Duane Alan Daws, 64, of Mt. Vernon, Indiana
The National Transportation Safety Board traveled to the scene of this accident.
Additional Participating Entity:
Federal Aviation Administration / Flight Standards District Office; Indianapolis, Indiana
Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf
Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms
Aviation Accident Data Summary - National Transportation Safety Board: https://app.ntsb.gov/pdf
http://registry.faa.gov/N129LZ
Location: Mt Vernon, IN
Accident Number: CEN17FA046
Date & Time: 12/02/2016, 1237 CST
Registration: N129LZ
Aircraft: Gordon PEGAZAIR P 100
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
Analysis
The 64-year-old pilot, who was the airplane owner, departed on a local personal flight in the airplane about 45 minutes before the accident. Witnesses saw the airplane at 400-500 ft above ground level when it entered a descent, pitched up, rolled right, and then pitched nose down impacting the ground. Ground scarring surrounding the airplane was consistent with a near-vertical nose-down impact attitude, which resulted in the engine separating and coming to rest about 20 ft from the airframe. Postaccident examination of the airplane revealed no evidence of any mechanical anomalies that would have precluded normal operation of the airplane.
According to his pilot logbook, the pilot had not completed a flight review since 2012, and the pilot's last Federal Aviation Administration (FAA) airman medical certificate was issued in 2012. At the time of the accident, he was operating an airplane that required a medical certificate, but his certification was no longer valid.
The pilot's personal medical records showed a history of a chronic progressive neurodegenerative disease beginning in 2011 with intermittent worsening of symptoms. The disease and its symptoms likely impaired his ability to safely operate the airplane. Toxicology testing of samples from the pilot detected ethanol at 0.070 gm/dl in vitreous and 0.038 g/dl in blood. Although blood levels of ethanol can change after death, the vitreous from an intact eye is not subject to significant postmortem changes. Therefore, it is likely the ethanol detected in blood and vitreous was from ingestion. The vitreous blood level was well above the FAA prohibited level of 0.04 gm/dl, and mild impairment has been shown at blood levels as low as 0.020 gm/dl. It is likely that the pilot was experiencing some level of impairment from alcohol ingestion and that the combination of the pilot's progressive degenerative neurologic condition and his use of alcohol impaired his ability to safely operate the airplane and contributed to the accident.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain airplane control, which resulted in a collision with terrain. Contributing to the accident was the pilot's impairment resulting from the combination of his progressive degenerative neurologic condition and his use of alcohol.
Findings
Aircraft
Performance/control parameters - Not attained/maintained (Cause)
Personnel issues
Aircraft control - Pilot (Cause)
Neurological - Pilot (Factor)
Alcohol - Pilot (Factor)
Qualification/certification - Pilot
Factual Information
History of Flight
Enroute
Loss of control in flight (Defining event)
Uncontrolled descent
Collision with terr/obj (non-CFIT)
On December 2, 2017, about 1237 central standard time, an experimental amateur-built Pegazair P 100 airplane, N129LZ, impacted a field near Mt Vernon, Indiana. The commercial pilot was fatally injured, and the airplane was destroyed. The airplane was owned and operated by the pilot under Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Day visual meteorological conditions prevailed, and no flight plan was filed. The flight originated from Carmi Municipal Airport (CUL), Carmi, Illinois, about 1150.
A witness stated that the airplane was flying overhead at about 400 - 500 feet above ground level, westbound, when he heard the engine quit running. The airplane then initiated a descending right turn, north bound, and then the engine started running again. The airplane maintained a northerly heading, for about ¼-1/2 mile, and then the engine quit a second time, started a decent, pitched up, rolled right, and then pitched nose down impacting the ground. The witness said that he went the accident site and there was a strong odor of gasoline and immediately called 911.
A second witness stated that he saw a similar flight path for the airplane but that the engine was running on impact.
Pilot Information
Certificate: Commercial
Age: 64, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-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: 03/21/2012
Occupational Pilot: No
Last Flight Review or Equivalent: 05/12/2012
Flight Time: (Estimated) 2000 hours (Total, all aircraft), 118 hours (Total, this make and model)
The pilot held a commercial pilot certificate with an airplane single-engine land rating. He reported a total flight experience of 2,500 hours, with 0 hours in last 6 months, at the time of his last airman medical exam on March 21, 2012, when he was issued a third-class medical certificate that expired on March 31, 2014.
According to Federal Aviation Administration (FAA) records, the pilot did not hold an airframe and powerplant mechanic certificate nor did he hold a repairman certificate for the airplane. The pilot had no FAA record of previous accidents, incidents, or enforcement actions.
The first and last entries in the pilot's logbook were dated December 2, 1978, and June 29, 2014, respectively. The logbook indicated that he received a private pilot check ride on June 22, 1980. The first logbook entry for flight in the accident airplane was dated March 18, 2012, and indicated that it was 25-minute local flight from CUL with two landings. The remarks section for this entry stated, "High speed taxi + lift (no pattern)." All the subsequent flight entries were for flights in the accident airplane.
The memoranda section of the pilot's logbook included an endorsement, dated May 12, 2012, by a flight instructor, stating that the pilot received a flight review. The only flight entry dated May 12, 2012, was for a 45-minute local flight from CUL in the accident airplane. The remarks section of this entry contained an individual's name and did not cite that a flight review was performed. There were no subsequent flight review endorsements in the pilot's logbook. Title 14 CFR 61.56 requires pilots to obtain a flight review every 2 years to act as pilot-in-command and flight reviews must include a minimum of 1 hour of flight training and 1 hour of ground training.
Aircraft and Owner/Operator Information
Aircraft Make: Gordon
Registration: N129LZ
Model/Series: PEGAZAIR P 100
Aircraft Category: Airplane
Year of Manufacture: 2007
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 9908108
Landing Gear Type: Tailwheel
Seats: 2
Date/Type of Last Inspection: 07/15/2013, Condition
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 194.65 Hours as of last inspection
Engine Manufacturer: Corvair
ELT:
Engine Model/Series: 190
Registered Owner: Deregistered
Rated Power: 120 hp
Operator: Pilot
Operating Certificate(s) Held: None
The airplane was a Gordon Pegazair P 100 model, which was manufactured in 2007 and was equipped with a Corvair 190 automotive engine.
According to the Federal Aviation Administration website, FAA Registry, Aircraft Inquiry, the airplane was originally registered to the previous aircraft owner, who was also the builder of the airplane. That registration expired May 14, 2013. The pilot, who was the owner of the airplane, had not reregistered the airplane after he had purchased it, and no subsequent application was made for registration.
Aircraft records obtained during the investigation had a special airworthiness certificate issued July 14, 2007 to the aircraft builder/previous owner. There was no current airworthiness certificate or an application for an updated airworthiness certificate in the aircraft records or in the FAA aircraft records database.
The last two logbook entries of the airframe logbook were dated April 2, 2012, at a tachometer time of 26.2 hours for a "completed annual conditional inspection" and July 15, 2013, tachometer time 194.65 hours for a "completed annual inspection." There were no subsequent maintenance entries in the logbook. Both entries were signed by the same the A&P who held an inspection authorization (IA).
The engine logbook had the last two entries for an "annual inspection" by the A&P IA, dated July 15, 2013, at a tachometer time of 194.65 hours. There were no subsequent inspections entered in the engine logbook that were signed by an A&P, but there were 10 later entries dated from July 15, 2013 to November 24, 2015, that cited maintenance work involving engine oil and filter changes, engine compression check, spark plug changes, the replacement of ignition points, and engine timing checks. The last entry dated November 24, 2015 had a tachometer time entry of 489.23 hours.
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: CUL, 388 ft msl
Distance from Accident Site: 7 Nautical Miles
Observation Time: 1235 CST
Direction from Accident Site: 345°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 270°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.27 inches Hg
Temperature/Dew Point: 7°C / 0°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Carmi, IL (CUL)
Type of Flight Plan Filed: None
Destination:
Type of Clearance: None
Departure Time: 1150 CST
Type of Airspace: Class G
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 37.955000, -87.892778 (est)
The accident site was located in a flat dirt field about 17 nautical miles southeast of CUL. The power lines and trees adjacent to the field were undamaged.
The engine was separated from the airframe and was about 20 ft south of the airframe. A ground scar consistent in shape and length to the wing's leading edge was oriented lengthwise north/south on each side of the separated engine. [SG1] The fuselage was upright, and the tail-to-nose orientation of the airplane was approximately north/northwest. There was no evidence of fire or soot on the engine or airframe.
Examination of the flight control system revealed that the wing flaps and both leading edge wing slats were in the retracted positions. Flight control continuity was confirmed from the control surfaces to the cockpit controls.
The left- and right-wing fuel tanks were empty, and the fuel lines from the tanks to the fuel selector and from the fuel selector to the engine were broken open. The fuel selector panel was damaged by impact forces, and the fuel selector was positioned between the "LEFT" and "BOTH" positions. Both fuel tanks exhibited outward expansion consistent with hydraulic forces. There was an odor consistent with fuel present at the accident site.
The engine did not exhibit any evidence of mechanical failure. Engine control continuity to the cockpit was confirmed through overstress separations of the controls. The cockpit engine control positions could not be determined due to impact damage. Both propeller blades were broken off at the blade roots and displayed features consistent with overstress.
The airplane was equipped with an MGL Avionics EFIS display that contained an SD memory card. The display and memory card were sent to the National Transportation Safety Board Vehicle Recorder Division for download. No data pertinent to the event were recovered due to the extent of the damage to the SD card.
Medical And Pathological Information
On his most recent medical certificate application, the 64-year-old pilot reported a history of a neurology evaluation in September 2011 for memory issues, but no records of the evaluation were contained in the FAA records. On that application, he denied any other medical concerns or the use of medications.
The pilot's personal medical records documented a history of a progressive neurodegenerative disease beginning in 2011. His symptoms included significant visual-spatial and language dysfunction, and he was diagnosed with alterations of consciousness and encephalopathy. In August 2015, he was prescribed the Alzheimer's treatment medication donepezil. His most recent record of altered consciousness was April 2016 when the pilot reported transient episodes of altered mental status, loss of balance, slurred speech, and weakness. At that time, he was no longer using any medications. No records of a detailed neurologic evaluation after April 2016 were located.
The Posey County Coroner's Office, Mt Vernon, Indiana, performed an autopsy of the pilot and determined that his cause of death was multiple blunt force injuries. No natural disease was identified.
The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing and detected ethanol at 0.070 gm/dl in vitreous and 0.038 g/dl in blood. No carbon monoxide or tested-for-drugs were detected. Ethanol is the intoxicant commonly found in beer, wine, and liquor. It acts as a central nervous system depressant. After ingestion, at low doses, it impairs judgment, psychomotor functioning, and vigilance; at higher doses it can cause coma and death. Title 14 CFR 91.17(a) prohibits any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dl or more ethanol in the blood. Because ingested alcohol is distributed throughout the body, levels from different postmortem tissues are usually similar. Ethanol may also be produced in body tissues by microbial activity after death. However, vitreous humor from an intact eye and urine do not suffer from such production to any significant extent in relation to blood.
Location: Mt Vernon, IN
Accident Number: CEN17FA046
Date & Time: 12/02/2016, 1237 CST
Registration: N129LZ
Aircraft: Gordon PEGAZAIR P 100
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal
On December 2, 2017, about 1237 central standard time, an experimental amateur-built Pegazair P 100 airplane, N129LZ, impacted a field near Mt Vernon, Indiana. The commercial pilot was fatally injured, and the airplane was destroyed. The airplane was owned and operated by the pilot under Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Day visual meteorological conditions prevailed, and no flight plan was filed. The flight originated from Carmi Municipal Airport (CUL), Carmi, Illinois, about 1150.
A witness stated that the airplane was flying overhead at about 400 - 500 feet above ground level, westbound, when he heard the engine quit running. The airplane then initiated a descending right turn, north bound, and then the engine started running again. The airplane maintained a northerly heading, for about ¼-1/2 mile, and then the engine quit a second time, started a decent, pitched up, rolled right, and then pitched nose down impacting the ground. The witness said that he went the accident site and there was a strong odor of gasoline and immediately called 911.
A second witness stated that he saw a similar flight path for the airplane but that the engine was running on impact.
Pilot Information
Certificate: Commercial
Age: 64, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: 3-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: 03/21/2012
Occupational Pilot: No
Last Flight Review or Equivalent: 05/12/2012
Flight Time: (Estimated) 2000 hours (Total, all aircraft), 118 hours (Total, this make and model)
The pilot held a commercial pilot certificate with an airplane single-engine land rating. He reported a total flight experience of 2,500 hours, with 0 hours in last 6 months, at the time of his last airman medical exam on March 21, 2012, when he was issued a third-class medical certificate that expired on March 31, 2014.
According to Federal Aviation Administration (FAA) records, the pilot did not hold an airframe and powerplant mechanic certificate nor did he hold a repairman certificate for the airplane. The pilot had no FAA record of previous accidents, incidents, or enforcement actions.
The first and last entries in the pilot's logbook were dated December 2, 1978, and June 29, 2014, respectively. The logbook indicated that he received a private pilot check ride on June 22, 1980. The first logbook entry for flight in the accident airplane was dated March 18, 2012, and indicated that it was 25-minute local flight from CUL with two landings. The remarks section for this entry stated, "High speed taxi + lift (no pattern)." All the subsequent flight entries were for flights in the accident airplane.
The memoranda section of the pilot's logbook included an endorsement, dated May 12, 2012, by a flight instructor, stating that the pilot received a flight review. The only flight entry dated May 12, 2012, was for a 45-minute local flight from CUL in the accident airplane. The remarks section of this entry contained an individual's name and did not cite that a flight review was performed. There were no subsequent flight review endorsements in the pilot's logbook. Title 14 CFR 61.56 requires pilots to obtain a flight review every 2 years to act as pilot-in-command and flight reviews must include a minimum of 1 hour of flight training and 1 hour of ground training.
Aircraft and Owner/Operator Information
Aircraft Make: Gordon
Registration: N129LZ
Model/Series: PEGAZAIR P 100
Aircraft Category: Airplane
Year of Manufacture: 2007
Amateur Built: Yes
Airworthiness Certificate: Experimental
Serial Number: 9908108
Landing Gear Type: Tailwheel
Seats: 2
Date/Type of Last Inspection: 07/15/2013, Condition
Certified Max Gross Wt.: 1320 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 194.65 Hours as of last inspection
Engine Manufacturer: Corvair
ELT:
Engine Model/Series: 190
Registered Owner: Deregistered
Rated Power: 120 hp
Operator: Pilot
Operating Certificate(s) Held: None
The airplane was a Gordon Pegazair P 100 model, which was manufactured in 2007 and was equipped with a Corvair 190 automotive engine.
According to the Federal Aviation Administration website, FAA Registry, Aircraft Inquiry, the airplane was originally registered to the previous aircraft owner, who was also the builder of the airplane. That registration expired May 14, 2013. The pilot, who was the owner of the airplane, had not reregistered the airplane after he had purchased it, and no subsequent application was made for registration.
Aircraft records obtained during the investigation had a special airworthiness certificate issued July 14, 2007 to the aircraft builder/previous owner. There was no current airworthiness certificate or an application for an updated airworthiness certificate in the aircraft records or in the FAA aircraft records database.
The last two logbook entries of the airframe logbook were dated April 2, 2012, at a tachometer time of 26.2 hours for a "completed annual conditional inspection" and July 15, 2013, tachometer time 194.65 hours for a "completed annual inspection." There were no subsequent maintenance entries in the logbook. Both entries were signed by the same the A&P who held an inspection authorization (IA).
The engine logbook had the last two entries for an "annual inspection" by the A&P IA, dated July 15, 2013, at a tachometer time of 194.65 hours. There were no subsequent inspections entered in the engine logbook that were signed by an A&P, but there were 10 later entries dated from July 15, 2013 to November 24, 2015, that cited maintenance work involving engine oil and filter changes, engine compression check, spark plug changes, the replacement of ignition points, and engine timing checks. The last entry dated November 24, 2015 had a tachometer time entry of 489.23 hours.
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: CUL, 388 ft msl
Distance from Accident Site: 7 Nautical Miles
Observation Time: 1235 CST
Direction from Accident Site: 345°
Lowest Cloud Condition: Clear
Visibility: 10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 4 knots /
Turbulence Type Forecast/Actual: / None
Wind Direction: 270°
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.27 inches Hg
Temperature/Dew Point: 7°C / 0°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Carmi, IL (CUL)
Type of Flight Plan Filed: None
Destination:
Type of Clearance: None
Departure Time: 1150 CST
Type of Airspace: Class G
Wreckage and Impact Information
Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 37.933333, 167.772500 (est)
The accident site was located in a flat dirt field about 17 nautical miles southeast of CUL. The power lines and trees adjacent to the field were undamaged.
The engine was separated from the airframe and was about 20 ft south of the airframe. A ground scar consistent in shape and length to the wing's leading edge was oriented lengthwise north/south on each side of the separated engine. [SG1] The fuselage was upright, and the tail-to-nose orientation of the airplane was approximately north/northwest. There was no evidence of fire or soot on the engine or airframe.
Examination of the flight control system revealed that the wing flaps and both leading edge wing slats were in the retracted positions. Flight control continuity was confirmed from the control surfaces to the cockpit controls.
The left- and right-wing fuel tanks were empty, and the fuel lines from the tanks to the fuel selector and from the fuel selector to the engine were broken open. The fuel selector panel was damaged by impact forces, and the fuel selector was positioned between the "LEFT" and "BOTH" positions. Both fuel tanks exhibited outward expansion consistent with hydraulic forces. There was an odor consistent with fuel present at the accident site.
The engine did not exhibit any evidence of mechanical failure. Engine control continuity to the cockpit was confirmed through overstress separations of the controls. The cockpit engine control positions could not be determined due to impact damage. Both propeller blades were broken off at the blade roots and displayed features consistent with overstress.
The airplane was equipped with an MGL Avionics EFIS display that contained an SD memory card. The display and memory card were sent to the National Transportation Safety Board Vehicle Recorder Division for download. No data pertinent to the event were recovered due to the extent of the damage to the SD card.
Medical And Pathological Information
On his most recent medical certificate application, the 64-year-old pilot reported a history of a neurology evaluation in September 2011 for memory issues, but no records of the evaluation were contained in the FAA records. On that application, he denied any other medical concerns or the use of medications.
The pilot's personal medical records documented a history of a progressive neurodegenerative disease beginning in 2011. His symptoms included significant visual-spatial and language dysfunction, and he was diagnosed with alterations of consciousness and encephalopathy. In August 2015, he was prescribed the Alzheimer's treatment medication donepezil. His most recent record of altered consciousness was April 2016 when the pilot reported transient episodes of altered mental status, loss of balance, slurred speech, and weakness. At that time, he was no longer using any medications. No records of a detailed neurologic evaluation after April 2016 were located.
The Posey County Coroner's Office, Mt Vernon, Indiana, performed an autopsy of the pilot and determined that his cause of death was multiple blunt force injuries. No natural disease was identified.
The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing and detected ethanol at 0.070 gm/dl in vitreous and 0.038 g/dl in blood. No carbon monoxide or tested-for-drugs were detected. Ethanol is the intoxicant commonly found in beer, wine, and liquor. It acts as a central nervous system depressant. After ingestion, at low doses, it impairs judgment, psychomotor functioning, and vigilance; at higher doses it can cause coma and death. Title 14 CFR 91.17(a) prohibits any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dl or more ethanol in the blood. Because ingested alcohol is distributed throughout the body, levels from different postmortem tissues are usually similar. Ethanol may also be produced in body tissues by microbial activity after death. However, vitreous humor from an intact eye and urine do not suffer from such production to any significant extent in relation to blood.
NTSB Identification: CEN17FA046
14 CFR Part 91: General Aviation
Accident occurred Friday, December 02, 2016 in Mt Vernon, IN
Aircraft: Gordon PEGAZAIR P 100, registration: N129LZ
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 December 2, 2016, about 1237 central standard time, a Gordon Pegazair P 100, N129LZ (deregistered N-number), impacted a field near Mt Vernon, Indiana. The airplane was destroyed by impact forces. The commercial pilot was fatally injured. The airplane was owned and operated by the pilot under 14 Code of Federal Regulations Part 91 as a personal flight that was not operating on a flight plan. Visual meteorological conditions prevailed at the time of the accident. The flight originated from Carmi Municipal Airport (CUL), Carmi, Illinois about 1150.
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