NTSB Factual Report

HISTORY OF FLIGHT

On June 7, 2014, about 1121 central daylight time, an experimental, amateur-built, Hermann Bjorn Lancair IV, N86NW, was destroyed when it impacted Lake Superior after departing from the Duluth International Airport (DLH), Duluth, Minnesota. The pilot, the sole occupant, received fatal injuries. The airplane was registered to A.O. Engineering Inc. and operated by the pilot under the 14 Code of Federal Regulations Part 91 as a personal flight. Marginal visual meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) flight plan was filed. The airplane departed DLH about 1116, and was en route to Goose Bay (YYR), Newfoundland, Canada.

The DLH air traffic control (ATC) transcript of the recorded radio conversations between ATC and the pilot indicated that the tower controller cleared the airplane to depart runway 9 and climb to 6,000 ft on a heading of 060 degrees. At 1117:24, the pilot contacted departure control. Departure control instructed the pilot to turn left and fly direct to Thunder Bay (YQT), and climb and maintain 12,000 ft. The pilot did not acknowledge this instruction. At 1117:25, the radar track data indicated the airplane was heading northeast at 4,467 ft at an airspeed of 131kts.

At 1118:00, departure control stated, "November 86 November Whiskey turn left fly heading 030 please." The pilot responded, "November Whisky left turn. Sorry about that." At 1118:03, the radar track data indicated the airplane was heading to the southeast at 4,689 ft at an airspeed of 167 kts.

At 1118:31, departure control stated, "And, ah Lancair 6 November Whiskey, it will be direct Yankee Quebec Tango present position. Direct present position." The pilot responded, "Present position direct Yankee Quebec Tango." There were no further recorded radio transmissions from the pilot. At 1118:31, the radar track data indicated that the airplane was heading to the northeast at 5,011 ft at 152 kts. The airplane continued on a northeasterly heading until 1119:46 when it started to turn right to a southeasterly heading.

At 1120:14, the airplane was heading to the south, southeast at 6,050 ft at 161 kts. At 1120:17, departure control stated, "November 86 November Whiskey, I still show you, ah, heading southeast bound. Verify you're direct to Yankee Quebec Tango."

At 1120:33, the airplane was heading to the south at 6,350 ft at 118 kts. At 1120:34, departure control stated, "November 86 November Whiskey, it appears you're heading southbound now. Ah, verify you're direct to Yankee Quebec Tango please."

At 1120:52, the airplane's last radar return was recorded. It indicated that the airplane was heading southbound at 2,400 ft at 201 kts.

At 1120:56, departure control stated, "November 86 November Whiskey, ah. Low altitude alert. Check your altitude. Immediately climb and maintain three thousand, immediately."

At 1121:05, departure control stated, "(unintelligible) 86 November Whiskey, climb. Altitude. Immediately maintain six, ah, maintain three thousand, three thousand."

The airplane impacted Lake Superior about 1 mile offshore from Brighton Beach, in Duluth, Minnesota. The airplane wreckage was located in 137 ft of water. The body of the pilot was retrieved from the wreckage on June 9, 2014.

PERSONNEL INFORMATION

The pilot was a 47 year-old German citizen who held a Federal Aviation Administration (FAA) commercial pilot certificate with single-engine land, multi-engine land, single-engine sea, and instrument airplane ratings. He held a third class medical certificate dated October 16, 2013, with the limitation for corrective lenses. The pilot's flight logbook was not obtained during the investigation. During his medical examination in October 16, 2013, the pilot reported that his total flight time was 2,500 hours. He had an estimated 22 hours of flight time in the accident airplane.

A witness who knew the pilot for 15 years reported that the pilot was an accomplished general aviation pilot with about 3,000 flight hours. He reported that the accident pilot had purchased a Mooney M20F in 1998 and had made several overseas flights in it, including trips across the South Atlantic and North Atlantic routes.

Aircraft records indicated that the accident pilot purchased the airplane on November 4, 2013. Witnesses who lived in Bend, Oregon, where the airplane was kept in a hangar, reported that the accident pilot received about 3 – 4 hours of airplane ground instruction after he purchased the airplane. It was not determined if the pilot received any dual flight instruction in the airplane. Witness statements and fuel receipts indicated that the accident pilot flew the airplane in December, January, February, and June, including a round trip flight from Bend, Oregon, to Las Vegas, Nevada.

On June 6, 2014, the day before the accident flight, the pilot flew the airplane from Bend, Oregon, to DLH. The time en route was about 4 hours and 32 minutes. The pilot planned to fly to YYR on the day of the accident. Flight planning documents indicated that the pilot planned to fly to Baden Airpark (EDSB) in Rheinmunster, Germany.

AIRCRAFT INFORMATION

The airplane was an experimental, amateur-built, Hermann Bjorn Lancair IV, serial number LIV-552, manufactured in 2005. The airplane was powered by a 750 shaft-horsepower Walter turbo-prop engine manufactured in 1992. The engine was subsequently rebuilt and reconfigured as a Walter XM601E-Prototype with a new serial number of 921012EX in 2003 identifying it as being manufactured specifically for the Lancair installation. The propeller was an Avia propeller which had a steel hub with three aluminum blades. The last conditional maintenance inspection was conducted on September 20, 2013, with a total airframe time of 666.3 hours.

The airplane was equipped with two Chelton CFR Sierra-SV Synthetic Vision Integrated Display Units (IDUs) used for primary flight display (PFD) and multifunction display (MFD), an Avidyne FlightMax Entegra MFD, and Garmin 530 and Garmin 430 radio and nav/com units. In addition, the airplane was equipped with standby flight instruments which included an airspeed indicator, attitude indicator, altimeter, and turn and bank indicator located in the center of the instrument panel.

The accident pilot installed a rubber auxiliary fuel bladder in the back seat of the airplane. The accident pilot sent an email dated March 17, 2014, that he expected that a new bladder tank from TurtlePac should arrive at the hangar where the airplane was kept. It's uncertain when the pilot installed the fuel bladder, but it was observed in the airplane prior to the accident. The lineman at the fixed base operator at DLH reported that the black colored fuel bladder located in the back seat was filled with 60 gallons of fuel on the morning of June 7, 2014. Both wing fuel tanks were also topped off. The fuel receipt showed that a total of 136 gallons of fuel was added to the airplane before the accident flight.

Witnesses and the pilot's emails indicated that the pilot was having autopilot problems with the airplane. The pilot wrote an email dated June 6, 2014, to the hangar owner in Bend, Oregon, which stated, "I am in town since Thursday and working on the plane. One problem solved, the next showing up. Right now the autopilot tries to kill me. Flying straight and level high speed my electric trim buddy pushes or pulls all of a sudden. Very bad feeling, even worse that the auto-trim is on his side. I will meet RDD in Redmond early in the morning, begging for help."

The owner of RDD (an aviation maintenance facility) in Redmond, Oregon, stated that he received a phone call from the pilot concerning the problems he was having with the autopilot. The accident pilot flew the airplane to Redmond about 0730 on June 6, 2014. The pilot indicated that the airplane was experiencing violent pitch ups. RDD diagnosed the problem as an auto-trim reverse sensing which caused the nose to trim up or down which was backward from what was required. The fix took less than 20 minutes. All that was required was to flip a switch on the auto-trim module. After the work was completed, the accident pilot flew back to Bend, Oregon. The pilot did not tell the owner of RDD that he was going to fly to DLH on the same day. The owner of RDD stated that he received a text message from the accident pilot later that night that stated that the autopilot was working much better.

The accident pilot wrote an email dated June 6, 2014, at 7:00 PM to the hangar owner in Bend, Oregon, which stated, "I took a chance today to start the ferry flight. Right now I am in Duluth, MN. Tomorrow aiming for Goose Bay. I have still my back seat in your hangar. Probably will fly next spring or I find another way to pick it up asap."

The airplane which seated four was made of primarily of composite materials and had a maximum gross weight of 3,800 pounds. The estimated weight and balance of the aircraft indicated that the aircraft takeoff weight on the accident flight was 4,309 lbs., which was 509 lbs. over the maximum gross weight of the aircraft. The estimated center of gravity (CG) of the aircraft was 93.2, which was within the CG range of the aircraft of flight stations 86.5 - 94.5.

METEOROLOGICAL INFORMATION

At 1102, the surface weather observation at DLH was: wind 080 at 4 kts; 10 miles visibility; scattered clouds 700 feet; overcast ceiling 2,500 feet; temperature 12 degrees C; dew point 9 degrees C; altimeter 30.06 inches of mercury.

At 1122, the surface weather observation at DLH was: wind 140 at 9 kts; 10 miles visibility; scattered clouds 300 feet; broken ceiling 1,000 feet; overcast ceiling 2,700 feet; temperature 11 degrees C; dew point 10 degrees C; altimeter 30.06 inches of mercury; ceiling variable 700 feet to 1,100 feet.

At 1132, the surface weather observation at DLH was: wind 120 at 6 kts; 10 miles visibility; ceiling 300 feet broken; overcast 1,000 feet; temperature 11 degrees C; dew point 10 degrees C; altimeter 30.07 inches of mercury.

A National Transportation Safety Board (NTSB) weather specialist reported that computer modeling of weather data indicated that clouds were likely from the surface through at least 32,000 feet above mean sea level (msl), with icing conditions likely starting at 10,000 feet msl and above at the time of the accident. The winds aloft from 3,000 to 6,000 feet were between 12 to 18 kts from the northeast.

WRECKAGE AND IMPACT INFORMATION

The airplane wreckage was recovered from Lake Superior on June 23, 2014, and relocated to a St. Louis County maintenance facility located in Duluth, Minnesota, for examination. The wings, horizontal stabilizer, and much of the composite fuselage structure of the airplane were not recovered; as such, flight control continuity could not be verified. The engine, propeller, landing gear, cockpit instrument panel, instruments, cabin floor structure, seats, interior pieces, vertical stabilizer, rudder, and various aircraft parts were recovered and examined.

The engine was removed from the remaining airframe and a cursory inspection of the engine was performed. The engine and propeller were shipped to the GE Aviation Czech (GEAC) factory in Prague, Czech Republic, for examination. The propeller was transferred to the Avia factory facility in Prague, Czech Republic, for a teardown examination.

An Avidyne Flight Max Integra Multi-function display (MFD) and two Chelton IDUs were sent to the NTSB Vehicle Recorders division for examination.

The rudder bellcrank, the rudder spherical bearings, and a section of the lower rudder were sent to the NTSB Materials laboratory for examination.

The rudder trim was found in a right rudder trim position with about 1/2 inch deflection. The electric rudder servo motor was tested by using a 9-volt dc power source. It exhibited full travel when power was applied.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy of the pilot was conducted on June 10, 2014, at the University of Minnesota School of Medicine in Duluth, Minnesota. The "Cause of Death" was noted as the "result of multiple severe impact injuries." A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aerospace Medical Institute. The results were negative for carbon monoxide and ethanol. The toxicological report indicated that 0.146 (ug/ml, ug/g) diphenhydramine was detected in the blood (cavity).

Diphenhydramine is a sedating antihistamine used to treat allergies and as a sleep aid. It is available over the counter under various names including Benadryl and Unisom. Diphenhydramine carries the following warning: may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery). The therapeutic range for the drug is 0.0250 to 0.1120 ug/ml.

The pilot's FAA medical certification examination did not identify any medical concerns or natural disease. His autopsy identified mild cardiomegaly with left ventricular enlargement and mild coronary atherosclerosis, but no evidence of heart muscle damage or other natural disease. Toxicology testing detected diphenhydramine in cavity blood at 0.146 ug/ml.

TESTS AND RESEARCH

On August 19, 2014, the engine and propeller were examined under NTSB oversight in Prague, Czech Republic. The engine examination revealed that the power turbine was intact; however the hub was rotationally scored on both faces. The leading edges of all the blades were rotationally scored and bent aft. The gas generator turbine was intact and the blade tips were circumferentially scored with metal transfer evident on the convex sides of the tip, consistent with contact against the gas generator turbine shroud. Additionally, there were randomly distributed bright shiny flakes deposited on the convex side of some of the blades, which is consistent with a metal spray condition. The compressor rotor, consisting of two axial compressors and one centrifugal impeller was intact. The axial compressor blades were intact and the tips were circumferentially scored consistent with contact against their respective shroud elements. The impeller vanes were rotationally scored, consistent with contact against the impeller shroud. The compressor and impeller shrouds exhibited rotational scoring.

The propeller examination revealed that the Nos. 1 and 2 blades were bent aft at the mid-span to a bend angle of about 90 degrees, with no evidence of blade twisting. The No. 3 blade had a slight bend with no evidence of blade twisting deformation. The No. 1 piston guide was slightly dented at a location which indicated that the blade pitch at impact was 15 degrees, a low angle corresponding to the hydraulic low pitch stop. This, in turn, corresponded to a low power setting of the engine.

The NTSB Materials laboratory examined the rudder bellcrank, the rudder spherical bearings, and a section of the lower rudder and vertical stabilizer bulkhead. The examination revealed that the rudder bellcrank was comprised of a left arm and a right arm. On each arm, there were attachment points for a control cable input and a rod output. There were two holes in the vertical stabilizer bulkhead that allowed the rods to connect to the forward rudder spar via an attachment fitting. The right and left rods were fractured. Pieces of the right and left rods were attached to the rudder and a piece of the right rod was attached to the bellcrank. By contrast, there was no corresponding piece of the left rod attached to the bellcrank. A closer examination of the right rod fracture surfaces revealed that they did not match; indicating that the right rod had fractured in two or more locations and an intermediate section had been separated and was not recovered. An examination of the bellcrank revealed a deformation mark on the forward portion of the right arm in the vicinity of the bellcrank stop.

The left and right rod fracture surfaces were visually examined using a stereomicroscope. The fracture surface on the left rod piece attached to the rudder consisted of inclined slant fractures, and no apparent out-of-plane deformation, consistent with a tensile overstress fracture. The right rod had collapsed near each fracture. Th

NTSB Probable Cause

The pilot's failure to maintain airplane control while operating in instrument flight rules (IFR) conditions, which was due to spatial disorientation resulting from erroneous heading and bank angle information shown on the primary flight display. Contributing to the accident were the pilot's impairment due to diphenhydramine and his improper decision to operate in IFR conditions with the airplane over gross weight and at an aft center of gravity.