Tuesday, November 19, 2019

Loss of Control in Flight: Unregistered Air Creation Clipper 582; accident occurred July 14, 2015 at Clark County Airport (8D7), South Dakota

The National Transportation Safety Board did not travel to the scene of this accident.

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Rapid City, South Dakota
Rotech Flight Safety Inc; Vernon, British Columbia, Canada

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

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

Location: Clark, SD
Accident Number: CEN15LA306
Date & Time: 07/14/2015, 1552 CDT
Registration: UNREG
Aircraft: AIR CREATION CLIPPER 582
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 2 Serious
Flight Conducted Under: Part 91: General Aviation - Personal

On July 14, 2015, about 1552 central daylight time, an unregistered Air Creation Clipper 582, collided terrain shortly after takeoff from Clark County Airport (8D7), Clark, South Dakota. The uncertificated pilot and passenger were seriously injured, and the weight-shift control aircraft sustained substantial damage. The aircraft was owned by the pilot and operated under the provisions of Title 14 Code of Federal Regulations Part 91. Day visual meteorological conditions prevailed for the personal local area flight that was originating at the time of the accident.

The uncertificated pilot told a Federal Aviation Administration (FAA) inspector that he did not recall the accident flight. Additionally, the pilot did not submit a completed National Transportation Safety Board (NTSB) Accident Report Form 6120.1 following the accident.

The passenger reported that when the weight-shift control aircraft was about 100 ft above the ground when it "turned onto its side" and descended into terrain.

A witness reported that the weight-shift control aircraft had departed runway 31 and climbed to about 100 ft above the runway when he heard a reduction in engine power. He then saw the aircraft pitch down about 10°-15° and roll into a 20° left wing down bank before it descended into terrain.

The passenger had recorded two videos using his handheld mobile phone during the flight. The Clark County Sheriff's Office coordinated with the Watertown Police Department to download the videos from the passenger's mobile phone. The downloaded videos were subsequently submitted to the NTSB Vehicle Recorder Laboratory in Washington, D.C., for additional review. The field of view of both videos show the front seat occupant (pilot) and a view of the right side of the weight-shift control aircraft. The weight-shift control bar, the right wing, and the right main landing gear were visible both videos. Additionally, the ground, sky, and horizon were visible in various portions of the recordings.

The first video was 9 seconds in duration and showed the aircraft taxiing on an unknown portion of the airport. The engine is heard operating at a low power setting as the weight-shift control aircraft moves along the taxiway at a moderate speed. The pilot is seen looking over his shoulder to the right and holding the weight-shift control bar. The cables associated with the weight-shift control bar appear to be intact and connected to the control bar.

The second video was 21 seconds in duration and depicts the weight-shift aircraft on takeoff roll, liftoff, and initial climb. The camera's initial view was forward and over the right shoulder of the pilot. The pilot is seen actively manipulating the weight-shift control bar. The same cable attachments that were viewed in the first video were still intact and connected to the control bar. The audio track recorded the engine was running steadily at a high rpm. The weight-shift aircraft became airborne about 3 seconds into the recording. The weight-shift control aircraft abruptly entered a steep left bank about 12 seconds after liftoff, with the right wingtip above the visible horizon. At one point of the recording, the right main landing gear was near level with the visible horizon. About 2 seconds after the abrupt left roll, the audio track recorded a reduction in engine power. The engine continued to operate at a low power setting for the remainder of the recording. The remaining video footage primarily showed the right main landing gear against the sky, and when the horizon was visible the right main landing gear was above the horizon. The recording ended with the weight-shift aircraft in a steep left wing down bank.

The wreckage was examined by a FAA airworthiness inspector and a representative of the engine manufacturer. The airplane had sustained significant impact-related damage to the forward cabin. The fuel tank contained automotive fuel premixed with two-cycle oil. The fuel shutoff valve was safety-wired in the open position. The engine, a Rotax 582, serial number 4656198, was rear-mounted and aft-facing. The engine remained attached to the fuselage mounts, and the 4-blade propeller remained attached to the propeller shaft. All 4 propeller blades exhibited impact-related damage. Several airframe and wing brace cables were found tightly wrapped around the propeller shaft, which is consistent with the engine operating at impact. There were no preimpact anomalies identified with the airplane fuselage, wing, or weight-shift control system.

The engine did not exhibit any crankcase or cylinder fractures, nor was there any evidence of oil leaks on the exterior engine components. The sparkplugs exhibited features consistent with normal engine operation. Both carburetors remained attached to their respective induction tubes, but the intake silencer airbox had separated from the carburetors. No contamination was observed in the carburetor bowls or their fuel screens and both carburetors had the correct metering jet installed. Internal engine and valve train continuity were confirmed as the engine crankshaft was rotated. Compression and suction were noted on both cylinders in conjunction with crankshaft rotation. The rotary induction valve was undamaged, and its lubrication reservoir contained ample oil. The cylinder walls, piston domes, piston skirts, and exhaust exhibited features consistent with normal engine operation. The engine was reassembled for an operational test run. The engine started and ran at various engine speeds without any hesitation or anomalies. The postaccident examination and engine test run revealed no evidence of a mechanical malfunction or failure that would have precluded normal engine operation.

Hospital records obtained from the initial treating institution indicated that the pilot was resuscitated, sedated, intubated, and placed on a ventilator to control his pain and allow his injuries to be evaluated. He was found to be critically injured and transferred for a higher level of care at another institution. The records indicated that the 57-year-old male pilot had a history of atrial fibrillation, Hepatitis C, chronic pain, and illicit drug use including methamphetamine, cocaine, and marijuana. The pilot also had previously reported drinking "a pint of brandy a day." Additionally, the pilot had been involved in another airplane accident about 10 years earlier that required surgery for a broken tibia.

Hospital records indicated that the pilot had a blood ethanol level of 0.046% about 40-60 minutes after the accident. Toxicological testing performed at the request of the Clark County Sheriff by the South Dakota Public Health Laboratory identified ethyl alcohol at 0.020 gm/dl, 628 ng/ml of benzoylecgonine, 35 ng/ml of methamphetamine, and a unspecified level of cannabinoids in peripheral blood samples that were obtained a couple hours after the accident.

Toxicology testing performed at the FAA Forensic Sciences Laboratory identified ethanol in urine at 0.019 gm/dl in a urine sample obtained in the hours following the accident. In addition, methamphetamine and its metabolite amphetamine, cocaine and its metabolites benzoylecgonine and cocaethylene, and tetrahydrocannabinol carboxylic acid were detected in urine. Cocaine, benzoylecgonine, methamphetamine, and 0.0114 μg/ml of tetrahydrocannabinol carboxylic acid were identified in peripheral blood samples obtained in the hours following the accident. Ketamine was detected in both blood and urine.

Ethanol is the type of alcohol present in beer, wine, and liquor. It is a social drug that acts as a central nervous system depressant. After ingestion at low doses, it impairs judgment, psychomotor functioning, and vigilance. Federal Aviation Regulations prohibits any person from acting or attempting to act as a crewmember of a civil aircraft while having 0.040 gm/dl or more alcohol in the blood. The effects of alcohol on aviators are generally well understood; alcohol significantly impairs pilots' performance, even at very low levels.

Methamphetamine is a central nervous system stimulant prescription medication available as a Schedule II controlled substance and is used medically to treat attention-deficit/hyperactivity disorder, attention deficit disorder, and narcolepsy. It is also frequently used illicitly; these users are seeking the intense euphoria produced by higher levels snort, smoke, or inject the drug. Its main metabolite is amphetamine, also a physiologically active sympathomimetic drug. In the early phase, users experience euphoria, excitation, exhilaration, rapid flight of ideas, increased libido, rapid speech, motor restlessness, hallucinations, delusions, psychosis, insomnia, reduced fatigue or drowsiness, increased alertness, a heightened sense of well-being, and poor impulse control. As the initial effects wear off users commonly experience dysphoria, restlessness, agitation, and nervousness; they may experience paranoia, violence, aggression, a lack of coordination, delusions, psychosis, and drug craving.

Cocaine is a central nervous system stimulant prescription medication available as a Schedule II controlled substance and is used medically as a topical solution to anesthetize the mucous membranes of the mouth and nasopharynx for medical or dental procedures. However, it is often used illicitly via snorting, smoking, or injection for its psychoactive effects. Benzoylecgonine is an inactive metabolite of cocaine. Cocaethylene is another inactive metabolite that only occurs when cocaine and ethanol are co-ingested. Cocaine is rapidly metabolized; its half-life is approximately 0.8 ± 0.2 hours, while the half-life of benzoylecgonine is 6 hours. Cocaine use acutely results in euphoria, excitation, feelings of wellbeing, general arousal, and increased sexual excitement; higher doses may result in psychosis, delusions, hallucinations, irritability, fear, paranoia, antisocial behavior, and aggressiveness. After the initial effects wear off, users may exhibit dysphoria, depression, agitation, nervousness, drug craving, fatigue, and inability to sleep.

Tetrahydrocannabinol carboxylic acid is an inactive metabolite of tetrahydrocannabinol, the active component in marijuana. Tetrahydrocannabinol has mood altering effects including inducing euphoria and relaxation, alterations in motor behavior, perception, cognition, and memory; it decreases ability to concentrate and maintain attention, and impairs hand-eye coordination, retention time, and tracking. Tetrahydrocannabinol concentrations typically peak during the act of smoking, while peak tetrahydrocannabinol carboxylic acid concentrations occur approximately 9-23 minutes after the start of smoking. Concentrations of both analytes decline rapidly and are often less than 0.005 μg/mL after 3 hours.

Ketamine is a non-barbiturate anesthetic available only in injectable forms and often used for sedation of critically ill patients in hospital settings.

Pilot Information

Certificate: None
Age: 57, Male
Airplane Rating(s): None
Seat Occupied: Front
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: None None
Last FAA Medical Exam:
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 

Aircraft and Owner/Operator Information

Aircraft Make: AIR CREATION
Registration: UNREG
Model/Series: CLIPPER 582
Aircraft Category: Weight-Shift
Year of Manufacture:
Amateur Built: No
Airworthiness Certificate:
Serial Number: Unknown
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection:  Unknown
Certified Max Gross Wt.: 995 lbs
Time Since Last Inspection:
Engines: 1 Reciprocating
Airframe Total Time: 284.5 Hours at time of accident
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

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: ATY, 1749 ft msl
Distance from Accident Site: 24 Nautical Miles
Observation Time: 1553 CDT
Direction from Accident Site: 87°
Lowest Cloud Condition: Few / 4800 ft agl
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: 5 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 40°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.88 inches Hg
Temperature/Dew Point: 31°C / 18°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Clark, SD (8D7)
Type of Flight Plan Filed: None
Destination: Clark, SD (8D7)
Type of Clearance: None
Departure Time: 1552 CDT
Type of Airspace: Class G

Airport Information

Airport: Clark County Airport (8D7)
Runway Surface Type: Asphalt
Airport Elevation: 1793 ft
Runway Surface Condition: Dry
Runway Used: 31
IFR Approach: None
Runway Length/Width: 3698 ft / 60 ft
VFR Approach/Landing: None

Wreckage and Impact Information

Crew Injuries: 1 Serious
Aircraft Damage: Substantial
Passenger Injuries: 1 Serious
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Serious
Latitude, Longitude: 44.895000, -97.710556 (est)

No comments: