxi tests but was unable to maintain a straight track down the runway. On the day of the accident, he performed another erratic high-speed taxi test during which the airplane veered left and right, but, instead of stopping and attempting to determine the reason for the directional control problem, he turned the airplane around and departed in the opposite direction. Shortly after rotation, the airplane began to roll left. The pilot applied corrective control inputs (right aileron and rudder), and, although the control surfaces responded appropriately, the left turn continued. The airplane then rapidly rolled to a steep left bank, the nose dropped, and the airplane rolled over into a spin. The airplane struck the ground in a nose-down attitude, and the pilot was fatally injured. Postaccident examination revealed that a load-carrying structural member on the forward left side of the airframe had not been properly secured when the pilot constructed the airplane. The unsecured structural member created a differential load between the left and right wing supporting structures and flying wires. This differential load was further increased as the airplane departed the runway surface, which transferred the weight of the pilot from the landing gear to the unsecured structural member. The resultant imbalance likely caused the left wing to warp, creating aerodynamic forces that could not be overcome by the flight controls. Witness marks on the structural member indicated that the error had gone undetected since construction was completed, and it was most likely the reason for the loss of control during the first flight test about 1 month before the accident. The airplane had not been registered with the FAA and did not have an airworthiness certificate, which should have been done before a flight test. Therefore, it did not benefit from receiving an official inspection from an FAA representative, who may have caught the error. The toxicology findings indicated that the pilot had used substantial amounts of methamphetamine in combination with hydrocodone (an impairing opioid), diazepam (an impairing benzodiazepine), THC (the active compound in marijuana), gabapentin (an impairing anti-seizure medication), and possibly alcohol before attempting flight. It could not be determined if the pilot was in the "high" phase of use and feeling grandiose and euphoric, or if he was beginning to come down from his high and feeling dysphoric and agitated at the time he elected to attempt flight. In either case, it is very likely that the pilot's judgement and decision-making were impaired by his use of methamphetamine in combination with multiple other impairing substances and that his impairment contributed to his willingness to attempt a flight in the airplane without having identified and repaired the known control problem with the airplane

According to the autopsy performed at the request of the San Bernardino County Sheriff's Department, Coroner Division, San Bernardino, California. The pilot's cause of death was multiple blunt force injuries, and the manner of death was accident. The pilot weighed 238 pounds and was 73 inches tall. According to the autopsy report, his heart was significantly enlarged and thickened, and weighed 615 grams; the expected weight was 345 +/- 40 grams. In addition, the right ventricle was 0.3-cm thick and both the lateral left ventricular wall and interventricular septum were 2.0-cm thick. No other cardiac abnormalities were noted. At the request of the coroner, toxicology testing was performed by NMS Labs of Willow Grove, Pennsylvania, on femoral blood. The testing identified the following: 38 mg/dL ethanol (0.038 g/100mL blood alcohol concentration) Caffeine 37 ng/mL nordiazepam 74 ng/mL hydrocodone 7.7 ng/mL dihydrocodeine 3.5 ng/mL tetrahydrocannabinol (THC) 5.4 ng/mL tetrahydrocannabinol carboxylic acid (THC-COOH) 1200 ng/mL methamphetamine 210 ng/mL amphetamine Specimens were also tested by the FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The results were as follows: 43 mg/dL ethanol detected in urine 20 mg/dL ethanol detected in cavity blood 147.69 ug/mL acetaminophen detected in urine 1.128 ug/mL amphetamine detected in cavity blood 5.599 ug/mL amphetamine detected in urine 7.406 ug/mL methamphetamine detected in cavity blood 43.948 ug/mL methamphetamine detected in urine Carvedilol detected in cavity blood Carvedilol detected in urine Dihydrocodeine detected in cavity blood 0.492 ug/mL dihydrocodeine detected in urine 0.154 ug/mL hydrocodone detected in cavity blood 3.189 ug/mL hydrocodone detected in urine Hydromorphone NOT detected in cavity blood 0.214 ug/mL hydromorphone detected in urine Gabapentin detected in cavity blood Gabapentin detected in urine Naproxen detected in urine 0.016 ug/g nordiazepam detected in urine 0.048 ug/mL nordiazepam detected in cavity blood 0.044 ug/mL oxazepam detected in urine Oxazepam NOT detected in cavity blood 0.004 ug/mL THC detected in cavity blood 0.0103 ug/mL THC detected in liver 0.0071 ug/mL THC-COOH detected in cavity blood 0.0514 ug/mL THC-COOH detected in liver 0.3053 ug/mL THC-COOH detected in urine Nordiazepam and oxazepam are psychoactive metabolites of diazepam, a sedating benzodiazepine identified by the Drug Enforcement Agency as a Schedule IV controlled substance. Diazepam is commonly marketed with the name Valium and used to treat anxiety, seizure disorders, and muscle cramping. Hydrocodone is an opioid analgesic available as a Schedule II controlled substance, commonly marketed in combination with acetaminophen with the names Lortab, Norco, and Vicodin. Dihydrocodeine and hydromorphone are active metabolites of hydrocodone. THC is the primary psychoactive compound in marijuana, and THC-COOH is its inactive metabolite. Methamphetamine is a sympathomimetic available by prescription as a Schedule II controlled substance and is a widely used drug of abuse. Therapeutic levels for medicinal purposes range from 0.01 to 0.05 ug/ml. Amphetamine is an active metabolite of methamphetamine. Carvedilol is a blood pressure medication commonly marketed with the name Coreg. Gabapentin is an antiseizure medication commonly marketed with the name Neurontin that is also used to treat chronic nerve pain. Naproxen is an anti-inflammatory analgesic available over the counter and commonly sold with the names Aleve and Naprosyn. All these substances, with the exception of carvedilol and naproxen, are potentially impairing. Methamphetamine, hydrocodone, gabapentin, and most benzodiazepines are disqualifying for FAA aeromedical certification. Federal Aviation Regulations prohibit any person from acting as a crewmember of a civil aircraft while having 40 mg/dl or more alcohol in the blood, and marijuana, due to its psychoactive effects, may adversely affect the pilot's faculties. Follow Up Examination A follow up examination of the engine and airframe was performed following recovery of the airplane from the accident site. A series of minor discrepancies, including inadequately tightened nuts and loose hardware, was noted. Additionally, the left wingtip displayed evidence of repair, presumably from the earlier event during the first test flight. A complete examination report is contained within the public docket for this accident. A witness to the first test flight event stated that the left side tail brace tube, which connected the wing trailing edge to the tail structure, was damaged during that event. He stated that he later observed the pilot "working" the tube and trying to straighten it out. Review of the accident video revealed that the tube had not been replaced and was still bent at the time of the accident flight. Federal Aviation Administration (FAA) records indicated that the pilot was awarded medical certificates in 1979 and 1983, and both were marked, "valid for student pilot purposes only." At the time of those examinations, he had no useful vision in his left eye, and he failed the color vision test in 1979 but passed it in 1983. The pilot's partner reported that he was blind in his left eye at the time of the accident. Acquaintances of the pilot stated that he had flown ultralight aircraft for an extended period but that he did not keep records documenting such experience. The pilot's partner stated that, although the pilot had experience flying ultralight aircraft, he had not flown recently and was considering formally attaining his private pilot certificate. She offered to help him with the process, and he reported that he would pursue it once the airplane was completed and flying. The two-seat, high-wing airplane had a primary structure that consisted of fabric-covered metal tubing braced with flying wires. It was powered by a Rotax 582-series engine, serial number 9618333, mounted in a "pusher" configuration. No maintenance records were recovered. The pilot's partner stated that, while building the airplane, the pilot had found the construction manual confusing and frustrating, and he had asked a friend to assist with some of the construction tasks. She stated that he planned to register the airplane with the FAA once it was finished and flying. The airplane came to rest about 750 ft beyond the runway 3 threshold and 315 ft left of the runway centerline. The airframe structure sustained crush and buckling damage from the nosewheel through to the main landing gear downtube and axle. Both wings and the empennage remained partially attached to the airframe, and the smell of gasoline was present throughout the site. The primary load carrying structure of the airplane was composed of an aluminum "root tube" to which the engine, wings, king-post, and lower trike assembly were attached. The trike assembly supported the pilot and passenger seats, along with the landing gear and cockpit controls. The trike assembly included the axle and axle struts and a series of steel cross- and down-tubes collectively known as the tri-bar assembly. The tubes of the tri-bar assembly were interconnected with slip-joints, which were secured by AN4-series bolts. The under-wing flying wires were connected to the forward lower corners of the tri-bar assembly, adjacent to the seat anchors. Examination of the trike structure at the accident site revealed that the bolt intended to secure the forward left (pilot side) tri-bar downtube to the upper tri-bar assembly was only attached to the upper assembly. Paint signatures revealed that the downtube was not fully inserted into the upper tube; it was 1 1/4 inch short of full insertion, such that the securing bolt only passed through the holes in the upper tube and was resting against the upper end of the lower tube rather than interlocking the upper and lower tubes (see figure)