Sunday, September 30, 2018

Zenair CH 701 SP, N701XL: Fatal accident occurred July 27, 2017 in Laddonia, Ralls County, Missouri

Analysis

Although he had no night or instrument flight experience, the sport pilot departed in a non-instrument-certificated light sport airplane at night with an overcast ceiling and thunderstorms in the area. Radar data showed that the airplane proceeded on course for about 9 minutes and then entered a right descending turn that continued to ground impact, which was consistent with the pilot attempting to return to the departure airport and not paying attention to his altitude. Examination of the accident site revealed that the airplane struck open level farm land in a right wing-low, nose-low attitude. Examination of the engine and airframe did not reveal any evidence of preimpact anomalies that would have precluded normal operation. It is likely that the pilot continued visual flight into an area of instrument meteorological conditions, which resulted in the pilot experiencing a loss of visual reference and subsequent spatial disorientation.

The pilot had a history of chronic insomnia treated with temazepam, a sedating benzodiazepine, and was regularly prescribed hydrocodone, an opioid analgesic. Toxicology testing detected these drugs and their metabolites in the pilot's system. The pilot was likely impaired by effects from his use of temazepam, and the impairing effects of temazepam were likely enhanced by the pilot's use of hydrocodone. It is likely that the pilot's decision-making was degraded due to his combined use of temazepam and hydrocodone. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's decision to take off at night and continue visual flight into instrument meteorological conditions. which resulted in the pilot becoming spatially disoriented and losing control of the airplane. Contributing to the accident were the pilot's degraded decision-making due to his use of a combination of impairing prescription drugs, and the pilot's lack of instrument and night flight experience. 

Findings

Aircraft
Performance/control parameters - Not attained/maintained (Cause)

Personnel issues
Decision making/judgment - Pilot (Cause)
Spatial disorientation - Pilot (Cause)
Aircraft control - Pilot (Cause)
Prescription medication - Pilot (Factor)
Decision making/judgment - Pilot (Factor)
Qualification/certification - Pilot (Factor)
Total instrument experience - Pilot (Factor)

Environmental issues
Below VFR minima - Contributed to outcome (Cause)
Personal pressure - Contributed to outcome

Factual Information

History of Flight

Enroute
VFR encounter with IMC (Defining event)

Maneuvering-low-alt flying
Collision with terr/obj (non-CFIT)

Shannon and Bobby Faulkner
~

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


Additional Participating Entity:

Federal Aviation Administration / Flight Standards District Office; Saint Louis, Missouri

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/N701XL



Location: Laddonia, MO
Accident Number: CEN17FA288
Date & Time: 07/27/2017, 0452 CDT
Registration: N701XL
Aircraft: ZENITH CH701SP
Aircraft Damage: Destroyed
Defining Event: VFR encounter with IMC
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On July 27, 2017, at 0452 central daylight time, a Zenith CH 701SP, N701XP, was destroyed when it impacted a bean field about 6.5 miles north of Laddonia, Missouri. The sport pilot and passenger were fatally injured. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Instrument meteorological conditions prevailed at the time of the accident, and no flight plan had been filed for the personal cross-country flight. The flight originated from Mexico Municipal Airport (MYJ), Mexico, Missouri, about 0440, and was en route to Whittman Regional Airport (OSH), Oshkosh, Wisconsin.

According to the airport manager at MYJ, the airplane with the pilot and his passenger on board arrived late in the day on July 26, 2017. The pilot said he wanted to get an early morning start because he wanted to arrive at OSH when the control tower opened at 0700. A self-service fuel receipt charged to the pilot's credit card indicated that he purchased 17.8 gallons of fuel at 2038 on July 26. The manager said he believed the pilot and his passenger camped that evening next to the airplane. When the manager arrived at the airport the next morning, the airplane was gone.

According to radar data provided by the U.S. Air Force/Civil Air Patrol, the airplane first appeared on radar at 0443:46 when it was about 5 miles east of MYJ. According to the data, the airplane's altitude varied between 2,000 and 2,800 feet above ground level (agl) as it maintained a northeast heading. The airplane then entered a right descending turn and had completed about 180° when radar contact was lost. The last radar return was at 0452:46, when the airplane was about 6.5 miles northeast of Laddonia, Missouri. 

A family member later reported that the airplane was missing and an Alert Notice (ALNOT) was issued on the evening of July 27. Search teams located the wreckage early on the morning of July 28. 

Pilot Information

Certificate: Sport Pilot
Age: 41, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): Powered-Lift
Restraint Used: 3-point
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Sport Pilot None
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent: 08/03/2016
Flight Time:  272 hours (Total, all aircraft), 98 hours (Total, this make and model), 31 hours (Last 90 days, all aircraft), 2 hours (Last 30 days, all aircraft) 

According to Federal Aviation Administration (FAA) records, the pilot held a sport pilot certificate with a single-engine land rating. He was not instrument rated. A copy of the pilot's logbook contained entries from December 28, 2014, to July 19, 2017. The pilot's logbook entries were inconsistent: some of the entries were entered in tenths of an hour, and other entries were in minutes. 

The logbook revealed that the pilot had accrued the following flight experience:

Pegasus powered parachute, 162.9 hours
Cessna 150, 5.1 hours
Piper PA-28, 5.0 hours
Aeroprakt A22LS, 0.8 hours
Zenith CH 701SP, 98.3 hours

No night or instrument flight time had been logged. According to 14 CFR 61.315(c)(5), sport pilots are prohibited from flying at night. 



Aircraft and Owner/Operator Information

Aircraft Make: ZENITH
Registration: N701XL
Model/Series: CH701SP
Aircraft Category: Airplane
Year of Manufacture: 2003
Amateur Built: Yes
Airworthiness Certificate: Experimental Light Sport
Serial Number: 7-4618
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 05/01/2017, Condition
Certified Max Gross Wt.: 1100 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time:  1142 Hours as of last inspection
Engine Manufacturer: Rotax
ELT: C91A installed, not activated
Engine Model/Series: 912ULS
Registered Owner: On file
Rated Power: 100 hp
Operator: On file
Operating Certificate(s) Held: None

The experimental light sport airplane was constructed by a private individual in 2003, and later purchased by the pilot. It was powered by a 100-horsepower Rotax 912ULS engine, driving a 3-bladed Warp-Drive 70-inch fixed pitch composite propeller.

A copy of the maintenance records contained entries from December 11, 2013, to May 1, 2017. A condition inspection was performed on the airframe and engine on May 1, 2017, with 1,142 flight hours recorded in the logbook.

The airplane was not equipped nor certified for instrument flight rules (IFR) flight. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Night
Observation Facility, Elevation: KMYJ
Distance from Accident Site: 17 Nautical Miles
Observation Time: 0415 CDT
Direction from Accident Site: 200°
Lowest Cloud Condition:
Visibility: 1.5 Miles
Lowest Ceiling: Broken / 1100 ft agl
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: /
Wind Direction: 230°
Turbulence Severity Forecast/Actual: /
Altimeter Setting: 29.94 inches Hg
Temperature/Dew Point: 22°C / 22°C
Precipitation and Obscuration:
Departure Point: Mexico, MO (KMYJ)
Type of Flight Plan Filed: None
Destination: Oshkosh, WI (KOSH)
Type of Clearance: None
Departure Time: 0400 CDT
Type of Airspace: Class G 

There was no record that the pilot had obtained a preflight weather briefing.

At 0414, MYJ reported a visibility of 1-1/2 miles in heavy rain, broken clouds at 1,100 feet, and overcast at 1,900 feet.

At 0435, MYJ reported winds from 240° at 7 knots, visibility 7 miles in light rain, broken clouds at 600 feet and 1,200 feet, and overcast at 1,900 feet. The temperature-dew point spread was 1° (23/22). There was distant lightning in the north through east quadrants, and in the west quadrant.

At 0455, MYJ reported winds from 230° at 7 knots, visibility 7 miles, with a thunderstorm and rain in the vicinity. There were scattered clouds at 600 feet, broken clouds at 3,300 feet, and overcast skies at 4,800 feet. The temperature-dew point spread was 1°, and there was distant lightning in the north through east quadrants and in the west quadrant. 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 1 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude:  39.334444, -91.685833

The accident site was located 6.5miles northeast of MYJ in open level farm land. Green position light lens fragments were found at the beginning of a ground scar that was 36 feet long and aligned on a magnetic course of 121°. At the end of the ground scar was a water-filled impact crater, followed by a debris path that extended 252 feet on a magnetic course of 130°, which was about the direction to MYJ. The crushed right wing and lesser damaged left wing were located farther down the debris path, preceded by a flap and aileron. The fuselage, cockpit, and empennage were located 84 feet from the impact crater and to the left of the debris path. The engine was located 210 feet from the impact crater.

Medical And Pathological Information

The Boone/Callaway County Medical Examiner's Office, Columbus, Missouri, performed an autopsy on the pilot. According to the autopsy report, death was attributed to "blunt force injuries." The toxicology screen on the pilot performed by St. Louis University's Toxicology Laboratory Berkeley, Missouri, revealed the presence of 0.040 gm% (40 mg/dl) ethanol, 0.11 micrograms/ml temazepam, 33 micrograms/ml acetaminophen, and 0.91 micrograms/ml sertraline.

FAA's Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, performed toxicology screening that revealed the presence of 10 (mg/dL, mg/hg) ethanol in urine, and 36 (mg/dL, mg/hg) ethanol in blood. Propanol, a metabolite of ethanol, was detected in blood and urine. The presence of propanol is consistent with postmortem alcohol production. The report noted that putrefaction had occurred, and the blood was unsuitable for carbon monoxide analysis. Also detected were 114.72 (ug/ml, ug/g) acetaminophen in urine; 0.007 (ug/mL, ug/g) dihydrocodeine in blood and 0.067 (ug/mL, ug/g) in urine; 0.144 (ug/ml, ug/g) hydrocodone in urine but not in blood; 0.054 (ug/mL, ug/g) hydromorphone in urine; 0.36 (ug/ml, ug/g) oxazepam in urine but not in blood; an unknown quantity of sertraline in urine and 1.23 (ug/mL, ug/g) in blood, and an unknown quantity of salicylate in urine.

According to the pilot's medical records, the pilot had a history of chronic insomnia that was being treated with temazepam. (Oxazepam is a psychoactive metabolite of temazepam. Temazepam (Restoril) is "a sedating benzodiazepine available by prescription and intended for short-term treatment of insomnia." The drug carries several warnings, including "concomitant use of benzodiazepines, including temazepam and opioids, may result in profound sedation, respiratory depression, coma, and death." There is also a warning that the drug can cause "behavior changes, such as increased aggressivity, and patients using it may engage in complex behaviors while under its influence, such as 'sleep driving'" that they may later not recall.

The pilot was also being treated for anxiety with sertraline, and had been regularly prescribed hydrocordone. Sertraline (Zoloft) is a prescription antidepressant that is not considered impairing.

Hydrocodone, an opioid analgesic, is considered impairing and carries warnings about risks of central nervous system and respiratory depression, particularly when combined with benzodiazepines. In addition, the drug information warns that it "may impair the mental or physical abilities needed to perform potentially hazardous activities such as driving a car or operating machinery."


Shannon Faulkner

Bobby Faulkner during 2016 Adventure Arkansas



NTSB Identification: CEN17FA288
14 CFR Part 91: General Aviation
Accident occurred Thursday, July 27, 2017 in Laddonia, MO
Aircraft: ZENITH CH701SP, registration: N701XL
Injuries: 2 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 July 27, 2017, about 0415 central daylight time, a Zenith CH 701SP, N701XP, piloted by a non-instrument rated sport pilot, was destroyed when the it impacted terrain approximately 6.5 miles north of Laddonia, and 16.5 miles northeast of Mexico, Missouri. Instrument meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 Code of Federal Regulations Part 91 without a flight plan. The pilot and passenger on board the airplane were fatally injured. The cross-country flight originated from Mexico Municipal Airport (KMYJ), Mexico, Missouri, about 0400, and was en route to Oshkosh (OSH), Wisconsin.

According to the airport manager, the airplane arrived late in the day on July 26. The pilot said he wanted to get an early start the next morning because he wanted to arrive at OSH when the control tower opened at 0700. The manager said he believed the pilot and his wife camped that evening next to the airplane. When the manager arrived at the airport the next morning, the airplane was gone. The airplane was later reported missing and an ALNOT (Alert Notice) was issued that evening. The wreckage was located early the next morning.

The on-scene investigation revealed the airplane struck the ground in a right wing low, nose down attitude as evidenced by green position light fragments at the beginning of the ground scar, followed by the impact crater. A crushed right wing and relatively intact left wing were located further down the debris path, followed by the fuselage and engine. The debris path was aligned on a heading back towards Mexico. There is no record that the pilot obtained a weather briefing or filed a flight plan.

4 comments:

Anonymous said...

remarkable it took this determined individual so long to finally kill himself.

Anonymous said...

My heart goes out to the passenger, they might not have realized how seriously doomed this flight was. I read a lot of these and many of the pilot error ones are similar but man this pilot had seemingly (from what the report says) no concern for safety.

Anonymous said...

Sad and pathetic. Nothing else to say. The photo skimming the lake surface tells it all.

Anonymous said...

No wx brief ? LSA ? No instument rating ? Before DAylight ? LSA regs ... I don't recall so many such accidents 30 years ago when I was active pilot. Seems now there's about one each week .