Robert Alexander
The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office: Riverside, California
Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
Analysis
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
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
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.
Findings
Aircraft
Frames (main fuselage) - Incorrect service/maintenance (Cause)
Frames (main fuselage) - Inadequate inspection (Cause)
Personnel issues
Illicit drug - Pilot (Factor)
Prescription medication - Pilot (Factor)
Decision making/judgment - Pilot (Factor)
Understanding/comprehension - Pilot (Factor)
Factual Information
History of Flight
Prior to flight
Aircraft maintenance event
Takeoff
Aircraft structural failure (Defining event)
Initial climb
Loss of control in flight
Uncontrolled descent
Collision with terr/obj (non-CFIT)
Location: Hesperia, CA
Accident Number: WPR17FA074
Date & Time: 03/07/2017, 1018 PST
Registration: UNREGISTERED
Aircraft: QUICKSILVER MXL II
Aircraft Damage: Substantial
Defining Event: Aircraft structural failure
Injuries: 1 Fatal
Flight Conducted Under:
Part 91: General Aviation - Flight Test
On March 7, 2017, at 1018 Pacific standard time, an unregistered experimental amateur-built Quicksilver MXL II collided with terrain after takeoff from Hesperia Airport, Hesperia, California. The pilot, who was operating with an expired student pilot certificate, sustained fatal injuries, and the airplane sustained substantial damage. The airplane was operated by the pilot/builder as a test flight under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan had been filed.
According to friends of the pilot, the pilot had been performing multiple high-speed taxi tests in the airplane since its completion about 2 months before the accident. He reported to his friends that, during those tests, the airplane had been pulling to the left. About 1 month before the accident, he performed the first flight test; however, shortly after getting airborne, the airplane rolled left, departed the runway area, struck a hangar, and sustained substantial damage. The pilot then spent the next month repairing the damage and performing more high-speed taxi tests.
On the day of the accident, a witness observed the pilot taxiing the airplane back and forth along the runway, before initiating a takeoff roll from runway 3. After rotation, the airplane climbed to about 50 ft above ground level (agl) while drifting to the left of the runway centerline. It continued in a shallow climbing left turn, and, after reaching about 100 ft agl, it transitioned to a 90° left roll. The nose of the airplane then dropped, and the airplane rolled inverted into the ground.
Video imagery recovered from a GoPro HERO 5 digital camera onboard the airplane revealed that, after starting the engine, the pilot performed a high-speed taxi along the full length of runway 21, lasting about 80 seconds. During that time, the airplane veered left and right, completely crossing the centerline eight times. After reaching the end of the runway, the pilot turned the airplane around and then increased engine power, and the airplane began to accelerate down runway 3. About 15 seconds later, the right wheel began to lift off the runway, followed a few seconds later by the left wheel. The airplane began a level climb over the centerline for the next 4 seconds, after which it began to bank to the left. The pilot moved the control stick to the right, and the ailerons responded by moving in the correct direction (right up, left down), and the right rudder cable went taught, consistent with an application of right rudder pedal. The airplane continued to bank to the left, as the nose started to pitch up. The left bank continued to increase, and the pilot moved the stick farther to the right. A few seconds later, the angle of bank reached about 45°, and the airplane's heading was now perpendicular to the runway. The nose of the airplane then dropped, and the airplane transitioned into a spiral, striking the ground in a nose-down attitude after about 3/4 of a turn. The engine was operating throughout the flight.
The video footage revealed that the pilot had exclusive use of the runway during the takeoff and taxi runs, and there were no other aircraft in the traffic pattern.
Pilot Information
Certificate: Student
Age: 55, Male
Airplane Rating(s): None
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 4-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 01/20/1983
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: (Estimated) 100 hours (Total, all aircraft), 0.1 hours (Total, this make and model)
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.
Aircraft and Owner/Operator Information
Aircraft Manufacturer: QUICKSILVER
Registration: UNREGISTERED
Model/Series: MXL II
Aircraft Category: Airplane
Year of Manufacture: 2017
Amateur Built: Yes
Airworthiness Certificate:
Serial Number: NONE
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: Unknown
Certified Max Gross Wt.: 725 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:
Engine Manufacturer: Rotax
ELT: Not installed
Engine Model/Series: 582
Registered Owner: On file
Rated Power: 65 hp
Operator: On file
Operating Certificate(s) Held: None
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.
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KVCV, 2885 ft msl
Observation Time: 1815 UTC
Distance from Accident Site: 13 Nautical Miles
Direction from Accident Site: 346°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 10°C / -5°C
Lowest Ceiling: None
Visibility: 10 Miles
Wind Speed/Gusts, Direction: 4 knots, 30°
Visibility (RVR):
Altimeter Setting: 30.3 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Hesperia, CA (L26)
Type of Flight Plan Filed: None
Destination: Hesperia, CA (L26)
Type of Clearance: None
Departure Time: 1017 PST
Type of Airspace: Class E
Airport Information
Airport: HESPERIA (L26)
Runway Surface Type: Asphalt
Airport Elevation: 3390 ft
Runway Surface Condition: Dry
Runway Used: 03
IFR Approach: None
Runway Length/Width: 3910 ft / 50 ft
VFR Approach/Landing: None
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 34.375278, -117.318889
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). The mating surfaces of the tubes exhibited rust-colored corrosion and longitudinal striations consistent with movement, and the upper end of the lower tube displayed dimple marks where it had been resting against the bolt shank on the upper tube. The entire interlocking assembly was wrapped with insulating foam and could not readily be observed by the pilot.
Figure - Tri-bar downtube and upper tri-bar assembly with securing bolt only attached to the upper assembly.
Flight Recorders
As previously discussed, the airplane was equipped with a GoPro HERO 5 digital camera, which was mounted on the tail structure facing forward. The camera was sent to the NTSB Recorders Division for data extraction. The camera recorded the entire flight, with a field of view that included the engine, propeller, inboard sections of both wings (including the ailerons), the rudder cables, both seats, and a view of the pilot from behind.
In addition to the accident flight, the camera contained multiple recordings taken during the days immediately preceding the accident, of the pilot performing taxi tests on the runway. In each recording he was unable to consistently keep the airplane tracking the runway centerline, and, in one recording, the airplane departed the paved surface of the runway altogether.
The recordings showed that the airplane was not equipped with a windshield, and, although the pilot was wearing a helmet that was equipped with a face shield, the shield was unused and in the up position throughout most of the taxi runs, and all of the accident flight.
Medical And Pathological Information
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.
14 CFR Part 91: General Aviation
Accident occurred Tuesday, March 07, 2017 in Hesperia, CA
Aircraft: QUICKSILVER MXL II, registration: UNREG
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 March 7, 2017, at 1018 Pacific standard time, an unregistered experimental amateur-built Quicksilver MXL II, collided with terrain after takeoff from Hesperia Airport, Hesperia, California. The airplane was operated by the pilot/builder as a test flight, under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The unlicensed pilot sustained fatal injuries, and the airplane sustained substantial damage. Visual meteorological conditions prevailed, and no flight plan had been filed.
The pilot had been performing multiple high-speed taxi tests in the airplane since it's completion about two months before the accident. He reported to friends that during those tests, the airplane had been pulling to the left. About one month prior to the accident, he performed the first flight test, however shorty after getting airborne the airplane rolled left, departed the runway, and struck a hangar. He spent the next month repairing the damage, and performing more high-speed taxi tests.
On the day of the accident, witnesses observed him taxing in the airplane back and forth along the runway at least two times, before initiating a takeoff roll from runway 3. A witness watched as the airplane rotated, climbed to about 50 ft above ground level, while drifting to the left of the runway centerline. It continued in a shallow climbing left turn to about 100ft agl, transitioning to a 90-degree left roll. The nose of the airplane then descended, and the airplane rolled inverted into the ground.
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 automobile gasoline was present throughout the site.
The primary load carrying member of the airplane was composed of an aluminum "root tube", which united the engine, wings, king-post, and lower trike assembly. The trike assembly supported the pilot and passenger seats, along with the landing gear and flight controls. The trike included the axle and axle struts, and a series of steel cross and downtubes 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 designed 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 inserted 1 1/4 inch short, such that the bolt only passed through the upper tube, rather than interlocking the upper and lower tubes.
No comments:
Post a Comment