WPR24FA104

The pilot's exceedance of the airplane's critical angle of attack during a turn, which resulted in an aerodynamic stall. Contributing to the accident was the pilot's use of potentially impairing substances with bipolar disorder, which resulted in a decreased reaction time during a stall recovery at a low altitude.

The pilot had recently installed an overhauled engine and decided to depart for a local flight. Witnesses observed that the pilot was in good spirits and that, after takeoff, the airplane turned left to the northwest, about 500 ft above ground level (agl). The airplane continued to turn left back towards the airport environment on a 30° to 40° bank angle (to the southeast). The witnesses stated that they saw the airplane descend about 100 ft in a slightly nose-down pitch attitude and subsequently entered a 90° nose-down attitude toward the ground. The airplane impacted the ground and came to rest in an open field, sustaining substantial damage to the fuselage and wings. Multiple witnesses confirmed that the engine was producing power. Examination of the wreckage did not reveal any mechanical anomalies to the airframe or engine. The pilot’s toxicology results identified multiple potentially impairing substances including diphenhydramine, gabapentin, and venlafaxine, all of which may adversely and unpredictably interact with one another to cause sedation, decreased reaction time, and impaired cognition. Venlafaxine may induce mania in people with bipolar disorder if used on its own to treat depression without an additional mood stabilizing medication. Based on information obtained from the patient’s family, the pilot had severe depression and bipolar disorder. The details of the pilot’s illness and his response to treatment are unknown. An episode documented by law enforcement the night before the accident was consistent with the pilot experiencing acute behavioral symptoms at that time. In people with bipolar disorder, the occurrence of acute symptoms decreases the threshold for further episodes, making the episodes occur more frequently if medical intervention is not provided. Additionally, bipolar disorder in people over 50 years of age increases the risk of cognitive defects including decreased executive function, impaired information processing speed, and impaired memory. Additionally, bipolar disorder is a disqualifying psychiatric condition that is required to be evaluated by a Federal Air Surgeon. The pilot never reapplied for a medical after he allowed it to lapse in 2002 and there are no records he was evaluated. With the available evidence, it is not possible to discern to what degree the effects of the medications used, as opposed to the pilot’s bipolar disorder, contributed to the accident. The pilot’s coronary artery disease placed him at some increased risk of a sudden impairing or incapacitating cardiac event, such as angina, arrhythmia, or heart attack, but there was no autopsy evidence that such an event occurred. However, such an event does not leave reliable autopsy evidence if it occurs immediately before death. Thus, whether the pilot's coronary artery disease contributed to the crash cannot be determined. The pilot's use of multiple potentially impairing substances and his bipolar disorder likely would have contributed to a diminished state of health during any attempts to recover the airplane after control was lost, given the pilot's experience with the airplane and the circumstances of the accident. The airplane was likely in an uncoordinated left turn (skid) as it turned back toward the airport. The lower (left) wing entered an aerodynamic stall initially during this skidding left turn, resulting in a nose-down pitch attitude, as is typical of straight-wing airplanes. The FAA suggests a margin of at least 1,500 ft agl for single-engine airplanes to recover from a full stall. Although the pilot was a certificated flight instructor and experienced pilot, his use of potentially impairing substances and medical history likely influenced his reaction time to recover from the stall at 500 ft agl. There was insufficient evidence to ascertain the specific recovery inputs the pilot implemented.

On March 7, 2024, about 1124 Pacific standard time, a Kolb Firestar KXP airplane, N4443G, was substantially damaged when it was involved in an accident near Cave Junction, Oregon. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.  Witnesses reported that the airplane departed on runway 36 for a local flight following the installation of an overhauled engine. The witnesses observed the airplane turn left to the northwest, at about 500 ft agl. The airplane continued to turn left in an approximate 30° to 40° bank to a southeast heading. One witness stated that they saw the airplane descend about 100 ft in a slightly nose-down pitch attitude before it entered a 90° nose-down attitude and descended towards the ground. The witness lost sight of the airplane before impact. According to witnesses, the light sport pilot had accumulated about 4,500 hours of flight time at the time of the accident. A review of the pilot’s logbook records indicated about 2,126 hours of total flight experience. Witnesses reported that the pilot displayed a positive attitude the morning of the accident and his behavior was not out of the ordinary. Examination of the accident site revealed that the main wreckage was located about 0.14 nautical miles northwest of the departure end of runway 36. The wreckage came to rest in an open field. The first identified point of contact was a tree with broken branches about 40 ft northwest of the main wreckage. Several broken branches were found adjacent to the tree. Ground scars were observed consistent with the airplane's left wing and nose section making initial contact with the ground, followed by the leading edge of the right wing. Two propeller blade fragments were the furthest identifiable components within the debris field, located about 50 to 60 ft northeast of the main wreckage. All major structural components of the airplane were located within the wreckage debris path.  Examination of the airframe did not reveal any pre-impact mechanical anomalies or failures. The fuselage cage and supporting steel structures were crushed aft, consistent with impact. The tailboom structure had sheared rivets at its attachment point located in the aft section of the fuselage. Flight control continuity was established from the cockpit to all major flight control surfaces. The left and right wings remained attached to the fuselage cage. Multiple wing truss ribs sustained damage consistent with impact and remained attached to the anchor points throughout the wings. The left and right ailerons remained attached to the respective anchor points. The aileron control tubes were traced, and the hardware was secured to its respective attachment points in the left and right upper tubular trusses. Fuel odor was present at the main wreckage site. The fuel tank was empty of fuel and was breached on its side wall. The externally mounted fuel filter was intact and connected to the fuel tank by fuel hoses. Examination of the engine did not reveal any pre-impact mechanical anomalies or failures. The engine was separated from its engine mounts. Both propeller blades were impact damaged but remained attached to the propeller hub and flange, which was connected to the crankshaft. The engine case sustained minor impact damage. Mechanical continuity was established throughout the rotating group, valvetrain, and accessory section as the crankshaft was manually rotated by hand using the propeller. The spark plugs displayed coloration consistent with normal wear. The electrode coloration was symmetrical, one electrode was free of mechanical damage, and the other electrode sustained impact damage. The air intake and exhaust systems remained attached and were both impact-damaged. The air filter was impact-damaged and remained attached to the carburetor. The interior of the filter was unremarkable. The fuel filter bowl remained attached and was secured and unremarkable. The BING carburetor was separated from its mounting pad and remained intact. The carburetor fuel filter was also unremarkable. According to information gathered from the patient's family, the pilot suffered severe depression and bipolar disorder. The details of the pilot’s illness and his response to treatment are unknown. The pilot’s wife called local authorities the night before the accident, as she believed that the pilot needed a mental health evaluation, and the pilot was then evaluated by a Sheriff’s deputy. The pilot reported that he was under the care of a physician, took medication for his mental illness, and denied any intent for self harm. The deputy determined that the pilot did not meet the criteria to be detained for safety. Following the crash, the pilot’s wife stated that he would not have killed himself due to his religious beliefs. According to Title 14 CFR Chapter I Subpart D, Part 67, Medical Standards and Certification, bipolar disorder is a psychiatric condition that is initially disqualifying and per Aviation Medical Examiner (AME) guidance, all applicants with this diagnosis must have their medical application denied or deferred. The AME must then submit all relevant medical information and clinical status reports, which will be examined and require an FAA decision, normally made by a Federal Air Surgeon. As stated under Title 14 CFR Chapter 1, Subpart D, Part 61 Subpart J - Sport Pilots, light sport aircraft pilots generally do not need an FAA medical certificate, instead using a valid U.S. driver's license to certify they are medically fit to fly. However, according to Title 14 CFR Part 61.306(b)(1-4): (b) A person using a U.S. driver's license to meet the requirements of this paragraph must— (1) Comply with each restriction and limitation imposed by that person's U.S. driver's license and any judicial or administrative order applying to the operation of a motor vehicle; (2) Have been found eligible for the issuance of at least a third-class airman medical certificate at the time of his or her most recent application (if the person has applied for a medical certificate); (3) Not have had his or her most recently issued medical certificate (if the person has held a medical certificate) suspended or revoked or most recent Authorization for a Special Issuance of a Medical Certificate withdrawn; and (4) Not know or have reason to know of any medical condition that would make that person unable to operate an aircraft in a safe manner. Based on FAA medical records, the pilot’s most recent medical examination took place on February 19, 2002, in which a subsequent Second-Class Medical certificate was issued without limitations. The pilot added that he was not taking any medications at the time. There are no FAA records of the pilot reapplying for a medical certificate of any class. The pilot’s autopsy was performed by the Josephine County Office of the Oregon State Medical Examiner, Clackamas, Oregon. According to the pilot’s autopsy report, the cause of death was massive blunt trauma due to aircraft crash, and the manner of death was accidental. Examination of the heart identified mild-to-moderate focal coronary artery disease approaching 40% narrowing. No additional anatomical details regarding the coronary artery disease were documented. The remainder of the autopsy did not identify other significant natural diseases. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological tests on specimens recovered from the pilot. The pilot’s postmortem toxicological testing detected diphenhydramine in cavity blood at 140 ng/mL and in urine at 3,562 ng/mL. Gabapentin was detected in cavity blood at 8,786 ng/mL and in urine at 924,590 ng/mL. Venlafaxine was detected in cavity blood at 448 ng/mL and in urine at 12,019 ng/mL. Desmethylvenalfaxine was detected in cavity blood and urine. Amlodipine, hydrochlorothiazide, and naproxe