Aviation Investigation Final Report Location: Bonita Springs, Florida Accident Number: ERA18FA064 Date & Time: January 22, 2018, 12:14 Local Registration: N262WS Aircraft: VANS AIRCRAFT INC RV-12 Aircraft Damage: Destroyed Defining Event: Aircraft structural failure Injuries: 1 Fatal Flight Conducted Under: Part 91: General aviation - Personal Analysis The sport pilot departed on the visual flight rules (VFR) cross-country flight under day visual meteorological conditions and climbed the airplane to 2,500 ft. While on the ground and during the climb and cruise portions of the flight, the pilot missed or did not respond to numerous radio calls from air traffic controllers, deviated from assigned altitudes, and used improper radio terminology. Data from onboard the airplane indicated that, throughout the flight, the pilot operated the airplane within the yellow airspeed caution range in excess of its maximum structural cruise speed of 108 knots. About 4 minutes before the accident, he began a descent toward the destination airport. When the controller advised the pilot of nearby traffic, the pilot responded that he was looking. The airplane's pitch then increased slightly nose-up, followed by a significant pitch change to 45° nose-down and a right roll of 37°. The pilot transmitted "mayday, mayday." The roll continued through inverted and the airspeed eventually increased to 169 knots, which was 33 knots in excess of the airplane's never-exceed (redline) speed. During the final 10 seconds of recorded data, the engine speed varied between 4,550 and 5,950 rpm (redline rpm was 5,800). The wreckage debris path and fracture signatures on the left wing indicated that it failed in-flight in a positive (wing up) direction, striking the airplane's canopy while departing the airplane. The wing spar fracture surfaces were consistent with overload with no evidence of preexisting corrosion or fatigue. It is likely that the wing failure occurred as the airplane descended and exceeded its redline speed. Although the airplane did not have a current condition inspection, there was no evidence of any preexisting mechanical malfunction or anomaly with the airplane or engine. The pilot did not possess a Federal Aviation Administration (FAA) medical certificate, nor was he required to in order to exercise the privileges of a sport pilot. According to personal medical records, he had been diagnosed with hypertension, high cholesterol, obstructive sleep apnea, neurogenic bladder, cataracts, peripheral neuropathy, depression, and post-traumatic stress disorder. It would have been the pilot's responsibility to report any medical deficiency that would interfere with the safe performance of sport pilot operations to the FAA; however, he did not do so. An autopsy of the pilot revealed an enlarged and thickened heart and significant coronary artery disease with about 50% to 75% narrowing of both the left main and left anterior descending coronary arteries. While possible, it could not be determined if the pilot experienced an acute cardiac event that may have affected his ability to control the airplane. Toxicology testing identified three different potentially impairing psychoactive medications in specimens of the pilot. What effects the pilot may have experienced from the use of this combination of medications could not be determined; additionally, the pilot's mental state at the time of the accident could not be established. Overall, the pilot's coronary artery and significant psychiatric disease put him at risk for distraction and inattention that could have led to the accident circumstances. His unreported psychiatric disease, if not well-controlled, could have led to intentionally unsafe maneuvering. Whether the effects from multiple psychoactive medications contributed to the accident could not be determined, but it was evident that, based on his interaction with air traffic controllers, the pilot was not performing at a competent level. While the exact cause of the pilot's behavior could not be determined, given the lack of mechanical anomalies or weather phenomena that could explain the accident sequence, it is likely that his underlying physiologic or psychiatric disease resulted in his exceedance of the airplane's operating limitations, which led to an in-flight failure of the left wing while maneuvering. Probable Cause and Findings The National Transportation Safety Board determines the probable cause(s) of this accident to be: The pilot's unsafe maneuvering and exceedance of the airplane's operating limitations, which resulted in an in-flight failure of the left wing. Contributing to the accident was the pilot's underlying physiologic or psychiatric disease. Findings Aircraft Spar (on wing) - Capability exceeded Personnel issues Aircraft control - Pilot Personnel issues Use of medication/drugs - Pilot Personnel issues (general) - Pilot Factual Information History of Flight Maneuvering Aircraft structural failure (Defining event) Uncontrolled descent Collision with terr/obj (non-CFIT) On January 22, 2018, about 1214 eastern standard time, an experimental light sport Van's Aircraft, Inc., RV-12, N262WS, was destroyed when it collided with terrain near Bonita Springs, Florida. The pilot was fatally injured. The airplane was privately owned and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Day, visual meteorological conditions prevailed, and no flight plan was filed for the flight, which originated at Page Field (FMY), Fort Myers, Florida, about 1148 and was destined for Everglades Airpark (X01), Everglades City, Florida. According to air traffic control (ATC) voice communications and radar data obtained from the Federal Aviation Administration (FAA), at 1146, the pilot contacted the FMY local controller and requested flight following to X01. At 1158, the pilot was instructed to fly runway heading and was cleared for takeoff. At 1200, the FMY controller instructed the pilot to contact departure control. The pilot did not respond. The controller repeated the instructions and the pilot again did not respond. The controller then called the departure controller, who reported that the pilot had not contacted them after departure. The controller called the pilot a third time and he did not respond. At 1201, the pilot contacted the Southwest Florida International Air Traffic Control Tower east radar controller. The controller directed the pilot to turn right to a heading of 170º and maintain 2,500 ft mean sea level (msl). At 1202, the pilot asked the controller to repeat the instruction. The controller repeated the instruction, and at 1202:03, the pilot responded, "course one two zero stay at twenty-five hundred." The controller responded, "November two six two whiskey sierra I don't have time to talk to you four times per control instruction cause there's a lot going on please listen up…" At 1203, the pilot climbed the airplane to 2,900 ft and then was instructed to return to 2,500 ft; the pilot acknowledged without using the airplane's call sign. The controller reminded the pilot to use his call sign when responding to instructions. At 1209, the controller instructed the pilot to contact approach control. The pilot responded that he could hear the controller, "but I can't understand you can you say it slower?" At 1210:39, the pilot contacted Fort Myers approach. At 1213:49, the approach controller stated to the pilot, "November two whiskey sierra traffic twelve to one o'clock six miles northeast bound altitude indicated two thousand six hundred." The pilot responded that he was looking for the traffic. Six seconds later, the pilot transmitted, "Mayday, mayday." No additional calls were received from the pilot and radar and radio contact were lost shortly thereafter. The airplane was equipped with a Dynon FlightDEK D180 wide screen display mounted in the cockpit, which recorded various flight, aircraft systems, and engine data throughout the accident flight. The display was recovered and the data was downloaded by NTSB Vehicle Recorders Laboratory specialists. During the cruise portion of the flight, the indicated airspeed exceeded 108 knots on several occasions, and frequently fluctuated between 108 and 116 knots. Interpolation of radar and recorded data revealed that the airplane descended out of 2,500 ft at 1210, about the same time that the pilot contacted the departure controller. The airplane continued to descend for about 4 minutes, and the airspeed stayed generally between 108 and 120 knots and engine rpm remained between 5,500 and 5,700 (red line rpm was 5,800). About the time the pilot reported that he was looking for traffic (1213:58), there was a small increase in pitch and the airplane slowed to about 103 knots. Over the next 7 seconds, the airplane pitched down from 5.25º nose low to 44.75º nose low, the right roll increased to 37.5º, and the airspeed increased from 104 to 136 knots; the pilot then made the "mayday" call. The airplane continued to roll right past inverted, and the airspeed increased to 169.25 knots before the end of the recording. During the final 10 seconds of recorded data, the engine speed varied between 4,550 and 5,950 rpm. The elapsed time from the mayday call to the end of the recording was about 8 seconds. Pilot Information Certificate: Sport Pilot Age: 68,Male Airplane Rating(s): Single-engine land Seat Occupied: Left Other Aircraft Rating(s): None Restraint Used: 5-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: January 6, 2017 Flight Time: 530 hours (Total, all aircraft), 130 hours (Total, this make and model) The pilot, age 68, held a sport pilot certificate with airplane single-engine land privileges. According to the FAA, the pilot never held an FAA medical certificate, nor was he required to as a sport pilot. The pilot's logbook contained entries from February 12, 2015, through January 10, 2017. No flight times were forwarded from a previous logbook. There was an endorsement for a flight review dated January 6, 2017. According to information provided by the pilot's insurer, the pilot reported, as of January 12, 2018, 530 total hours flight experience, including 130 hours in the RV-12, and 10 hours in the preceding 12 months. Aircraft and Owner/Operator Information Aircraft Make: VANS AIRCRAFT INC Registration: N262WS Model/Series: RV-12 NO SERIES Aircraft Category: Airplane Year of Manufacture: 2011 Amateur Built: Airworthiness Certificate: Experimental light sport (Special) Serial Number: 120262 Landing Gear Type: Tricycle Seats: 2 Date/Type of Last Inspection: July 24, 2016 Condition Certified Max Gross Wt.: 1320 lbs Time Since Last Inspection: Engines: 1 Reciprocating Airframe Total Time: 95 Hrs as of last inspection Engine Manufacturer: Rotax ELT: C126 installed, activated, did not aid in locating accident Engine Model/Series: 912 ULS Registered Owner: On file Rated Power: 100 Horsepower Operator: On file Operating Certificate(s) Held: None The all-metal, two-place, low-wing, single-engine, experimental light sport airplane incorporated a fixed tricycle landing gear. The airplane was equipped with a Rotax 100-horsepower reciprocating engine, and a Sensenich ground-adjustable composite propeller. The removable wings were built around a main spar that connected to the center section bulkhead. The wings were secured with two removable pins. The airplane was built in 2011 and the pilot purchased it in 2017. The total airframe time was 190.4 hours. A condition inspection was completed on July 24, 2016, at 95.0 hours total time. The mechanic who performed the 2016 condition inspection continued to perform maintenance on the airplane until about 3 months before the accident. At that time, he was at the pilot's hangar, escorted there by the pilot's wife, to perform another condition inspection. During the inspection, he noted a crack near the trailing edge of the elevator. He was on the phone discussing the crack with Van's Aircraft personnel when local law enforcement officers arrived and demanded that he leave the premises. He complied and did not complete the inspection nor did he make a logbook entry for the work in progress. He did not know why the officers asked him to leave. He attempted to find someone to finish the inspection, but he was unsuccessful. According to the Pilot's Operating Handbook, the maximum structural cruise speed (Vno) was 108 knots, the caution band was 108 to 136 knots, and the never exceed speed (Vne) was 136 knots. Meteorological Information and Flight Plan Conditions at Accident Site: Visual (VMC) Condition of Light: Day Observation Facility, Elevation: FMY,17 ft msl Distance from Accident Site: 18 Nautical Miles Observation Time: 11:53 Local Direction from Accident Site: 325° Lowest Cloud Condition: Clear Visibility 8 miles Lowest Ceiling: None Visibility (RVR): Wind Speed/Gusts: 9 knots / Turbulence Type Forecast/Actual: / None Wind Direction: 140° Turbulence Severity Forecast/Actual: / N/A Altimeter Setting: 30.11 inches Hg Temperature/Dew Point: 26°C / 18°C Precipitation and Obscuration: No Obscuration; No Precipitation Departure Point: Fort Myers, FL (FMY ) Type of Flight Plan Filed: None Destination: Everglades City, FL (X01 ) Type of Clearance: VFR flight following Departure Time: 11:48 Local Type of Airspace: FMY was located about 18 nautical miles (nm) northwest of the accident site. The FMY weather at 1153 included wind from 140º at 9 knots, 8 statute miles visibility, clear sky, temperature 26°C, dew point 18°C, and altimeter setting of 30.11 inches of mercury. Wreckage and Impact Information Crew Injuries: 1 Fatal Aircraft Damage: Destroyed Passenger Injuries: Aircraft Fire: None Ground Injuries: N/A Aircraft Explosion: None Total Injuries: 1 Fatal Latitude, Longitude: 26.338611,-81.663612(est) The airplane impacted a forested area about 33 nm northwest of X01. There was no fire. The wreckage debris field was oriented in a south-to-southwest direction and measured about 715 ft long and about 100 ft wide. All components of the airplane were accounted within the wreckage debris field. The first piece of wreckage found along the debris path was the left wing. Adjacent to the left wing were fragments of the cockpit canopy. The left wing was located about 670 ft north-northeast of the main wreckage. The flaperon separated into three sections. The inboard section remained attached to the wing. The center and outboard sections were found in close proximity to each other, about 410 ft south- southeast of the left wing. The main wing spar was fractured at the wing root. The spar was bent in an upward direction at the area of fracture. All fracture surfaces of the left wing spar exhibited characteristics of overload. No areas of corrosion were found on or near the fracture surfaces. The main wreckage consisted of the fuselage, the inboard half of the right wing, and the empennage. These sections came to rest against trees and were highly fragmented. The engine and propeller were separated and found within the fuselage debris. The empennage was adjacent to the fuselage and the vertical stabilizer was still partially attached. The rudder was separated and found adjacent to the vertical stabilizer. The outboard section of the right wing was found about 55 ft northeast of the fuselage. The aft section exhibited impact signatures consistent with tree contact. The right stabilator was impact-separated and found about 137 ft northeast of the main wreckage. The left stabilator was impact-separated and found about 83 ft northeast of the main wreckage. The painted surfaces of the right stabilator exhibited brown transfer marks consistent with tree impact. The wreckage was recovered to a storage facility for additional examination. Flight control continuity was confirmed from all flight control surfaces to the cockpit controls. All separations and fractures to cables and control rods exhibited overload signatures or were cut by recovery personnel. The flap handle was found in the retracted position. The autopilot pitch servo was located intact in its mount beneath the right seat pan. The servo arm remained connected to the control column, with no deformation of bolts or rod end bearings at either the servo or the control column attach points, and the servo rod was undamaged along its entire length. The servo linkage was disconnected from the control column, and the pitch servo moved freely in rotation. The shear pin on the servo was intact. All associated wiring was examined for fraying or rubbing, and for loose connections. None were found. A single, 20-gallon fuel tank was installed. The fuel shutoff handle/valve assembly was separated during the impact sequence and a pre-accident position could not be determined. The fuel tank was breached and no fuel was present. All recovered fuel lines were clear and unobstructed. Fuel tank filler cap was in place and secure. The filler neck and sheet metal surrounding the filler neck were separated during the impact sequence. The fuel pump/strainer was opened for examination. There was no fuel in the bowl; however, there was an odor of fuel on the filter. A small amount of organic matter, identified as a fragment of pine straw, was found inside the bowl. The engine was examined at the wreckage recovery facility. Both carburetors separated from the engine during the impact sequence. One carburetor was impact-damaged and its fuel bowl was separated and found loose in the wreckage; it was dry and clean inside. The floats were missing. The other carburetor's fuel bowl was intact and secure; when removed, it contained no fuel and was clean and dry. The composite floats were intact. The engine-driven fuel pump was separated from the engine due to impact forces. The pumping mechanism operated when the pump actuator was pushed in manually. No fuel pumped from the unit when actuated. The Nos. 2 and 4 cylinder valve covers exhibited impact damage; the No. 4 cover was broken open from impact forces, exposing the internal components. The four top spark plugs were removed for examination. The electrodes were normal in wear and color when compared to a Champion Check-A-Plug chart. The engine contained an undetermined amount of oil. Due to impact damage, the engine could not be rotated manually and internal continuity could not be established. The propeller separated from the engine with the splined shaft still attached to the propeller hub. One composite blade was separated at the hub; the other remained mostly intact and the tip was separated. The pilot was wearing a five-point harness. The anchors were separated from the cockpit structure during the impact sequence. The buckle and clips were found connected and operated normally. The seat and harness were found outside the area of main wreckage, about 30 ft south of the fuselage. Medical and Pathological Information The Office of the State of Florida, District 21 Medical Examiner performed the autopsy of the pilot. The cause of death was multiple blunt force injuries. The heart was enlarged and thickened; it weighed about 60 grams more than that of an average man of his weight. There was significant coronary artery disease with about 50% to 75% narrowing of both the left main and left anterior descending coronary arteries. The FAA Forensic Sciences Laboratory performed toxicology testing on specimens from the pilot. Testing was negative for carbon monoxide and ethanol. Naproxen was identified in the urine. Atenolol was identified in the liver. Citalopram, its metabolite N-desmethylcitalopram, mirtazapine, and trazodone were detected in cavity blood and in the urine. Naproxen is an analgesic available over-the-counter or by prescription, often with the names Aleve® and Naprosyn®. Atenolol is a blood pressure medication that may also be used to reduce the risk of recurrent heart attacks. Neither of these are considered impairing. Citalopram is an antidepressant often sold under the name Celexa® that carries a precaution for patients that it impairs mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). It has not been shown to degrade performance in psychological testing experiments using healthy volunteers. Mirtazapine is another prescription antidepressant commonly marketed with the name Remeron®. It is well known to cause somnolence (sleepiness) in the majority of people using it and carries the precaution, "Mirtazapine may impair judgment, thinking and particularly, motor skills, because of its prominent sedative effect. The drowsiness associated with mirtazapine use may impair a patient's ability to drive, use machines, or perform tasks that require alertness. Thus, patients should be cautioned about engaging in hazardous activities until they are reasonably certain that mirtazapine therapy does not adversely affect their ability to engage in such activities." Trazodone is another antidepressant that is sedating enough that it is often prescribed as a sleep aid. It carries this information for prescribers: "Antidepressants may impair the mental and/or physical ability required for the performance of potentially hazardous tasks, such as operating an automobile or machinery; the patient should be cautioned accordingly. Trazodone hydrochloride may enhance the response to alcohol, barbiturates, and other central nervous system depressants." 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. Thus, depression is a disqualifying condition for pilot medical certification. According to the Guide for Aviation Medical Examiners, an aviation medical examiner should not issue a medical certificate to a depressed pilot. The FAA will consider a special issuance of a medical certificate for depression after six months of treatment if the applicant is clinically stable on one of four approved medications. Records from the pilot's usual source of care, the Veterans Administration, for the period between January 2015 and the accident date were obtained and reviewed. The records documented that the pilot had hypertension, high cholesterol, obstructive sleep apnea, neurogenic bladder, cataracts, peripheral neuropathy, depression, and post-traumatic stress disorder (PTSD). At the time of his last annual exam (March 2017), he was prescribed atenolol and lisinopril to treat his blood pressure, simvastatin for his cholesterol, use of a continuous positive airway pressure (CPAP) machine for his sleep apnea, and citalopram and trazodone for his psychiatric disease. Records indicated that the pilot complained of worsening symptoms from PTSD, including nightmares and intrusive thoughts, during the end of 2016 and early 2017. This was apparently brought on by legal issues. The underlying issue was that the pilot had been discovered misrepresenting his military service, which had been revealed on the internet by a group he considered "terrorists." The pilot was facing charges for repeatedly breaking the conditions of a restraining order regarding threatening the wife of the individual who revealed his misrepresentation. The pilot's wife told investigators that she was unaware that her husband was being treated for mental health issues. Administrative Information Investigator In Charge (IIC): Hicks, Ralph Additional Participating Persons: Timothy Annis; FAA/FSDO; Tampa, FL Vic Syracuse; Van's Aircraft; Aurora, OR Original Publish Date: April 8, 2020 Last Revision Date: Investigation Class: Class Note: The NTSB traveled to the scene of this accident. Investigation Docket: https://data.ntsb.gov/Docket?ProjectID=96636 The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in other modes of transportation— railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable causes of the accidents and events we investigate, and issue safety recommendations aimed at preventing future occurrences. In addition, we conduct transportation safety research studies and offer information and other assistance to family members and survivors for each accident or event we investigate. We also serve as the appellate authority for enforcement actions involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and US Coast Guard, and we adjudicate appeals of civil penalty actions taken by the FAA. The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are not conducted for the purpose of determining the rights or liabilities of any person” (Title 49 Code of Federal Regulations section 831.4). Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report (Title 49 United States Code section 1154(b)). A factual report that may be admissible under 49 United States Code section 1154(b) is available here.