Wednesday, April 15, 2020

Loss of Control in Flight: ICON A5, N922BA; fatal accident occurred November 07, 2017 in Clearwater, Florida

Airplane fuselage and cockpit sections found floating in the accident area.

DAC flight recorder during onscene recovery.

Exterior of DAC Data Memory Unit recorder after drying. 

Altitude and Airspeed Recovered from Icon DAC Data Module

Recorded DAC GPS Altitude Anomalies.

Angle-of-Attack and Load Factor Recovered from Icon DAC Data Module 

Multipath Error Associated with GPS Altitude Near Water 

Exterior of Rotax Engine Control Unit after drying. 

N922BA Icon A5 wreckage at the accident scene on the evening of November 7, 2017.
Pasco County Sheriff’s Office

Icon A5 wreckage during examination at the recovery yard.

Engine section (inverted) and empennage during examination.

Airplane wings (bottom) indicating leading edge impact damage.

Pilot’s harness system during successful functional test.

Airplane instrument panel with AOA indicator missing from the panel.

Rotax 912 iS Engine during examination.


 GPS flight track from October 26, 2017 data illustrated on a Google Earth image. The red track indicates a flight under the Sunshine Skyway Bridge in Florida. 

Logbook entry on October 31, 2017, stating flight under the Skyway Bridge.

Roy Halladay's Flight Log cover.

Bird Feather Analysis

Axillary feather (held with forceps) from accident #ANC18FA007 compared with a museum wing specimen of Double-crested Cormorant (USNM560556).

Tiny (5 mm) white feather found inter-twined in cotton sampling gauze from Sample #5 collected by Brice Banning. 

Twitter statement October 31, 2017

Photograph taken by Mr. Perkins using iPhone 7 Plus at 1202:51 EST.  Reportedly taken after the airplane had completed the turn.

Roy Halladay

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

Additional Participating Entities: 
Federal Aviation Administration / Flight Standards District Office; Tampa, Florida
Rotax Aircraft Engines; Vernon, British Columbia, Canada
Icon Aircraft Inc.; Vacaville, California
BRS Aerospace; Miami, Florida 

Aviation Accident Factual Report - National Transportation Safety Board:

Investigation Docket  - National Transportation Safety Board:

Location: Clearwater, FL
Accident Number:ANC18FA007 
Date & Time: 11/07/2017, 1204 EST
Registration: N922BA
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries:1 Fatal 
Flight Conducted Under: Part 91: General Aviation - Personal 

On November 7, 2017, about 1204 eastern standard time, an Icon Aircraft A5 special light sport amphibious airplane, N922BA, sustained substantial damage when it was involved in an accident near Clearwater, Florida. The private pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.

The airplane departed from Island Ford Lake in Odessa, Florida, about 1147. According to data from the Icon digital to analog (DAC) data memory unit that was installed on the airplane, the airplane climbed to a GPS altitude of 1,909 ft and proceeded north for 4 nautical miles (nm) before turning west toward the Gulf of Mexico. The airplane then flew for 10 nm at a GPS altitude of about 600 ft and descended over the gulf before turning south. During the final 3 minutes of the flight, the airplane was traveling in a southerly direction along the shoreline; figure 1 shows the flight track. During the last 2.5 minutes of the flight, the pilot conducted three maneuvers with high angles of attack (AOA) and load factors of almost 2 Gs; at that time, the airplane was over the water at GPS altitudes between 0 and 358 ft. During the final maneuver of the flight, the airplane entered a right turn, the engine power decreased, and the AOA reached 16°. The last recorded data point, at 1203:41, showed that the airplane's airspeed was 75 knots and heading was 354°.

Figure 1. Last 3 minutes of GPS flight track.

The airplane was also equipped with a Rotax engine control unit. The last recorded data point, at 1203:43, indicated an engine speed of 2,829 rpm and a throttle position of 27%.

Multiple witnesses in the area stated that they saw the airplane flying very low, between 5 and 300 ft, over the water as the airplane maneuvered south close to the shoreline. Some witnesses reported that the airplane was making steep turns and high-pitch climbs up to about 500 ft and that the engine sounded normal. A witness provided an image of the airplane over the water, as shown in figure 2. A commercial fisherman stated that the airplane flew over his vessel at an altitude that was less than 300 ft. Another commercial fisherman, who was located about 900 ft north of the accident site, stated that he observed the airplane flying from the north "really close" to houses. The airplane then flew south past his position, descended briefly, and climbed. After entering a steep climb, the airplane descended on an easterly heading in a steep nose-down attitude; the airplane's pitch attitude decreased as the airplane continued to descend. The witness reported that the airplane impacted the water in a 45° nose-down, wings-level attitude.

Figure 2. Still image of the accident airplane just before the crash (Courtesy of Mr. Fred Grunden.)

Pilot Information

Age: 40, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 05/25/2017
Occupational Pilot: No
Last Flight Review or Equivalent: 05/18/2016
Flight Time:   721.5 hours (Total, all aircraft), 51.8 hours (Total, this make and model), 507.6 hours (Pilot In Command, all aircraft), 42.5 hours (Last 90 days, all aircraft), 22.8 hours (Last 30 days, all aircraft)

The pilot had 14.5 hours of total flight experience in the accident airplane. The pilot made an entry into his logbook indicating that, while en route from the Peter O. Knight Airport in Tampa, Florida, to his home, he flew under the Skyway Bridge; the bridge has a 180-ft vertical clearance over the water. Recovered GPS data showed that the pilot flew under the bridge on October 26, 2017. A few days later, the pilot stated on social media, "flying the Icon A5 over the water is like flying a fighter jet!" 

Aircraft and Owner/Operator Information

Registration: N922BA
Model/Series: A5 NO SERIES
Aircraft Category: Airplane
Year of Manufacture: 2017
Amateur Built: No
Airworthiness Certificate: Special Light-Sport
Serial Number: 00022
Landing Gear Type: Amphibian
Seats: 2
Date/Type of Last Inspection: 10/10/2017, Condition
Certified Max Gross Wt.: 1510 lbs
Time Since Last Inspection: 15 Hours
Engines: 1 Reciprocating
Airframe Total Time: 46.5 Hours at time of accident
Engine Manufacturer: Rotax
ELT: Not installed
Engine Model/Series: 912iS
Registered Owner: N529PG LLC
Rated Power: 100 hp
Operator: On file
Operating Certificate(s) Held: None

The pilot accepted delivery of the airplane about 4 weeks before the accident. The airplane was equipped with an AOA indicator and a ballistic complete aircraft parachute (CAP) system.

The Icon A5/Pilot's Operating Handbook, section 2.7, indicated that the design maneuvering limits with flaps 0° and an airplane weight of 1,510 pounds were +4 and -2 G. (The accident airplane's takeoff weight was estimated to be 1,476 pounds.)

Section 2.16 stated that "there are no restrictions on the use of the CAP system. Optimal CAP actuation is from level flight above 500 ft AGL [above ground level]." Section 3.19 provided the following emergency procedures for a loss of control:

1. CAP Handle – PULL HARD

2. Ignition Key – OFF

Section 4.3 showed the After Cockpit Entry checklist, which included a step to remove and stow the CAP safety pin so that the pilot could activate the system quickly if necessary.

Section 7.2.1 stated the following:

A5 incorporates numerous features to help control the dynamics of stall and improve spin resistance, including blended wing shapes, stall strips and wing cuffs. Stall characteristics depend on a number of factors, the most important being rate of stall onset, which can affect the dynamics of stall progression along the span. The A5 remains controllable throughout these various stall progressions up to 30° bank angles, even when fully stalled.

Section 7.6.2 stated that the airplane's AOA system works "by using static ports to measure the difference in pressure from the top and bottom of the left wing near the leading edge. These values are compared and computed to drive the AOA indicator electronically." The section also stated that "the AOA gauge provides a visual indication of how hard the wing is working to generate lift and how much more lift it can supply at any given time." The face of the AOA gauge incorporates green, yellow, and red bands, as shown in figure 3, to indicate the available lift margin above stall. The Icon Sport Flying Academics manual indicated that, at the lower green band, the wing is not working hard, and lift forces are generated mostly by airspeed. The yellow band signifies that the wing is working harder (taking "a bigger bite" from the airflow); at the top of the yellow band, the wing will begin to stall. The red band begins at 15.6°, which is also shown in figure 3, and signifies an aerodynamic stall, at which point lift would begin to degrade.

Figure 3. AOA information from the Icon Sport Flying Academics information.

The A5 Sport Flying Operations manual discussed energy management as part of the low-altitude considerations section. The energy management discussion stated the following:

Recall that our energy state at any given time is defined by our altitude and airspeed. So at low altitudes our energy is determined almost completely by our airspeed. If we get slow at higher altitudes, we can just push over and trade altitude for airspeed. At low altitude the throttle is our only tool for maintaining or adding energy to our airplane. We said during our discussion of turn performance that 60-75 KIAS [knots indicated airspeed] was the sweet spot for maneuvering the A5, and this holds true at low altitude as well. Much below 60 KIAS we find ourselves at relatively low energy. The aircraft remains controllable but will be more sluggish and less responsive to our control inputs. Lower speed also means less stall margin – meaning our AOA is high and approaching aerodynamic stall. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: PIE
Distance from Accident Site: 19 Nautical Miles
Observation Time: 1153 EST
Direction from Accident Site: 150°
Lowest Cloud Condition: Clear
Visibility:  10 Miles
Lowest Ceiling: None
Visibility (RVR):
Wind Speed/Gusts: Calm /
Turbulence Type Forecast/Actual: / None
Wind Direction:
Turbulence Severity Forecast/Actual: / N/A
Altimeter Setting: 30.08 inches Hg
Temperature/Dew Point: 28°C / 19°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Odessa, FL
Type of Flight Plan Filed: None
Destination: Odessa, FL
Type of Clearance: None
Departure Time: 1147 EST
Type of Airspace: Class G 

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: 28.218333, -82.769444 (est) 

The airplane came to rest inverted in about 4 ft of water and was oriented on a 192° heading, as shown in figure 4. The empennage was separated and displaced forward of the wings. All major airplane components were located at the accident scene. The front fuselage and cockpit were highly fragmented, with pieces scattered within a 300-ft radius of the main wreckage.

Figure 4. Airplane wreckage at the accident scene.

The CAP system was not deployed, and the CAP cockpit handle pin was in its installed position. The fuselage canopy was located about 50 ft west of the wreckage with about 50% of the plexiglass fractured and missing. The left (pilot's) seat was separated from the fuselage. The pilot's three-point harness system was anchored securely to the left wall with the inertia reel intact, secure, and fully operable. The webbing exhibited fraying about 12 inches from the reel. The seatbelt buckle operated normally and locked in place when the tab was inserted.

The wings, wing tips, and nose section exhibited symmetrical fragmentation consistent with a wings-level impact. Both wings were attached and secured in the locked position.

Control continuity was established from the cockpit controls to the elevator, which exhibited full movement between stops. The torque tube was bent about 10° near the center; the forward pulley was intact with the bracket separated at the bond. The cables were traced through the system with no fractures. Secondary elevator stops were observed in place near the forward bellcrank. The pitch trim actuator rod remained intact. The pitch trim electrical connector remained attached to the torque tube, and all contact pins were intact.

Control continuity was established from the cockpit to the rudder through separations. The separations were consistent with overload.

Control continuity was also established from the cockpit controls to each aileron. All aileron pulleys displayed impact indentations but exhibited full roll movement. The secondary aileron stops were observed in place. The right wing root aileron bellcrank was displaced inboard about 6 inches from the airframe mount but remained attached to the cables. Both flaps and the flap handle were in the retracted position.

The fuel tank cap was secure, the fuel tank was breached by the engine throttle cable, and no fuel was present. The engine remained attached to the airframe. The engine was manually rotated at the propeller, and continuity and compression were established for each cylinder. The propeller remained attached to the crankshaft.

No preaccident anomalies were noted with the airframe or engine that would have precluded normal operation. 

Medical And Pathological Information

The Office of the Medical Examiner, District Six, Pasco and Pinellas Counties, Florida, performed an autopsy of the pilot. His cause of death was blunt trauma, and drowning was a contributory condition.

Toxicology testing performed at the Federal Aviation Administration (FAA) Forensic Sciences Laboratory identified the following drugs in the pilot's specimens:

Zolpidem was identified in the pilot's cardiac blood (0.088 µg/ml) and urine. Zolpidem is a sleep aid available by prescription as a schedule IV controlled substance that is often sold with the name Ambien. The drug information states the following:

Complex behaviors such as 'sleep-driving' (i.e., driving while not fully awake after ingestion of a sedative-hypnotic, with amnesia for the event) have been reported with sedative-hypnotics, including zolpidem. These events can occur in sedative-hypnotic-naive as well as in sedative-hypnotic-experienced persons. Although behaviors such as ''sleep-driving' may occur with zolpidem tartrate alone at therapeutic doses, the use of alcohol and other CNS [central nervous system] depressants with zolpidem tartrate appears to increase the risk of such behaviors.

Amphetamine was identified in the pilot's cardiac blood (2.2 µg/ml) and urine. Amphetamine is a schedule II controlled substance that stimulates the central nervous system. It is available by prescription for the treatment of attention deficit disorder and narcolepsy. It carries a boxed warning about its potential for abuse and has warnings about an increased risk of sudden death and the potential for mental health and behavioral changes. In some preparations, the prescription drug is metabolized to amphetamine; commonly marketed names in this category include Adderall, Dexedrine, and Vyvanse. After a single 30-mg oral dose, early blood levels averaged 0.111 µg/ml, and average blood levels in adults using the long-acting prescription orally for a week were about 0.065 µg/ml. Amphetamine is also prepared and used as a street drug that can be snorted, inhaled, or injected. Generally, levels above 0.2 µg/ml indicate amphetamine misuse to maximize the drug's psychoactive effects.

Morphine was identified in the pilot's cardiac blood (0.192 µg/ml) and urine. Morphine is a powerful opioid pain medication available as an injection, a tablet, or a capsule and is identified as a schedule II controlled substance. Ranges for therapeutic levels are typically determined by giving novice users one or two doses and measuring their blood levels; such ranges are 0.010 to 0.100 µg/ml. With regular opioid use, brain physiology changes, leading to tolerance for both the desired analgesic and sedative effects and resulting in increased dosing. Chronic users may need the drug to feel and act "normally"; thus, a chronic user may appear to function normally at levels that could be toxic or even fatal to a first-time user.

Fluoxetine and its metabolite norfluoxetine were identified in the pilot's cardiac blood (0.984 and 1.569 µg/ml, respectively) and urine. Fluoxetine is an antidepressant available by prescription. It carries the following warning:

As with any CNS-active drug, fluoxetine has the potential to impair judgment, thinking, or motor skills. Patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that the drug treatment does not affect them adversely. However, major depression itself is associated with significant cognitive degradation, particularly in executive functioning. The cognitive degradation may not improve even with remission of the depressed episode, and patients with severe disease are more significantly affected than those with fewer symptoms or episodes.

Baclofen was identified in the pilot's cardiac blood (0.72 µg/ml) and urine. Baclofen is a muscle relaxant available by prescription. It carries the following warning:

Because of the possibility of sedation, patients should be cautioned regarding the operation of automobiles or other dangerous machinery, and activities made hazardous by decreased alertness. Patients should also be cautioned that the central nervous system effects of baclofen may be additive to those of alcohol and other CNS depressants.

Hydromorphone was found in the pilot's urine. Hydromorphone is an opioid pain medication available by prescription as a schedule II controlled substance. Other common names are Dilaudid and Exalgo. Hydromorphone is also a relatively uncommon active metabolite of morphine and a common metabolite of hydrocodone, which is not a metabolite of morphine. Hydromorphone carries the following warning:

Hydromorphone and other Schedule II opioid agonists, including morphine, oxymorphone, oxycodone, fentanyl, and methadone, have the highest potential for abuse and risk of producing respiratory depression. Alcohol, other opioids and central nervous system depressants (sedative-hypnotics) potentiate the respiratory depressant effects of hydromorphone, increasing the risk of respiratory depression that might result in death.

Ibuprofen was found in the pilot's urine. Ibuprofen is an over-the-counter pain medication commonly sold as Motrin and Advil. It is not considered impairing.

No ethanol was detected in the pilot's vitreous specimens.

Review of the available personal medical records for the pilot indicated a history of substance abuse requiring inpatient rehabilitation twice between 2013 and early 2015 and diagnoses of chronic back pain, insomnia, and depression, which were treated with various prescribed medications. The pilot's personal medical records for 2016 and 2017 were not available.

Tests And Research

Airplane Performance Study

The data from the Icon DAC data memory unit and the Rotax engine control unit were used to evaluate the airplane's performance. The last second of data (11 recorded points) was not used in the study due to unreliable GPS altitude information.

The recorded data indicated that, at 1201:19, the pilot began a rapid climbing "S" turn from a GPS altitude of 0 to 134 ft and then descended to 36 ft; the airplane reached a maximum load factor of 1.94 Gs and a maximum AOA of 7.53°. At 1202:29, the pilot performed a second maneuver, a climbing right 360° turn from a GPS altitude of 19 to 136 ft; the airplane reached a maximum load factor of 1.93 Gs and a maximum AOA of 15.73°, which is within the red band on the AOA indicator (shown as an inset in figure 3).

At 1203:34, the pilot initiated a final maneuver: a climbing right turn from a GPS altitude of 210 ft and an indicated airspeed of 81 knots. The airplane's load factor increased rapidly to 1.91 Gs and then varied between 1 and about 2 Gs as the AOA increased steadily to 15°, which is at the top of yellow band on the AOA indicator. About 3 seconds after initiating the climb, the engine throttle lever was retarded from 99% to 27%, resulting in a corresponding decrease in engine speed from about 5,393 to 2,261 rpm. The lowest recorded indicated airspeed during the maneuver, 54 knots, occurred as the airplane reached a GPS altitude of 358 ft, the apex of the maneuver, with a low energy state. The computed bank angle exceeded 50° and the computed pitch angle exceeded 30° before the airplane descended toward the water.

Feather Study

Ten samples were recovered from the wreckage and were submitted to the Smithsonian Institution Feather Identification Laboratory for analysis. Two of the 10 samples contained feathers. No avian DNA was present in any of the samples. The airplane showed no impact damage that was consistent with a bird strike.

Additional Information

Minimum Safe Altitude

Title 14 CFR 91.119, Minimum Safe Altitudes, states in part that, except during takeoffs or landings, a pilot cannot operate an aircraft over "other than congested areas" below "an altitude of 500 feet above the surface, except over open water or sparsely populated areas. In those cases, the aircraft may not be operated closer than 500 feet to any person, vessel, vehicle, or structure."

Icon Aircraft Low-Altitude Flying Guidance

On May 8, 2017, an Icon Aircraft A5 impacted terrain while maneuvering near Lake Berryessa, California. The pilot and passenger were fatally injured, and the airplane was substantially damaged. The National Transportation Safety Board (NTSB) determined that the probable cause of the accident was "the pilot's failure to maintain clearance from terrain while maneuvering at a low altitude. Contributing to the accident was the pilot's mistaken entry into a canyon surrounded by steep rising terrain while at a low altitude for reasons that could not be determined." (For more information about this accident, see case number WPR17FA101 at the NTSB's website.)

According to Icon Aircraft management, as a result of that accident, a document titled "Low Altitude Flying Guidelines" was issued on October 23, 2017, and was distributed to A5 clients and owners. According to the chief executive officer of the company at that time, the document was created to emphasize some of the known hazards of flying light sport aircraft and provide mitigating solutions, even though that information was already available in company training and operating manuals. The company official stated that he "was certain" that the accident pilot received and reviewed the guidelines.

The preamble of the guidelines stated the following:

Low altitude…flying while exploring the planet in seaplanes and bush planes can be one of the most rewarding and exciting types of flying possible. Low altitude flying also comes with an inherent set of additional risks that require additional considerations. Traditional general aviation training focused on higher-altitude transportation flying does little to prepare pilots for the unique challenges of low altitude flying. This document is intended to help raise awareness and provide some time-tested guidelines and techniques for low altitude flying to help pilots cope with those additional challenges. These are not a substitute for FAA regulations or good judgment or training. Many of the guidelines and philosophies here were adopted from military, seaplane, and bush-flying techniques.

The guidelines reiterated the minimum safe altitudes in 14 CFR 91.119 and stated in part the following:

While good judgment and airmanship always takes precedence over any guidelines, the following maneuvering limits should generally be observed:

• Above Soft Deck [in general, 300 ft agl]: Normal, non-aerobatic maneuvering (+/- 60 bank +/- 30 pitch)

• Below Soft Deck: Benign maneuvering (+/- 45 bank +/- 10 pitch)

The guidelines also warned pilots "Do not show off."

Roy Halladay: Report of autopsy - autopsy findings:


  1. Obviously any accident or incident in aviation is unfortunate, but this guy was a flying prescription drug experiment.

    Sad to see this in aviation.

  2. thankfully he didnt take anyone else out

    1. He "took out" hundreds of millions of investors' dollars.

  3. Why do some people persist in taking drugs like this and then think they can fly safely ?

    1. Drug addiction may be similar to a heart attack. Knowing the definition of a heart attack doesn't prepare anyone when it occurs. Drugs taken over the years by major league players injured with multiple million dollar contracts along with sports physicians facilitating drug abuse tends to dull the senses over a long period of time. A false sense of normalcy may occur while hiding drug abuse. Flying may have been introduced early in Halladay's baseball career and followed thru as normal despite undergoing rehab. He may have felt perfectly fine and went out for a joy ride without considering his mental acuity degrading from illegal drugs. Most pilots know their limits. Those taking risks and end up as another NTSB statistic may live to realize their mistake or never survive a crash.


    1. From the docket- his family knew what was going on

  5. ^^That link is sad to read. The father knew his son had issues but apparently felt helpless in dealing with a grown man other than speaking words of warning that didn't register. Sad all the way around. Great aircraft, wrong personality behind the controls. I'd love to have one of these as a lake plane (no thank you to Florida salt water).

  6. He was a retired professional baseball player playing since a young child. The injuries, necessary surgeries and medications to keep going are probably not uncommon in professional athletics, sometimes already during their teenage years as see in my practice - and the pain and dysfunctions that come with it are felt for the rest of the life as one can find out from several in-depth articles over the past many years.
    What led to this, who thought and did what etc. is probably much more complex than our imaginations try to piece together from the few published pieces of information out there, including the NTSB docket. We only see the end, and - sorry for being blunt - who knows if that was an accident or a death wish.
    Professional sports is nothing but entertainment business and whatever gets out, whoever is interviewed, even in retirement long after the show and if closely enough connected, has been carefully curated, prepared, briefed and scripted to create an image of spontaneity, honesty, openness, innocence, naivety, sudden tragedy etc. when it is nothing like that.

  7. This is a terrible inditement on the aviation community as a whole - this guy (because he could hit a ball with bat ) is some sort of 'celebrity' and his accident is getting attention because of this.

    The sob stories about his medical condition and therefore he needed to be a walking pharmacy but somehow kept a licence is beyond belief.

    As for his father - a professional aviator who was concerned about his son's condition but left it at a few 'fatherly chats'... well, the father is culpable for endangering other peoples lives ( which fortunately didn't occur) by not reporting his sons attitude/condition to the FAA. He should hang his head in shame as this kind of media attention affects all the good people out there in GA.