NTSB Factual Report

HISTORY OF FLIGHT

On September 14, 2012, about 1615 central daylight time, an experimental North Wing Design model Apache Sport light sport aircraft, N850GB, was destroyed when it collided with terrain shortly after takeoff from the Harold Davidson Field Airport (VMR), Vermillion, South Dakota. A postimpact ground fire ensued. The sport pilot, who was the sole occupant, was fatally injured. The weight-shift-control aircraft was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. Day visual meteorological conditions prevailed for the personal flight. The cross-country flight was originating at the time of the accident and was en route to a private airstrip near Kimball, South Dakota.

A witness to the accident reported that he was working outside his residence when he heard the weight-shift-control aircraft depart the airport. He initially heard the sound of the aircraft's engine before he spotted the aircraft climbing at a steep angle. He reported that the aircraft then rolled to the left and entered a near vertical descent. The aircraft descended below his sightline before he heard a sound similar to a ground impact and saw smoke rising-up from the same general area.

Another witness reported that he was working in his garage when he heard the sound of an aircraft engine "having trouble." He looked up and saw the weight-shift-control aircraft in a steep bank angle as it descended toward the ground. He stated that the engine was making a loud noise during the descent.

Another witness reported that he was watching the weight-shift-control aircraft takeoff from the airport. He stated that the engine initially sounded like it was operating normally, but as the aircraft continued to climb the engine began to run roughly. He noted that the airplane then descended below a nearby tree line.

PERSONNEL INFORMATION

According to Federal Aviation Administration (FAA) records, the pilot, age 75, held a sport pilot certificate with weight-shift-control and powered-parachute ratings. He also held a repairman certificate, which allowed him to maintain the accident weight-shift-control aircraft and two other light-sport aircraft. According to FAA records, the pilot had never applied for an aviation medical certificate; however, the operation of a light-sport aircraft only required a valid driver's license. A search of FAA records showed no previous accidents, incidents, or enforcement proceedings.

The most recent pilot logbook entry was dated September 11, 2012. At that time, the pilot had accumulated 571.3 hours total flight time, of which 375.7 hours were logged as pilot-in-command. He had logged 375.7 flight hours in weight-shift-control aircraft and 195.6 hours in powered-parachutes. All of his documented flight experience was in daytime visual meteorological conditions. He had logged 44.5 hours during the past year, 27.2 hours during the prior 6 months, 16.3 hours during previous 90 days, and 3.7 hours in the last 30 days. The pilot did not log a flight within 24 hours of the accident. His last flight review was completed on September 9, 2011, in an Edge XT-582-L weight-shift-control aircraft.

AIRCRAFT INFORMATION

The weight-shift-control aircraft was a 2005 North Wing Design model Apache Sport, serial number (s/n) 51188. A two-stroke, two-cylinder, water cooled, 65-horsepower, Rotax model 582 UL DCDI engine, s/n 5743300, powered the aircraft. The engine was equipped with a ground-adjustable, three blade, Ivoprop model Quick Adjust propeller. The aircraft could seat two individuals, and had an empty weight and a maximum takeoff weight of 473 pounds and 950 pounds, respectively.

The weight-shift-control aircraft was issued an experimental airworthiness certificate on April 24, 2007. The pilot purchased the aircraft on February 23, 2011. According to available information, the airframe and engine had accumulated a total service time of 210.6 hours at the time of the accident.

The last conditional inspection was completed on April 10, 2012, at 184.1 hours airframe total time. A postaccident review of the maintenance records found no history of unresolved airworthiness issues.

METEOROLOGICAL INFORMATION

At 1555, the VMR automatic weather observing station reported the following weather conditions: wind from 280 degrees at 2 knots, visibility in excess of 10 miles, temperature 28 degrees Celsius, dew point 4 degrees Celsius, and an altimeter setting of 30.24 inches of mercury. Review of photographs taken by local law enforcement immediately following the accident revealed no appreciable cloud cover or visibility restrictions at the accident site, consistent with visual meteorological conditions.

A pilot reported experiencing moderate turbulence, updrafts, and dust-devils while flying near the accident site about 30 minutes before the accident occurred.

AIRPORT INFORMATION

The Harold Davidson Field Airport (VMR), a public-use airport, located about 1 mile south of Vermillion, South Dakota, was served by a single runway: 12/30 (4,105 feet by 75 feet, concrete). The airport elevation was 1,147 feet mean sea level (msl).

WRECKAGE AND IMPACT INFORMATION

A postaccident on-scene examination, completed by a FAA Airworthiness Inspector, confirmed that all airframe structural components were located at the accident site. The main wreckage was located on the extended runway 30 centerline, about 1/2 mile past the end of the runway. The entire wreckage was contained within an area comparable to the lateral dimensions of the aircraft. The lack of a wreckage debris path or any lateral impact damage to the surrounding corn crop was consistent with a near vertical impact angle. A majority of the fuselage structure and wing were consumed during the postimpact fire. Flight control continuity could not be established due to damage; however, all observed separations were consistent with either an overstress failure or prolonged exposure to fire.

The engine exhibited damage consistent with prolonged exposure to fire. The dual electronic ignition system and both carburetors were destroyed during the fire. A postaccident engine examination confirmed internal engine and valve train continuity as the engine crankshaft was rotated. Compression and suction were noted on both cylinders in conjunction with crankshaft rotation. The spark plugs were removed and exhibited features consistent with normal engine operation. All three composite propeller blades remained attached to the metal hub assembly and exhibited damage consistent with impact and prolonged exposure to fire. The engine examination revealed no preimpact mechanical malfunctions or failures that would have precluded normal engine operation.

MEDICAL AND PATHOLOGICAL INFORMATION

On September 17, 2012, an autopsy was performed on the pilot at Sanford Health Pathology Clinic, located in Sioux Falls, South Dakota. The cause of death for the pilot was attributed to multiple blunt-force injuries sustained during the accident. The autopsy report also described extensive postmortem thermal injuries. Additionally, the autopsy report indicated that there was significant blunt-force damage to the heart that precluded a detailed examination.

The FAA Civil Aerospace Medical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on samples obtained during the pilot's autopsy. Ethanol and n-propanol were detected in muscle samples, but was not detected in brain tissues. The presence of ethanol and n-propanol was attributed to sources other than ingestion. Metoprolol was detected in muscle and liver samples. Metoprolol, brand name Lopressor or Toprol XL, is a prescription medication used to treat high blood pressure, angina, and to control heart rate in some arrhythmias. Rosuvastatin was detected in liver samples. Rosuvastatin, brand name Crestor, is a prescription medication used to treat high cholesterol and prevent heart disease. Tamsulosin was detected in muscle and liver samples. Tamsulosin, brand name Flomax, is a prescription medication used to treat benign prostatic hyperplasia. Warfarin was detected in muscle and liver samples. Warfarin, brand name Coumadin, is a prescription anticoagulant.

During the postaccident investigation, the NTSB Investigator-In-Charge and a FAA Medical Officer interviewed the pilot's spouse to ascertain the pilot's previous medical history. The pilot had an artificial aortic heart valve replacement for the past 38 years and was on a daily regimen of Coumadin. Additionally, he had coagulation studies done monthly, which were reportedly normal and there were no known issues with his replacement heart valve.

The pilot had heart bypass surgery in the 1990's. In 2006 he had a cardiac catheterization to evaluate ischemia and to install a stent in an artery that was 90-percent occluded; however, the location of the occlusion prevented stenting and his previous surgeries prevented additional surgical intervention. The pilot was reportedly receiving medical treatment for his ischemic coronary artery disease.

The pilot had a craniotomy after developing slurred speech resulting from a slowly expanding subdural hematoma sustained during a ski accident about 10 years before his fatal aviation accident. Following the craniotomy, his slurred speech resolved and he had no residual neurological symptoms.

The pilot's spouse reported that the pilot had 4 or 5 episodes of transient ischemic attack; however, the symptoms of each episode were always different. More than 10 years before the accident flight and before his craniotomy surgery, the pilot experienced double vision while driving. Then about a year later he had another episode when he told his wife that he was experiencing eye problems and his wife noted that his eyes were bulging; however, the symptoms resolved after a few seconds. Since his craniotomy procedure, while operating an automobile, the pilot reportedly lost vision and had to pull over and let his wife drive. The final episode occurred 3 or 4 years before the accident flight, when the pilot told his wife that he felt the table was tipping, but she noted he was leaning instead. The pilot's spouse reported that each episode lasted only a few seconds and after which, the pilot exhibited no residual symptoms. Following his most recent episode, which occurred 3 to 4 years before the accident flight, the pilot's spouse asked her husband to tell his physician about his latest episode; however, she did not know if he indeed told his doctor or not.

The pilot was evaluated by his personal physician in February 2008 and was diagnosed with dizziness and counseled him against driving or flying. However, records show that in April 2010, the pilot passed an exam for a commercial driver's license.

The pilot's spouse reported that her husband had no recent complaints of fatigue, shortness of breath or chest pain. On the day of the accident, the pilot was reportedly alert with no noticeable fatigue or complaints, and was looking forward to his upcoming cross country flight.

According to FAA regulations, a pilot operating light-sport aircraft does not need to apply for nor possess a FAA medical certificate. In lieu of a FAA medical certificate, a pilot can operate light-sport aircraft if they possess a valid driver's license; although, a pilot must not know of or have reason to know of any medical condition that would make them unable to operate a light-sport aircraft in a safe manner.

TESTS AND RESEARCH

A handheld GPS device was recovered from the wreckage and sent to the NTSB Vehicle Recorder Laboratory for further examination. The GPS device exhibited significant thermal damage, consistent with a prolonged exposure to fire. The damage to the GPS device prevented a normal download via a cabled connection to a host computer. A nonvolatile memory chip, which normally contains recorded position data, was extracted from the damaged GPS; however, the NTSB Vehicle Recorder Laboratory was unable to perform a chip-level download due to heat damage sustained to the memory chip.

NTSB Probable Cause

The pilot’s failure to maintain control of the weight-shift-control aircraft during initial climb, which resulted in an aerodynamic stall/spin.