NTSB Factual Report

HISTORY OF FLIGHT

On July 18, 2009, about 1205 Pacific daylight time, an experimental Weiss Lancair, N244RR, collided with terrain while maneuvering near Santa Clarita, California. The pilot/owner operated the airplane as a personal flight under the provisions of 14 Code of Federal Regulations Part 91. The pilot and one passenger were fatally injured; the airplane was substantially damaged. Visual meteorological conditions prevailed for the local area flight that departed the Whiteman Airport (WHP), Los Angeles, California, at an undetermined time. No flight plan had been filed.

One witness interviewed by law enforcement was in his back yard, and heard the sound of a low flying airplane. He thought that it might be a friend flying over, so he looked up and observed the airplane when it was just about over his property. He stated that he clearly heard the sound of an engine throttle reduction as the airplane went into a steep, almost vertical, climb. Near the top of the climb, he thought that it sounded like the engine power was reduced to idle. He thought that the airplane stalled during the vertical maneuver, and was falling backward. It appeared to him as if smoke was coming from the outward edge of the wingtips, as if the pilot were performing some type of aerobatics. He estimated that the airplane tumbled two or three times before it ended up in a downward spiral. It made two rotations in the spiral at a 45-degree angle until it impacted a roadway. He could clearly see the rudder and ailerons moving until the impact, and felt that the pilot was manipulating them in an attempt to regain control. He thought that the engine was at idle power the entire way down.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed that the 43-year-old pilot held a private pilot certificate with a rating for airplane single-engine land. The pilot held a third-class medical certificate issued on May 12, 2008. It had the limitations that the pilot must wear corrective lenses.

No personal flight records were located for the pilot. The National Transportation Safety Board investigator-in-charge (NTSB IIC) obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. The pilot reported on his medical application that he had a total time of 285 hours with zero (0) hours logged in the last 6 months.

AIRCRAFT INFORMATION

The airplane was an experimental Weiss Lancair, serial number JC003. The engine was a Textron Lycoming IO-360-M1B, serial number L-31004-51A. Total time recorded on the airframe and engine was approximately 100 hours since new.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest upright in a drainage ditch on the 27000 block of Triumph Avenue, a residential street, in Santa Clarita. The propeller assembly, cowling, and portions of the cockpit area came to rest about 5 feet forward of the main wreckage. The main wreckage consisted of the engine, which remained attached to the airframe, the cockpit, wings, fuselage, and tail section. All of the primary flight control surfaces were accounted for, and a visual examination of the engine revealed no evidence of a catastrophic mechanical malfunction.

MEDICAL AND PATHOLOGICAL INFORMATION

The Department of Coroner, County of Los Angeles (LA), did not perform an autopsy due to family objection recorded on July 21, 2009. The coroner identified the immediate cause of death as multiple traumatic injuries. Toxicology specimens were obtained and sent the Forensic Science Laboratories for the LA County Corner, as well as to the FAA. The toxicology test conducted by the LA County Coroner yielded positive results for buprenorphine; 18 ng/gm. According to the LA County Sheriff's department report, a bottle of buprenorphine was found in the wreckage; the physician listed on the bottle was contacted for additional information. According to the report, the physician indicated that he had been treating the pilot for "approximately the past two years for heroin addiction," and he confirmed that he had in fact prescribed buprenorphine, 15mg per day.

Review of the records maintained on the pilot by the FAA Aerospace Medical Certification Division revealed that the pilot's most recent application for a third-class medical certificate, issued on May 12, 2008, indicated "NO" in the response to "Do you Currently Use Any Medication" and to "Substance dependence."

The FAA Forensic Toxicology Research Team, Oklahoma City, performed toxicological testing of specimens of the pilot. Analysis of the specimens for the pilot contained no findings for ethanol detected in the liver or muscle. They did not perform tests for carbon monoxide or cyanide.

The report contained the following findings for tested drugs: 0.083 (ug/ml, ug/g) buprenorphine detected in the liver, 0.0124 (ug/ml, ug/g) buprenorphine detected in the kidney, and norbuprenorphine detected in kidney and liver.

TESTS AND RESEARCH

Wreckage Exam

The NTSB IIC, an FAA inspector, and an investigator from Textron Lycoming examined the wreckage at Aircraft Recovery Service, Chino, California, on August 10, 2009. A report of their findings is part of the public docket. They discovered no mechanical anomalies that would have precluded normal operation of the engine. Due to the damage to the forward bottom section of the engine, rotation of the crankshaft was not performed. The rocker box covers were removed, as well as the top spark plugs. The spark plugs remained secure at each position with its respective spark plug lead attached. The spark plugs were removed; the electrodes were mechanically undamaged, and when compared to the Champion Aviation Spark Plug check-a-plug chart AV-27, the spark plug electrodes displayed coloration consistent with normal operation. The oil filter was cut open exposing the filter media; there was no metal contamination observed on the filter.

An examination of the combustion chamber for each cylinder was performed via a lighted borescope. No mechanical damage was noted to the combustion chambers, and no evidence of foreign object ingestion; the vales were intact and undamaged. Both of the magnetos were displaced from their respective mounting pads. Manual rotation of the left magneto produced spark at all four leads. Resultant impact damage rendered the right magneto inoperative and it could not be functionally tested.

The two-bladed Hartzell constant speed propeller assembly, along with the crankshaft flange, separated from the engine. The propeller blades remained secure in their respective hub sockets. Both propeller blades exhibited leading edge damage, chordwise scratching along the length of the blades, and some S-bending. The crankshaft fracture surface was angular and granular, consistent with torsional overload.

The airplane was equipped with an Advanced Flight Systems, Inc., AF3000, serial number 60706 primary flight display (PFD) glass cockpit instruments, and an Advanced Flight Systems ACS 2002 Engine Monitor (EM), serial number 30070, which was shipped to the NTSB's research and engineering division for examination. The AF3000 has a liquid crystal display (LCD) that shows the pilot the airplane's altitude, heading, navigation, moving map, airway and approach database, engine and airplane's fuel status on a one page selectable cockpit display. The software version installed on the unit allowed it to record approximately 10 discrete data parameters to the internal non-volatile memory. The ACS2002 was also an LCD display that showed the pilot various airplane engine and fuel status on a page selectable cockpit display. The software installed on the accident unit was older and did not support recorded engine data to the internal non-volatile memory.

This system included the accident flight along with the global positioning system (GPS) coordinates, both of which were recorded once every 5 seconds. A vehicle recorder's specialist extracted data from the accident flight, and the last few minutes were plotted using local time (from 1203:56 to 1205:42). Parameters plotted included pitch, roll, groundspeed in knots, and pressure altitude.

All of the parameters were relatively stable until 1205:21. At that time, the pitch was about 6 degrees nose up; groundspeed was 170 knots; and the pressure altitude was 4,400 feet. The pitch decreased, and was about 62 degrees nose low at 1205:32. The groundspeed remained at 170 for 6 seconds, and then decreased to 0 knots by 1205:32. The pressure altitude went to 4,700 feet and then decreased to 4,200 feet at 1205:31, and reached its lowest value of 2,300 feet at 1205:42.

NTSB Probable Cause

The pilot's failure to maintain adequate airspeed and control while maneuvering.