NTSB Factual Report

HISTORY OF FLIGHT

On June 11, 2013, at 0038 central daylight time (CDT), a Pipistrel LSA SRL Alpha Trainer light sport airplane, N477PA, impacted terrain 22 miles north of Pampa, Texas, following a loss of engine power. The airline transport pilot was fatally injured and the commercial pilot was seriously injured. The airplane sustained substantial damage. The airplane was registered to Wisdom Aviation LLC., and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Dark night visual meteorological conditions prevailed at the time of the accident, which operated without a flight plan. The flight originated from Anderson Municipal Airport – Darlington Field (KAID), Anderson, Indiana, on June 10, 2013, at 1336 and was en route to Hutchinson County Airport (KBGD), Borger, Texas.

According to the owner, the airplane was being flown to Moriarty, New Mexico, to receive a repair on the composite material behind the main landing gear. He stated that the airline transport pilot had volunteered to take the airplane to New Mexico for the maintenance. The airline transport pilot intended to fly to Texas, stay overnight, and then continue to New Mexico the next day.

According to the commercial pilot, he elected to ride along for the flight to gain flight experience and familiarity with the airplane. The decision was made to depart on June 10, as the commercial pilot had mandatory training he had to return for on June 13. During the flight, the commercial pilot sat in the left seat and the airline transport pilot sat in the right seat. The preflight inspection and engine start checklists were all performed by the airline transport pilot. Both pilots took turns flying.

The commercial pilot stated that the airplane stopped in Mexico, Missouri, for fuel. During this stop the airline transport pilot had difficulty restarting the engine and had to call Pipistrel for assistance. The airline transport pilot removed the cowling from the engine to let it cool down and after 15 to 20 minutes they were able to restart the engine.

The commercial pilot stated that the flight stopped in Eldorado, Kansas, for fuel. He estimated that they took on 10.9 gallons of fuel and that they departed Eldorado around 2115. He stated that, during the last leg of the flight, the airplane's ground speed (according to the Global Positioning System (GPS)) was between 75 and 85 knots. He further stated that the GPS calculated their flight at 3 hours and 30 minutes. He recalled that, about 0030, the fuel gauge was reading "close to empty" and they were 20 miles (10 minutes) from their destination airport. About 5 minutes later, the engine lost power, at which time, the airline transport pilot took control of the airplane.

The commercial pilot recalled that the airline transport pilot turned on the emergency locator transmitter, dialed in 121.5 on the radio, and announced a Mayday. He did not recall anyone responding to their Mayday. The airline transport pilot attempted to glide the airplane to a nearby airstrip. When he realized that they would not make it to the airport, he and the commercial pilot discussed the necessity of deploying the ballistic recovery parachute. They agreed that it was time and the commercial pilot deployed the parachute. The commercial pilot estimated that they were between 3,500 and 3,100 feet mean sea level (msl) or 200 to 400 feet above ground level. About 5 to 10 seconds later, the airplane hit the ground.

The commercial pilot recalled that the initial impact was "brutal" and that the nose of the airplane pitched up. Following the initial impact, he felt like the airplane was flipping and never really came to rest.

PERSONNEL INFORMATION

Airline Transport Pilot

The airline transport pilot, age 64, held an airline transport pilot certificate with an airplane multiengine land rating. He also held a commercial pilot certificate with airplane single engine land, instrument airplane, and glider ratings, and a flight instructor certificate with airplane single and multiengine, instrument airplane, and glider ratings.

The airline transport pilot was initially issued a first class airman medical certificate without limitations on March 31, 2008. Upon further review of his application, the Federal Aviation Administration (FAA) denied his airman medical certificate on May 2, 2008. The pilot appealed the denial and, on June 26, 2008, a final agency denial was issued. There were no further applications for special-issuance medical certificates following this denial. The commercial pilot stated that he was not aware of this. The pilot's wife and the owner of the airplane both stated that the airline transport pilot's denied medical was common knowledge.

At the time of medical certificate application, the airline transport pilot reported that he had logged 24,215 hours of flight time; 6 hours were logged in the previous 6 months. At the time of application for his commercial glider certificate, the pilot reported a total flight time of 25,000 hours, 22.7 of which had been logged in gliders. Investigators did not obtain recent flight information for day or night operations or for the make and model of the accident airplane.

Commercial Pilot

The commercial pilot, age 22, held a commercial pilot certificate with airplane single and multiengine land and instrument ratings issued on October 7, 2011. He was issued a first class airman medical certificate, without limitations, on January 7, 2010. The commercial pilot also held a flight instructor certificate with airplane single engine privileges issued on July 10, 2012. The commercial pilot successfully completed the requirements of a flight review upon issuance of his most recent pilot certificate.

The commercial pilot's logbook was located in the wreckage and was recovered by the FAA. The logbook contained entries between August 16, 2012, and April 20, 2013. A review of the logbook indicated that the commercial pilot had logged no less than 388.6 hours total time; 377.5 hours in single engine airplanes and 11.1 hours in multiengine airplanes. The commercial pilot had not logged any flight time in the make and model of the accident airplane. The commercial pilot had logged 28 hours of night-flight experience; 3.4 hours of which (including 7 landings) had been logged within the previous 90 days.

AIRCRAFT INFORMATION

According to FAA records, the 2012 Pipistrel LSA SRA Alpha Trainer airplane (serial number 453 AT 912 LSA) had been manufactured by Pipistrel. It was registered with the FAA on a special airworthiness certificate for experimental light sport operations. A Rotax 912 UL2 engine rated at 80 horsepower at 5,800 rpm powered the airplane. The engine was equipped with a 2-blade, fixed pitch, wooden, Pipistrel propeller. The airplane was not equipped for night operations. A placard on the switch panel stated "NOT APPROVED FOR NIGHT FLIGHT" and the airplane did not have cockpit lightning.

The airplane was maintained under a condition inspection program. A review of the maintenance records indicated that the airplane was inspected and a special airworthiness certificate was issued on January 10, 2013, by the FAA Indianapolis Flight Standards District Office. The condition inspection had been completed on January 4, 2013, at an airframe total time of 5.0 hours. The airplane had flown approximately 27.6 hours between the last inspection and the accident and had a total airframe time of 32.6 hours.

METEOROLOGICAL INFORMATION

The closest official weather observation station was Perry Lefors Field Airport (KPPA), Pampa, Texas, located 22 nautical miles south of the accident site. The elevation of the weather observation station was 3,245 feet msl. The routine aviation weather report (METAR) for KPPA, issued at 0035, reported, wind 190 degrees at 17 knots, gusting to 23 knots, visibility 10 miles, sky condition clear, temperature 25 degrees Celsius (C), dew point temperature 09 degrees C, altimeter 29.98 inches.

According to the United States Naval Observatory, Astronomical Applications Department Sun and Moon Data, the sunset was recorded at 2059 CDT and the end of civil twilight was 2129 CDT. The Moon rose at 2149 CDT on June 9, 2013, and set at 2031 CDT on June 10, 2013. The phase of the Moon was waxing crescent with 8 percent of the Moon's visible disk illuminated.

FLIGHT RECORDERS

A Garmin Aera 500 GPS was installed in the accident airplane. The GPS was sent to the National Transportation Safety Board (NTSB) Vehicle Recorders Lab in Washington D.C. for download. Flight track information, including time, latitude, longitude, altitude, ground speed, and heading was recovered from the unit for the accident flight. The flight departed Anderson, Indiana, and stopped in Mexico, Missouri, and El Dorado, Kansas.

According to the data recovered from the GPS, the flight departed a location consistent with El Dorado, Kansas, around 2113. The flight track record was consistent with a relatively direct flight to KBGD. The altitude increased to 6,200 feet and ground speed varied throughout the flight but averaged 72 knots. At 0033:47, the airplane started to descend. At 0037:44, at an altitude of 2,765, the ground speed decreased to 15 knots consistent with the deployment of the ballistic parachute. The last line of data was recorded at 0038:13, at an elevation of 2,748 feet msl.

WRECKAGE AND IMPACT INFORMATION

The accident site was located in hilly desert canyon terrain vegetated with short grass, sagebrush, and yucca plants, at a terrain elevation of 2,700 feet msl. The horizontal stabilizer and elevator assembly was located approximately 500 feet from the initial impact point. A debris field extended 1.7 miles from the initial impact point to the main wreckage. The main wreckage came to rest entangled in the metal post and wires of a barbed wire fence.

The main wreckage consisted of the fuselage, engine, both wings, empennage, and the canopy. The empennage had separated partially and remained attached through the flight control connections. The canopy remained attached to the fuselage. The FAA inspectors who responded to the accident scene reported that there was no fuel in the fuel pump or the fuel tank. The fuel tank was not impact damaged.

MEDICAL AND PATHOLOGICAL INFORMATION

Airline Transport Pilot

The autopsy on the airline transport pilot was performed by the South Plains Forensic Pathology Lab on June 12, 2013, as authorized by the Roberts County Justice of the Peace. The autopsy concluded that the cause of death was blunt force injuries and the report listed the specific injuries. The pilot had an enlarged heart at 675 grams, (normal for a 205 pound man (the weight of the pilot) is 375 grams with a range from 285-495 grams) with concentric ventricular wall hypertrophy. He had 3-vessel coronary artery by-pass grafting to the native vessels, but patency of graft vessels was not described. The heart muscle had areas of fibrous scarring in the in the left ventricular free wall at the base of the heart which extended nearly to the apex. There was no evidence of changes consistent with new ischemia (heart attack). The examination of the brain did not identify any evidence of the remote stroke or new natural disease.

During the autopsy, specimens were collected for toxicological testing to be performed by the FAA's Civil Aerospace Medical Institute (CAMI), Bioaeronautical Sciences Research Laboratory (CAMI Reference Number 201300099002). Testing for cyanide was not performed. No carbon monoxide was detected in the blood and no ethanol was detected in the vitreous. Citalapram, Metoprolol, valsartan, and metabolites of these drugs were detected in the liver. Metoprolol, 0.417 ug/ml of Citalopram, and 0.123 ug/ml of the Citalopram metabolite were detected in cavity blood. Citalopram is a prescription selective serotonin reuptake inhibitor (SSRI) antidepressant marketed as Celexa. The therapeutic range for the medication is from 0.0300 to 0.4000 ug/mL. Additionally, metoprolol and valsartan were detected in the cavity blood and liver. These are prescription medications used to treat high blood pressure and heart disease.

At the time of his most recent medical certificate application, the pilot reported having had a pontine stroke in December 2006, diabetes, and depression. The pilot's stroke symptoms had reportedly resolved by March 2008. He was treated until March 2008 with escitalopram, an SSRI marketed as Lexapro, for the treatment of depression. His high blood pressure was treated with valsartan and nifedipine. These are prescription high blood pressure medications marketed under the respective names Diovan and Adalat. He also reported that his diabetes was treated with metformin, a prescription oral antihyperglycemic drug used in the management of type 2 diabetes marketed as Glucophage.

Commercial Pilot

The commercial pilot was seriously injured in the accident and subsequently transported to a local hospital for medical treatment. Both blood and urine specimens were submitted for testing performed by CAMI, (CAMI Reference Number 201300099001). No carbon monoxide was detected in the blood and no ethanol was detected in the urine. Tests for cyanide were not performed. Testing of the blood revealed 0.044 ug/ml Hydrocodone and Ondansetron. Testing of the urine revealed 27 ug/ml Acetaminophen, Cetirizine, 0.12 ug/mL Dihydrocodeine, 3 ng/mL Fentanyl, 2.249 ug/mL Hydrocodone, 0.161 ug/mL Hydromorphone, 0.545 ug/ml Morphine, and Ondansetron Cetirizine is a sedating antihistamine used to treat allergies marketed as Zyrtec. The other medications noted are commonly prescribed in an emergency medical setting, during, and following surgery.

TESTS AND RESEARCH

The wreckage was recovered to a facility in Greeley, Colorado, for storage and further examination. Investigators from the NTSB, Pipistrel, and Rotax examined the wreckage.

The wreckage consisted of the fuselage, empennage, both wings, and the canopy. The wings and canopy were removed from the airplane during the recovery.

The fuselage included the engine and propeller assembly, the fuel tank, both seats, and the instrument panel. The composite material on the bottom aft portion of the fuselage in addition to the engine cowling was torn and cracked.

The instrument panel was not impact damaged. The fuel gauge read empty and the Hobbs meter showed 32.6. The Kollsman window was set to 30.03 inches. All other instruments indicated zero.

The fuel tank was not impact damaged. The fuel lines were intact and approximately 1 tablespoon of fuel was observed at the bottom of the fuel tank. The fuel vent line separated and the fuel filter at the tank was clean and dry.

Neither the rocket nor the cover for the parachute system were recovered. The canopy had several tears in the fabric on one side and was dirty. The risers were tangled and one area of Kevlar was abraded, as if it rubbed on something.

The right wing assembly included the right flaperon. The leading edge exhibited scratches and scrapes. There was a circular puncture on the inboard bottom portion of the wing and multiple small punctures on the upper skin of the wing. The right flaperon was unremarkable. The left wing assembly included the left flaperon. The leading edge exhibited scratches and scrapes. There were multiple punctures on the upper and lower wing skin. The outboard portion of the wing tip was fragmented. The outboard portion of the left flaperon was fragmented. The aileron push/pull tubes were continuous from the control stick to the aileron.

The empennage included the vertical stabilizer and rudder. The empennage was separated from the fuselage, just aft of the fuel tank. The composite material was broken and cracked in multiple locations. The lower leading edge of the vertical stabilizer was crushed aft and broken. The rudder was separated partially at the top of the assembly.

The horizontal stabilizer and elevator assembly was separated from the empennage and was located within the debris field. The right side of the elevator was cracked at midspan, and the left side of the elevator was intact. The composite material on the upper center portion

NTSB Probable Cause

The loss of engine power due to fuel exhaustion as a result of the manufacturer providing the incorrect Pilot’s Operating Handbook to the owner, which prevented the pilot from accurately calculating the fuel requirements before the flight. Contributing to the accident were the pilot’s inadequate preflight planning and poor decision-making.