Monday, February 6, 2017

Vans RV-6A, N216LA: Fatal accident occurred September 02, 2015 in Bon Aqua, Hickman County, Tennessee

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf 

Docket And Docket Items -  National Transportation Safety Board: https://dms.ntsb.gov/pubdms

Aviation Accident Factual Report  -  National Transportation Safety Board:  https://app.ntsb.gov/pdf

http://registry.faa.gov/N216LA

The National Transportation Safety Board traveled to the scene of this accident. 

FAA Flight Standards District Office:  FAA Nashville FSDO-19

NTSB Identification: ERA15FA336
14 CFR Part 91: General Aviation
Accident occurred Wednesday, September 02, 2015 in Bon Aqua, TN
Probable Cause Approval Date: 01/18/2017
Aircraft: HENDERSON W A/JOHNSON W L RV 6A, registration: N216LA
Injuries: 1 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

During the cruise portion of a cross-country flight, about 20 minutes after takeoff, the commercial pilot stopped responding to air traffic controllers as the airplane reversed course. It then climbed from 6,500 ft to 9,000 ft mean sea level and completed two left circuits before descending rapidly into the ground. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. The pilot's autopsy revealed that he had severe coronary artery disease, scarring from previous heart attacks, and evidence of ongoing or recent damage to two new areas of heart muscle, indicating recent heart attacks. All of these conditions put him at risk of experiencing acute heart failure or a disturbance of heart rhythm (arrhythmia). Both acute heart failure and arrhythmia can rapidly lead to decreased consciousness due to low blood pressure. It is likely that acute symptoms from complications of the pilot's ongoing heart attacks resulted in impairment /incapacitation of the pilot and led to his loss of airplane control.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's incapacitation from complications of a recent heart attack, which resulted in a loss of control during cruise flight.




 
Cdr. James O. House III, USNR Ret




HISTORY OF FLIGHT

On September 2, 2015, about 1545 central daylight time, an experimental amateur-built RV-6A, N216LA, was substantially damaged when it impacted wooded terrain near Bon Aqua, Tennessee. The commercial pilot was fatally injured. The airplane was registered to Chelsea Aviation Enterprises LLC and operated by the commercial pilot as a personal flight conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Shelby County Airport (EET), Alabaster, Alabama. The flight originated from Bomar Field (SYI), Shelbyville, Tennessee, about 1400.

The airplane was fueled with 12 gallons of 100 low-lead aviation gasoline prior to departing from SYI. According to information from the Federal Aviation Administration (FAA), the pilot was receiving flight following services from air traffic control (ATC). About 20 minutes after departure, while the flight was in radio and radar contact with Huntsville Approach, the pilot stopped responding to ATC as the airplane reversed course, from south to north. The airplane continued north, climbed from 6,500 feet to 9,000 feet mean sea level and completed two left circuits, before descending rapidly into terrain.

PILOT INFORMATION

The pilot held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, instrument airplane and glider. He also held a flight instructor certificate with a rating for glider. His most recent FAA second-class medical certificate was issued on June 10, 2015. At that time, the pilot did not report any cardiac issues and according to his wife, the pilot was not aware of any issues. He reported a total flight experience of 1,672 hours at that time. Review of the pilot's logbook revealed that he had accumulated about 1,682 total flight hours at the time of the accident; of which, 7 hours and 3 hours were flown during the 90-day and 30-day periods preceding the accident, respectively.

AIRCRAFT INFORMATION

The two-seat, low-wing, fixed tricycle-gear airplane, was assembled from a kit and issued an experimental airworthiness certificate in 2005. It was powered by an Aero Sport Power O-360-A2A, 180-horsepower, experimental engine, equipped with a Sensenich two-blade, fixed-pitch propeller. Review of maintenance records revealed that the airplane's most recent condition inspection was completed on April 12, 2015. At that time, the airplane and engine had accumulated about 147 hours since new. The airplane flew approximately 14 hours from the time of the most recent inspection, until the accident.

METEOROLOGICAL INFORMATION

Maury County Airport (MRC), Columbia, Tennessee, was located about 20 miles south of the accident site. The recorded weather at MRC, at 1555, included wind from 190 degrees at 3 knots, clear sky, and visibility 10 miles.

WRECKAGE INFORMATION

A debris path was observed, beginning with several freshly cut tree branches, extending on a magnetic course about 260 degrees for 110 feet to the main wreckage. Sections of the outboard right wing were located along the beginning of the debris path. The right flap and right aileron separated from the right wing, but the left flap and left aileron remained partially attached to the left wing. The left flap was extended beyond its full travel-point and the left aileron was hanging from one hinge. The empennage remained intact and exhibited less damage. Control continuity was confirmed from the elevator and rudder to the pilot's control stick and rudder pedals in the cockpit. Continuity was also confirmed from the pilot's control stick to the point of aileron separation on both wings. Additionally, the elevator trim cable remained attached from the elevator trim tab to the cockpit.

The cockpit was crushed, but the pilot's seat and four-point harness remained intact. The magneto switch remained in the both position and the fuel selector was positioned to the right main fuel tank. The throttle, mixture, and carburetor heat control levers were in the full forward position. The engine remained partially attached the fuselage. The two-blade propeller separated from the hub. Both propeller blades exhibited chordwise scratching. One blade was s-bent while the other was bent aft.

The engine was separated from the airframe for examination. The top spark plugs were removed; the electrodes were intact and light gray in color, except for the No. 3 top spark plug that was impact damaged. The valve covers were removed and oil was noted throughout the engine. The crankshaft was rotated via an accessory gear drive. Camshaft, crankshaft, and valve train continuity were confirmed and thumb compression was attained on all cylinders. The oil screen and oil filter was absent of contamination. The carburetor had separated from the engine during impact. Its floats and needle were intact and the valve was mid-range. Some fuel was recovered from the engine-driven fuel pump, consistent with 100 low-lead aviation gasoline. Both magnetos produced spark at all leads when rotated by hand.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot on September 3, 2015, by the Hickman County Medical Examiner, Nashville, TN. The cause of death was multiple blunt force injuries and the manner of death was accident. Contributing to the death were hypertensive and atherosclerotic heart disease.

The autopsy also revealed that there was up to 90 percent stenosis in the right and left anterior descending coronary arteries with thrombi past the area of stenosis in both. The remainder of the coronary arteries were diffusely 40 percent stenosed. In addition, there were multiple white, fibrous plaques within the myocardium of the left ventricle and the interventricular septum indicating scarring from previous heart attacks. Finally, there were two areas of erythema and wall softening: on the medial-most aspect of the interventricular septum and on the inner aspect of the posterior aspect of the left ventricle. On the microscopic evaluation, there were dense areas of fibrosis and collagen deposition; hemorrhage into myocardium; wavy myocytes with enlarged, pyknotic nuclei; edema; and inflammatory infiltrates into the myocardium. These indicate previous scarring and recent damage from heart attacks.

Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. The results were negative for carbon monoxide, alcohol, and drugs.

NTSB Identification: ERA15FA336 
14 CFR Part 91: General Aviation
Accident occurred Wednesday, September 02, 2015 in Bon Aqua, TN
Aircraft: HENDERSON W A/JOHNSON W L RV 6A, registration: N216LA
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On September 2, 2015, about 1545 central daylight time, an experimental, amateur-built RV-6A, N216LA, was substantially damaged when it impacted wooded terrain, following a loss of control from cruise flight near Bon Aqua, Tennessee. The commercial pilot was fatally injured. The airplane was registered to Chelsea Aviation Enterprises LLC and operated by a private individual as a personal flight conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Shelby County Airport (EET), Alabaster, Alabama. The flight originated from Bomar Field (SYI), Shelbyville, Tennessee, about 1400.

The airplane was fueled with 12 gallons of 100 low-lead aviation gasoline prior to departing from SYI. According to preliminary information from the Federal Aviation Administration (FAA), the pilot was receiving flight following services from air traffic control (ATC). About 20 minutes after departure, while the flight was in radio and radar contact with Huntsville Approach, the pilot ceased communicating with ATC as the airplane reversed course, from south to north. The airplane continued north, climbed from 6,500 feet to 9,000 feet mean sea level and completed two left circuits, before descending rapidly into terrain.

A debris path was observed, beginning with several freshly cut tree branches, extending on a magnetic course about 260 degrees for 110 feet to the main wreckage. Sections of the outboard right wing were located along the beginning of the debris path. The right flap and right aileron separated from the right wing. The left flap and left aileron remained partially attached to the left wing. The left flap was extended beyond its full travel-point and the left aileron was hanging from one hinge. The empennage remained intact and exhibited less damage. Control continuity was confirmed from the elevator and rudder to the pilot's control stick and rudder pedals in the cockpit. Continuity was also confirmed from the pilot's control stick to the point of aileron separation on both wings. Additionally, the elevator trim cable remained attached from the elevator trim tab to the cockpit.

The cockpit was crushed, but the pilot's seat and four-point harness remained intact. The magneto switch remained in the both position and the fuel selector was positioned to the right main fuel tank. The throttle, mixture, and carburetor heat control levers were in the full forward position. The engine remained partially attached the fuselage. The two-blade propeller separated from the hub. Both propeller blades exhibited chordwise scratching. One propeller blade was s-bent while the other was bent aft.

The engine was separated from the airframe for examination. The top spark plugs were removed; their electrodes were intact and light gray in color, except for the No. 3 top spark plug that was impact damaged. The valve covers were removed and oil was noted throughout the engine. The crankshaft was rotated via an accessory gear drive. Camshaft, crankshaft, and valve train continuity were confirmed and thumb compression was attained on all cylinders. The oil screen and oil filter were absent of contamination. The carburetor had separated from the engine during impact. Its floats and needle were intact and the valve was mid-range. Some fuel was recovered from the engine-driven fuel pump, consistent with 100 low-lead aviation gasoline. Both magnetos produced spark at all leads when rotated by hand.

The pilot held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, instrument airplane and glider. He also held a flight instructor certificate with a rating for glider. His most recent FAA second-class medical certificate was issued on June 10, 2015. At that time, he reported a total flight experience of 1,672 hours.

The two-seat, low-wing, fixed tricycle-gear airplane, serial number 60527, was assembled from a kit and issued an FAA experimental airworthiness certificate in 2005. It was powered by an Aero Sport Power O-360-A2A, 180-horsepower, experimental engine, equipped with a Sensenich two-blade, fixed-pitch propeller.

Maury County Airport (MRC), Columbia, Tennessee, was located about 20 miles south of the accident site. The recorded weather at MRC, at 1555, included wind from 190 degrees at 3 knots, clear sky, and visibility 10 miles. 

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