NTSB Factual Report

HISTORY OF FLIGHT

On September 7, 2014, approximately 1545 central daylight time, an experimental amateur-built Cismowski Tierra II airplane, N622MC, impacted terrain near the Montevideo-Chippewa County Airport (MVE), Montevideo, Minnesota. The private pilot and one passenger were fatally injured. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as personal flight. Day visual flight rules conditions prevailed for the flight, which did not operate on a flight plan. The local flight was originating from MVE at the time of the accident.

According to a witness that watched the airplane take off from the runway at MVE, the airplane climbed to 200-300 feet above ground level and then it leveled off. The airplane then started to make a left turn and suddenly the right wing went "straight up." He reported that it was "almost like it was hit by a gust of wind." The airplane "did a 1/2 turn" and then descended straight down into the ground. He called 911 and then went to check on the individuals in the airplane. First responders subsequently found the wreckage in a soybean field about 1/2 mile south of MVE.

PERSONNEL INFORMATION

The 52-year-old pilot held a Federal Aviation Administration (FAA) private pilot certificate with a single-engine land airplane rating. His FAA third-class medical certificate was issued on June 26, 2007, with a limitation for corrective lenses. On his application for that flight physical, the pilot reported that he had accumulated 150 hours of total flight time and he reported that he had accumulated 5 hours of flight time in the six months prior to that exam. The application indicated that he was 73 inches tall and weighed 257 pounds.

An inspection all of the available information that the family members were able to locate and bring to the FAA for review revealed no records regarding flight times or currency of the pilot.

AIRCRAFT INFORMATION

N622MC was an experimental amateur-built Cismowski Tierra II, two-place, single-engine, high-wing airplane with serial number 622020. According to the accident airplane's data plate information, it was powered by a Rotax 582 engine with serial number 3971817. The data plate indicated that the airplane's empty weight was 383.5 pounds and it had a gross weight of 800.75 pounds.

According to an airframe and powerplant mechanic, the airplane arrived at the MVE in the spring of 2014 on a trailer after sitting in a hanger for four to five years. Between June and September of 2014, the airplane's wings were installed with new bolts at spar to fuselage attach points and new bolts at wing strut to fuselage attach points. The rudder, elevator, and stabilator were installed with new bolts and nuts as needed. The mechanic supplied a list of other airframe and engine maintenance that was completed during this time period. After all work above was completed, airplane was tied down and test run for 30 minutes to check cooling system, exhaust temperature, fuel supply, and overall condition of the engine systems.

The mechanic was told by the owner that the airplane had new covering, newer (thicker wall) front spars, and closer rib spacing than the older version had. The owner indicated to the mechanic that the modifications were accomplished before the airplane had sat for four to five years in a hanger. The mechanic reported that there was a list of items to be installed and an airplane weight and balance update to be conducted before the condition inspection would have been complete. These items had not been completed at the time of the accident.

There were no additional records found for the aircraft that showed inspection and maintenance status.

METEOROLOGICAL INFORMATION

At 1554, the recorded weather at MVE was: Wind 230 degrees at 10 knots gusting to 14 knots; visibility 10 statute miles; sky condition clear; temperature 27 degrees C; dew point 11 degrees C; altimeter 30.00 inches of mercury.

AIRPORT INFORMATION

MVE was a public, non-towered airport, which was owned by the city of Montevideo, Minnesota. It was located about two miles north of Montivedo. The airport had a surveyed elevation of 1,034 feet above mean sea level. Two runways, 14/32 and 3 /21 serviced the airport. Runway 14/32 was a 3,999 feet by 75 feet runway with an asphalt surface. Runway 3/21 was a 2,361 feet by 165 feet runway with a turf surface.

WRECKAGE AND IMPACT INFORMATION

A FAA inspector conducted an on-scene investigation. He reported that the airplane damage appeared to be substantial with extensive damage to the nose and forward fuselage and damage to outer four to five feet of left wing leading edge. The observed damage appeared to be consistent with a nose and left wing low impact with the ground. Two of the three propeller blades were broken off near its propeller hub. The entire fuselage exhibited tubing structure damage. The nose landing gear was broken off. About one quarter cup of fuel drained from the fuel line below the fuel tank. The drained fuel appeared to be clean, uncontaminated, and had a blue/green color consistent with fuel that is mixed with oil for two-cycle engine applications. Flight control continuity was observed to all of the airplane flight control surfaces. Both cylinders appeared to have compression when the propeller was turned by hand. There was no observed evidence of preimpact failure of aircraft structure, engine, propeller, or controls.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Ramsey County Medical Examiner's Office. The autopsy listed multiple traumatic injuries as the cause of death.

The FAA Civil Aerospace Medical Institute (CAMI) prepared a Final Forensic Toxicology Accident Report. The report, in part, indicated:

0.2033 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Lung

0.0475 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Liver

0.0094 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Blood (Cavity)

0.3965 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Liver

0.2142 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Urine

0.0507 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Lung

0.041 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Blood (Cavity)

The National Transportation Safety Board Chief Medical Officer reviewed the CAMI findings, FAA documents, and autopsy. According to these items, the pilot reported no chronic medical conditions and no medications to the FAA. He was issued a third class medical certificate limited by a requirement to wear corrective lenses. His medical certificate was no longer valid after June 31, 2009. However, the accident airplane met the criteria for a light sport aircraft and no medical certificate was required.

The autopsy determined that the pilot weighed 274 pounds. The pilot's heart was enlarged. However, no coronary artery disease was identified and the remainder of the cardiac evaluation was unremarkable.

In addition to CAMI's testing, toxicology testing performed by NMS Labs at the request of the medical examiner identified tetrahydrocannabinol (THC) (0.041 ug/ml) and tetrahydrocannabinol carboxylic acid (THC-COOH) (0.050 ug/ml) in the pilot's peripheral blood.

According to details in the CAMI description of Marijuana and in a National Highway Traffic Safety Administration technical report titled Drugs and Human Performance Fact Sheets, THC is a psychoactive drug with therapeutic levels as low as 0.001ug/ml. THC concentrations typically peak during the act of smoking, while peak metabolite concentrations occur approximately 9-23 minutes after the start of smoking. Concentrations of both decline rapidly and are often < 0.005 ug/mL at 3 hours. Peak plasma THC concentrations ranged from 0.046-0.188 ug/mL in 6 subjects after they smoked 8.8 mg THC over 10 minutes. Most behavioral and physiological effects return to baseline levels within 3-5 hours after drug use, although some investigators have demonstrated residual effects in specific behaviors up to 24 hours. Psychomotor impairment can persist after the perceived high has dissipated.

ADDITIONAL DATA/INFORMATION

According to data plate indications on the accident airplane, the airplane's calculated useful load was 417.25 pounds. According to the driver's license for the passenger, his weight was 290 pounds. Using the pilot's autopsy weight, the total calculated weight of the occupants would be 564 pounds, which would put the aircraft at approximately 146.75 pounds over the airplane's placarded gross weight without taking into consideration fuel weight.

A kit manufacturer's representative, in part, stated that other than typical training expectations, there is no kit manufacturer recommended flight training and that the airplane is a very easy and forgiving airplane to fly.

NTSB Probable Cause

The pilot's impaired judgment due to the use of marijuana, which led to his improper decision to fly the airplane over its maximum gross weight and his subsequent loss of airplane control during takeoff with gusting wind conditions.