Sunday, November 10, 2019

Visual Flight Rules Encounter with Instrument Meteorological Conditions: Zenith Zodiac 601XL, N929GB; fatal accident occurred December 21, 2017 in Thompson's Station, Williamson County, Tennessee

Jerry Elton Travis
Jerry was a retired pipeline welder and was a veteran of the United States Marine Corps. Jerry was an airplane enthusiast. 
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The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Nashville, Tennessee
Australian Transport Safety Board

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


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


http://registry.faa.gov/N929GB



Location: Thompson's Station, TN
Accident Number: WPR18FA053
Date & Time: 12/21/2017, 1307 CST
Registration: N929GB
Aircraft: BROWNING GREGORY S ZODIAC 601XL
Aircraft Damage: Substantial
Defining Event: VFR encounter with IMC
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On December 21, 2017, about 1307 central standard time, a Zodiac 601XL experimental, amateur-built airplane, N929GB, was substantially damaged when it impacted terrain while maneuvering at low altitude near Thompson's Station, Tennessee. The sport pilot sustained fatal injuries. The airplane was owned by the pilot, who operated it as a Title 14 Code of Federal Regulations Part 91 personal cross-country flight. Instrument meteorological conditions prevailed at the time of the accident, and no flight plan was filed for the flight, which departed Bomar Field-Shelbyville Municipal Airport (SYI), Shelbyville, Tennessee, about 1230, with an intended destination of Whifferdill Airport (TN77), Chapmansboro, Tennessee.

According to a family member, the pilot completed the 57-nautical-mile flight from TN77 to SYI a few weeks earlier to have an autopilot system installed in the airplane. On the day of the accident, the family member drove the pilot to SYI so the pilot could fly the airplane back to TN77. The owner of the maintenance facility where the work was completed stated that he was surprised to see the pilot, as the pilot had not informed him of his intention to pick up the airplane that day. Additionally, the weather conditions were well below visual flight rules (VFR) minimums. The maintenance facility owner asked the pilot if he had looked at the weather, to which the pilot replied that it was improving, and it would be fine. The maintenance facility owner then informed the pilot that the current weather at SYI was 400 ft overcast and not good for flying and that Nashville, located almost directly between SYI and TN77, was reporting the same. When he suggested that the pilot come back and get the airplane after the weather had improved, the pilot replied, "No. I will get it today. The weather is fine, and I know the area I am flying to." The owner subsequently assisted the pilot with fueling the airplane; airport records revealed that the pilot purchased 8.5 gallons of 100LL aviation fuel.

The maintenance facility owner saw the pilot board the airplane; after starting the engine, the pilot taxied the airplane away from the ramp, then turned the airplane onto the taxiway. The pilot did not perform a pretakeoff engine run up. He advanced the throttle to full power, and, about 3 to 4 seconds later, as the airplane accelerated in its takeoff roll, the maintenance facility owner saw dust flying and heard the airplane rattling loudly as it departed the left side of the taxiway into the grass; the airplane continued through the grass. The maintenance facility owner reported that, during the departure, "…the engine sounded to be running wide open." He heard "a very loud bang" just before the airplane became airborne, as if the airplane had hit something. During the initial climb, the airplane entered a very high nose-up attitude and appeared to be "wallowing" left and right. The maintenance facility owner also stated that, at this time, he could clearly see something venting from the left wing, which he thought may have been fuel. As the airplane continued to climb, its nose lowered, and it gained speed as it proceeded south at low altitude. Before reaching the south end of the runway, the airplane entered a steep left turn at an altitude about 200 ft above ground level (agl) while reversing course to a northwest heading.

A witness about 0.3 mile north of the accident site reported that he saw a small, white airplane with red trim flying west about 1/4-mile ahead of him. The witness stated that the airplane had just cleared the high-tension power lines that cross the highway between 150 ft and 200 ft agl. When he first observed the airplane, it was flying northeast to southwest, parallel to and directly above the highway. As the airplane flew over his location, he heard the engine running at high rpm as the airplane continued to fly toward the west. The witness mentioned that, at this time, he saw the airplane dip slightly then pull up in a banking turn; he was not sure which direction it was turning.

About 35 minutes after departing SYI, the airplane impacted a stand of trees and terrain about 35 nautical miles northwest of SYI on a magnetic heading of about 120°. The airplane came to rest upright and mostly intact just off a rural residential road, on a magnetic heading about 130°. A first responder who lived nearby reported that she heard a very loud noise outside of her residence, after which she saw that an airplane had crashed. She stated that the weather in the area at the time of the accident consisted of low clouds about treetop level with very limited visibility. 


Pilot Information

Certificate: Sport Pilot
Age: 78, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s):None 
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Sport Pilot With Waivers/Limitations
Last FAA Medical Exam: 04/04/2005
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time: 1000 hours (Total, all aircraft), 10 hours (Total, this make and model) 

The sport pilot had previously possessed a private pilot certificate, which he surrendered in 2012 following an airplane accident. His most recent Federal Aviation Administration third-class medical certificate was issued on April 4, 2005, with a limitation for corrective lenses and that the certificate was not valid for night flying or by color signal control. On the application for that certificate, the pilot reported 1,000 total hours of flight experience, with 25 hours in the previous 6 months.

A flight instructor, who reported that the accident pilot contacted him for transition training in the accident airplane, stated that he provided the pilot 2 hours of training over a 2-week period in November 2016. The next time he saw the pilot was on February 15, 2017, when he was again scheduled for training. When the pilot arrived, instead of doing the training as scheduled, the pilot stated that he was taking the airplane home; the instructor told him that was not a good idea. Two hours later, the pilot called the instructor to inform him that he had made it home. The instructor stated that he typically requires 5 hours of transition training for a signoff, which the pilot did not want to pay for. The instructor stated, " He was behind the airplane; it was too fast for him. He could not judge distance, and he was always cutting the [traffic] pattern short and low." 


Aircraft and Owner/Operator Information

Aircraft Make: BROWNING GREGORY S
Registration: N929GB
Model/Series: ZODIAC 601XL XL
Aircraft Category: Airplane
Year of Manufacture: 2009
Amateur Built: Yes
Airworthiness Certificate: Special Light-Sport; Experimental
Serial Number: 66785
Landing Gear Type: Tricycle
Seats: 2
Date/Type of Last Inspection: 10/10/2017, Condition
Certified Max Gross Wt.: 1300 lbs
Time Since Last Inspection: 1 Hour
Engines: 1 Reciprocating
Airframe Total Time: 541.5 Hours as of last inspection
Engine Manufacturer: JABIRU
ELT: C91A installed, activated, did not aid in locating accident
Engine Model/Series: 3300A
Registered Owner: On file
Rated Power: 160 hp
Operator: On file
Operating Certificate(s) Held: None

The accident airplane was a two-seat, side-by-side, low-wing, tricycle-gear airplane with a maximum gross weight of 1,300 lbs and an empty weight of 695 lbs. The airplane was equipped with two wing fuel tanks with a total capacity of 24 gallons. According to maintenance records, the airplane's most recent condition inspection was performed on October 10, 2017, at a total time of 541.5 hours.

The airplane was also equipped with a Jabiru 3300A, six-cylinder, horizontally opposed, air-cooled, direct-drive, reciprocating engine, serial number 33A1341, capable of developing 120 horsepower at 3,300 rpm. It was also equipped with a Sensenich 2-blade propeller, model W64ZK49. The engine had accumulated about 541.5 hours total time since the most recent condition inspection.

Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: BNA, 600 ft msl
Distance from Accident Site: 26 Nautical Miles
Observation Time: 1303 CST
Direction from Accident Site: 44°
Lowest Cloud Condition: Unknown
Visibility:  10 Miles
Lowest Ceiling: Overcast / 100 ft agl
Visibility (RVR):
Wind Speed/Gusts: 9 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 120°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 30.03 inches Hg
Temperature/Dew Point: 13°C / 11°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Shelbyville, TN (SYI)
Type of Flight Plan Filed: None
Destination: Chapmansboro, TN (TN77)
Type of Clearance: None
Departure Time: 1230 CST
Type of Airspace: Class G

The Surface Analysis Chart for 1200 showed a west-to-east-oriented stationary front in northern Tennessee immediately north of the accident location. Station models in the area identified overcast sky conditions and generally southerly winds of 10 knots or less; some models denoted dew point depressions of 0°C.

An Automated Weather Observing System (AWOS) located at SYI, about 34 miles southeast of the accident site at an elevation of 800 ft indicated overcast ceilings between 1,100 and 1,400 ft agl, visibilities of 10 statute miles or greater, and dew point depressions of 2°C during the times surrounding the accident.

An AWOS located at Maury County Airport (MRC), Columbia, Tennessee, about 17 miles south-southwest of the accident site at an elevation of 681 ft indicated overcast ceilings between 400 and 600 ft agl, visibilities from 7 statute miles to 10 statute miles or greater, and dew point depressions of 0°C during the times surrounding the accident.

Weather observations from John C. Tune Airport (JWN), Nashville, Tennessee, about 23 miles north-northeast of the accident location at an elevation of 501 ft, identified overcast ceilings between 600 and 800 ft agl, visibilities from 8 to 10 statute miles or greater, and dew point depressions of 1°C and 2°C during the times surrounding the accident.

An Area Forecast Discussion (AFD) was issued at 1147 by the NWS Weather Forecast Office in Nashville, Tennessee. The Aviation section of that AFD stated:

Widespread IFR ceilings have been slow to lift and expected to generally remain this way, although some breaks into MVFR are likely later this afternoon, at least for a few hours. IFR expected to redevelop later this evening and overnight ahead of precipitation that will overspread the region early Friday. This activity will initially begin light, possibly as drizzle, then increase in intensity by late Friday morning and last through much of the day and evening. Prolonged IFR or LIFR is likely through this time.

(For additional information, refer to the NTSB Weather Study, which is appended to the docket for this accident.)

There was no record of the pilot having obtained a weather briefing prior to departure.


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: 35.819167, -87.046944 

The airplane came to rest intact except for the main landing gear and some small pieces of fuselage. First responders reported the presence of fuel upon initial arrival at the accident site.

The initial impact point was a stand of trees about 60 ft high and about 115 ft northwest of the main wreckage site. The second impact point, about 35 ft southeast of the first impact point, was with another stand of trees about 40 ft high. The airplane subsequently came to rest upright in an open field next to a residential rural dirt road.

Postaccident examination of the airframe and engine revealed no mechanical anomalies that would have precluded normal operation.

An iFLY 740 portable GPS, serial number VH16050313, and a Lowrance AIRMAP 1000 GPS receiver, serial number 100660358, were sent to the NTSB Vehicle Recorder Division for examination and potential data download.

Examination of the iFLY 740 revealed that data extracted from the unit included about 3 minutes 39 seconds of the accident flight data. The data corresponded to the flight's takeoff, but the recording ended shortly thereafter, possibly due to the device being powered off.

The Lowrance AIRMAP 1000 contained data from 41 previous flights, none of which were associated with the accident. 

Medical And Pathological Information

The Office of the Medical Examiner, Center for Forensic Medicine, Nashville, Tennessee, conducted an autopsy on the pilot. The cause of death was determined to be "multiple blunt force injuries." The autopsy revealed a significantly enlarged heart with left ventricular and septal hypertrophy. Additionally, the pilot had significant coronary artery disease with a stent in the right coronary artery. The mid left circumflex coronary artery showed up to 75% narrowing and the mid left anterior descending and proximal first diagonal coronary arteries each showed 50% and 60% narrowing, respectively. Interrogation of a Medtronic implanted defibrillator did not identify evidence of a heart rhythm that would have resulted in defibrillation around the time of the accident.

Toxicology testing performed at the FAA's Forensic Sciences Laboratory was negative for ethanol and carbon monoxide. Testing for drugs revealed the following: Naproxen was detected in urine; metoprolol, rosuvastatin were detected in urine and blood; clonazepam was detected in urine and blood; 0.019 (µg/mL, µg/g) amino-clonazepam (7-) was detected in blood and a nonquantified amount was in urine; 0.332 (µg/mL, µg/g) sertraline was detected in blood and a nonquantified amount was in urine; 0.418 (µg/mL, µg/g) desmethylsertraline was detected in blood and a nonquantified amount was in urine, and clopidogrel detected in blood and urine.

Naproxen is a non-narcotic pain medication, metoprolol is a blood pressure medication, clopidogrel is a blood thinner, and sertraline is an antidepressant. These medications are generally considered not to be impairing. The potentially impairing Schedule IV benzodiazepine (clonazepam) and its metabolite were detected below quantifiable/therapeutic levels.

On September 18, 2017, the pilot's family physician worked with the pilot's caregiver to coordinate rehabilitation care due to weakness following a knee replacement. The patient was not present for the evaluation, but the caregiver, stated that the pilot was often short-tempered and impulsive, would occasionally hear something that no one else did, and needed help with directions while driving along a route that he traveled many times. Based on this history, the physician wrote in the pilot's medical record that the pilot had possible early dementia with heightened impulsivity. The physician referred the pilot to a rehabilitation center and prescribed 0.5 mg clonazepam with up to 2 pills every 12 hours. The patient terminated care with the physician's office on October 11, 2017, when he was told the physician was not available to refill medications; no additional primary care treatment records were available.

Records from the rehabilitation center from September 20 through October 4, 2017, were reviewed. The pilot was admitted due to progressive weakness at home following his total knee replacement. During his stay, he underwent physical therapy and his strength and mobility improved. He was noted to have anxiety treated with clonazepam. Neurologic and psychiatric examinations during his rehabilitation documented no abnormalities; however, the pilot declined a formal neuropsychiatric evaluation during his rehabilitation stay. He was discharged to outpatient physical therapy. No additional post-rehabilitation progress or neuro-psychiatric evaluations were available.

12 comments:

Anonymous said...

just glad this idiot didn't take anyone with him.

KV said...

Long read, found the instructor comments (midway through the article) and doctor's diagnosis (near the end) shed some light on what was going on.

Anonymous said...

Agitation and short temperament in those over 50 is most definitely a sign of early dementia. Add on his other health issues and heart disease, and this man had no business being in the air at all, sport license (another red flag*) or otherwise. RIP Marine and thank you for your service.

*Unlike getting a full PPL, you are never "under the hood" in training with a sport license to get you out of IFR conditions in a pinch nor is the aircraft you are flying required to be IFR capable.

Anonymous said...

Seriously, why did the NTSB spend $$$ to investigate this man’s accident beyond the interviews with the instructor and AMT ?

Anonymous said...

Sounded like he was a "ticking time bomb" and he finally went off. Glad there wasn't any collateral damage. Semper fi, RIP

Anonymous said...

If his sport license would have been pulled he probably would have continued to fly until the bitter end - just glad he didn't hurt anyone on the ground.

Anonymous said...

He surrendered his PPL in 2012 after an accident. Anyone know what accident that was?

KV said...

2012 Accident: Sonex N484PC @ TN77 Whifferdill
Crashed it into trees on takeoff.

https://aviation-safety.net/wikibase/148829

Anonymous said...

If I ever get this bad mentally I hope someone will just tie me to a rope and leave me in the back yard.

Anonymous said...

Too funny!
"If I ever get this bad mentally I hope someone will just tie me to a rope and leave me in the backyard."

KV said...

It was a family member that drove him to the airport with 400 foot overcast overhead.

Anonymous said...

This guy is my new hero. Taking off from a taxiway, bouncing down the grass, hitting something, and then launching nonetheless. Ride 'em, cowboy! I have $5 he was screaming "yeeeeeeeeeeehaw!!!!!" as he was on his takeoff roll!

And why not? He didn't have much time left anyway, and he got one last flight in.

Mad props!