NTSB Factual Report

HISTORY OF FLIGHT

On October 5, 2017, about 1830 eastern daylight time, an experimental amateur-built Ultra Pup airplane, N484HC, collided with terrain following a go-around at Samuels Field Airport (BRY), Bardstown, Kentucky. The private pilot was fatally injured, and the airplane was substantially damaged. The airplane was registered to and was being operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Day, visual meteorological conditions existed near the airport, and no flight plan was filed for the local, personal flight, which originated about 1815.

A pilot-rated witness spoke to the pilot before the flight, and the pilot told him this was his first flight in the airplane. The witness reported that he saw the airplane in a left traffic pattern for runway 3 at BRY, and the pilot was seated in the aft cockpit seat; the first approach appeared normal. He added that, during the landing flare, the pilot appeared to be "over controlling the plane," and the pilot subsequently performed a go-around without touching down. The airplane remained in the traffic pattern for a second approach. The witness momentarily went inside the airport's fixed-base operator, and when he returned to the ramp, he saw the airplane about two-thirds of the way down the runway. As the airplane neared the departure end of the runway, it did not appear to be climbing the rate of the previous two departures. The witness added that, as the airplane passed the departure end of runway 3, the right wing dropped, and the airplane appeared to "go straight down at a high rate of speed with the nose generally pointing east." The airplane descended behind a stand of trees and then reappeared with the nose slightly up and pointing generally north before it disappeared behind the trees for a second time and then crashed. The engine sounded normal during the entire flight.

PERSONNEL INFORMATION

The pilot held a private pilot certificate with an airplane single-engine land rating. According to the Federal Aviation Administration (FAA), the pilot did not hold a current medical certificate. On an October 2, 2014, application for an FAA second-class medical certificate, he reported 800 hours of total flight experience. The application was denied by the FAA for physical and mental health reasons, and the pilot did not repeal the denial. For additional information, see the section in this report titled "MEDICAL AND PATHOLOGICAL INFORMATION."

A review of the pilot's logbook revealed that he had no recent flight experience, and no logged flights in the accident airplane were recorded; his most recent flight review was recorded on September 14, 1992.

AIRCRAFT INFORMATION

The high-wing, single-engine, two-seat, tandem-cockpit airplane had a tailwheel landing gear. The airplane was equipped with a Revmaster 2100-D, 65-horsepower reciprocating engine, which was modified for aviation applications from a Volkswagen air-cooled engine core. The engine was fitted with a Tennessee Propellers fixed-pitch wooden propeller. The airplane was not equipped with wing flaps or a stall warning system. The airplane was built in 2013, and the pilot purchased it in May 2017 from its previous owner. The total airframe time was 54.3 hours. A condition inspection was completed on September 22, 2016, at 52.4 hours total time.

METEOROLOGICAL INFORMATION

At 1835, Addington Field Airport, Elizabethtown, Kentucky, located about 18 miles west of the accident site, recorded weather that included wind calm, visibility 10 statute miles, scattered clouds at 11,000 ft, temperature 25°C, dew point 15°C, and altimeter setting 30.13 inches of mercury. BRY was not equipped with weather measuring or recording equipment.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed in a soybean field about 1,635 ft northeast of the departure end of runway 3. The airplane came to rest in a near vertical, nose-down attitude at the location of initial ground impact. All airplane components were accounted for at the accident site.

All primary flight control surfaces remained attached. Flight control cable continuity was confirmed to all flight controls. The elevator control cables were observed attached to the aft bell crank at the torque tube and at the forward push-pull tube under the floor. The rudder control cables were observed attached to the rudder bellcrank at the empennage and at the rudder pedals at the cockpit area. The right and left aileron control cables were connected to the attachment points on both ailerons. All cables were attached at the control sticks. The balance cable was intact.

The fuselage frame was buckled immediately aft of the aft cockpit seat. The forward fuselage frame was crushed against the engine, and the engine firewall was crushed against the engine and engine mount. The aft seat four-point harness straps were cut by rescue personnel. The seatbelt buckle remained connected.

The rudder was undamaged. The upper rudder hinge pin was in place; however, the cotter pin was missing. The vertical stabilizer was undamaged. The horizontal stabilizer and elevator were undamaged.

The left wing leading edge was twisted in an upward direction about 15°. The left wing tip fairing was broken and held on by wing skin. Forward-to-aft crushing signatures were noted on the left wing leading edge. The left wing fuel tank was intact, and no fuel was present. The left wing lift struts remained attached and were undamaged.

The right wing leading edge was twisted downward about 20°. Forward-to-aft crushing signatures were noted on the right wing leading edge. The right wing fuel tank was intact, and about 1 gallon of clean, blue fuel was recovered from the tank. The right wing lift struts remained attached and were undamaged.

The lines from both fuel tanks were found disconnected and were leaking fuel. The fuel shutoff valve had separated from the instrument panel and was found loose in the wreckage, and its preaccident position could not be determined. All fuel lines from the wing tanks to the engine were clear and unobstructed. The fuel tank vents were unobstructed. Clear, blue fuel was found in the fuel gascolator. Fuel was observed in the strainer bowl, and no water or debris were present. The fuel tank caps were securely attached and undamaged.

The elevator trim control cable was continuous from the trim lever at the rear cockpit seat position to the trim tab. The trim lever was full aft, and the tab was full down; however, there was deformation of the area due to impact.

The main landing gear (MLG) remained attached to the fuselage. The support struts on both MLG were bent and broken. The main tires remained attached. The main tire wheel brakes appeared normal. The tailwheel assembly was attached and operable.

Engine examination revealed that the carburetor remained secured to the engine. The intake system remained attached to the carburetor. The air filter was clean and unobstructed. The four spark plugs were removed for inspection. The fine wire electrodes were normal in wear and color when compared to a Champion Check-A-Plug chart. The engine crankshaft was rotated by hand-turning the propeller hub. No internal restrictions or unusual noises were noted. Compression and suction were observed on all cylinders, and valve action was correct. The ignition harness leads were intact and undamaged. The magneto was not removed or examined due to airframe damage. The engine case contained oil. The mixture and throttle cables remained attached. The wooden propeller blades had separated at the hub and were found in multiple pieces at the accident site.

MEDICAL AND PATHOLOGICAL INFORMATION

The Office of the Chief Medical Examiner, Louisville, Kentucky performed the autopsy of the pilot. The cause of death of the pilot was attributed to "blunt force injuries of the head, torso, and extremities."

The FAA's Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. Testing was negative for carbon monoxide and ethanol. Testing was positive for the antidepressant sertraline (0.118 µg/mL) and its metabolite desmethylsertraline (0.316 µg/mL) in the blood and liver.

According to personal medical records obtained from the Veterans Administration, the pilot had obsessive compulsive disorder, depression/anxiety (not further specified), paroxysmal atrial fibrillation/supraventricular tachycardia, and chronic obstructive pulmonary disease. He had also had a hernia and had undergone back surgery.

During the 8 months preceding the accident, the pilot had additional health issues. He had fallen in February 2017 and fractured a small area of the posterior wall of his acetabulum (hip socket), which was treated conservatively and resolved. He also struck his left elbow, which caused a tiny chip fracture, but the elbow developed an infection several months later, and surgery was required to remove the infected tissue. His prostate specific antigen rose significantly, and he required a biopsy that was complicated by significant bleeding (the result was negative). He developed a tear in his retina that required laser surgery, and because of persistent symptoms, he was scheduled to have a cataract removed in November 2017. As part of the evaluation of his eye symptoms, he underwent an ultrasound evaluation of his carotid arteries, which identified an early stenosis of his right carotid (when more severe, these stenoses can lead to strokes); he was considering additional medical treatment.

The pilot regularly visited a mental health counselor. At his last visit on September 5, 2017 (1 month before the accident), he told the counselor that things had gone "from bad to worse" in terms of his anxiety and stress, primarily due to his recent medical issues. His coping mechanism was to retreat to the "dark and quiet" of his basement when he was overwhelmed. The counselor found him anxious with logical thought content but rated his judgment and insight as "fair."

NTSB Probable Cause

The pilot's improper decision to initiate a flight in an airplane he had never flown and with no currency in any airplane nor a medical certificate, which resulted in his loss of airplane control. Contributing to the accident was the pilot's psychiatric disease, which likely affected his decision-making and judgment.