NTSB Factual Report

HISTORY OF FLIGHT

On May 24, 2016, about 1625 eastern daylight time, an experimental light sport Jihlavan KP 5 ASA (Skyleader 500), N440JM, was destroyed when it impacted terrain in Rhoadesville, Virginia. The sport pilot/owner and the flight instructor were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the flight, which originated from Culpeper Regional Airport (CJR), Culpeper, Virginia, about 1530. The instructional flight was conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91.

The sport pilot had recently purchased the airplane and had another pilot ferry it from California to CJR. The airplane arrived at CJR on May 13, 2016. According to an insurance adjuster, the sport pilot had less than 5 hours of flight experience in the make and model airplane. Therefore, his insurance policy required that he receive a "checkout" flight by a certificated flight instructor. The flight was required to include a minimum of 2 hours dual instruction with 15 takeoffs and landings. When the sport pilot inquired about obtaining flight instruction, the airport manager at CJR referred him to the flight instructor.

According to Federal Aviation Administration (FAA) data, no air traffic control services were provided to the flight. Radar returns indicated that, after departing CJR, the airplane flew southwest to Orange County Airport (OMH), Orange, Virginia. There, radar indications disappeared and reappeared four times, consistent with approaches below radar coverage to runway 26. After the fourth approach, the airplane proceeded northeast and later turned east before disappearing from radar. There were no altitude readouts from the airplane during the entire flight. As the airplane traveled east toward the end of the data, the groundspeed slowed from 94 to 62 knots, consistent with slow flight and stall practice. The last target was recorded near the accident site at 1624:28.

According to several witnesses near the accident site, they heard what sounded like thunder or a "crack." They then saw a parachute deployment and the airplane's nose pointed straight down before impacting the ground. Witnesses could not determine the airplane's altitude at the time other than that it was low, nor could they report whether the engine was operating.

One witness provided a photograph of the airplane descending with the parachute still attached and partially inflated.

PERSONNEL INFORMATION

The pilot, age 57, held a sport pilot certificate with endorsements for airplane single-engine land and powered-parachute land. He did not possess an FAA medical certificate nor was he required to. Review of the pilot's logbook revealed that he had accumulated a total flight experience of about 121 hours, of which 2.5 hours were in the accident airplane. The pilot had flown 4.5 and 0 hours during the 90- and 30-day periods preceding the accident, respectively. Further review of his logbook revealed that the 2.5 hours of experience in the accident airplane consisted of two flights on March 20, 2016, and March 22, 2016, in California. The pilot recorded those flights in his logbook as prebuy flights. During the second prebuy flight, the pilot also recorded "Slowflight Stalls" in his logbook. Additionally, the pilot recorded those two flights as dual instruction received; however, there were no accompanying endorsements from a flight instructor. Other than the 2.5 hours in the accident airplane, the pilot did not have any prior experience in the accident airplane make and model.

The flight instructor, age 81, held an airline transport pilot certificate with a rating for airplane multiengine land. He also held a commercial pilot certificate with ratings for airplane single-engine land and airplane single-engine sea. Additionally, he held a flight instructor certificate with ratings for airplane single-engine and instrument airplane. His most recent FAA second-class medical certificate was issued on March 1, 2016. Review of the flight instructor's logbook revealed that he had accumulated a total flight experience of about 32,840 hours, of which 100 and 43 hours were flown during the 90- and 30-day periods preceding the accident, respectively. There was no record of the flight instructor having any prior experience in the accident airplane make and model.

AIRCRAFT INFORMATION

The two-seat, low-wing, retractable tricycle landing gear-equipped airplane, serial number 5141163M, was manufactured in 2007. It was powered by a Rotax 914 UL, 115-horsepower engine, equipped with a DUC Swirl ground-adjustable three-blade propeller. The airplane was issued an FAA special light sport aircraft (S-LSA) airworthiness certificate in 2008, which was superseded by an FAA experimental light sport aircraft (E-LSA) airworthiness certificate in 2010. According to the previous owner of the airplane, he chose to have the airplane subsequently recertified as an E-LSA, rather than an S-LSA because he could perform more of the maintenance work himself under the E-LSA certification. The previous owner further stated that he had to be vigilant during stall practice because the airplane always seemed to yaw abruptly right and into a spin, more so than any other airplane he had ever flown. The airplane's maximum gross takeoff weight was 1,279 lbs.

Review of the airplane's logbook revealed that its most recent annual condition inspection was completed on May 6, 2016. At that time, the airframe and engine had accumulated 534 hours since new.

Review of the airplane's Pilot's Operating Handbook revealed, "Acrobatic, intentionally driven stalls and spins are prohibited!"

The airplane was equipped with a Galaxy Rescue Systems (GRS) ballistic parachute. According to the manufacturer label, the model parachute could be deployed at a maximum weight of 1,350 lbs and maximum speed of 138 mph. Review of the parachute manual revealed instructions for the engine to be turned off before activation. The parachute attached to the airframe via four risers (cables) and three anchors. Two of the risers shared an anchor (front) attached by eight bolts with nuts to the aluminum bulkhead behind the seats. The other two risers (rear) attached to an anchor located at each wing root near the trailing edge of the wing. According to a representative of the parachute manufacturer, the double-riser front anchor was designed to carry the majority load. The remaining two rear risers were designed to stabilize the airplane in an optimal descending attitude and could not carry the full load if the double-riser front anchor failed. Specifically, the double-riser front anchor could withstand a maximum shock/load of 40.1 kiloNewtons [kN] (9,015 pounds of force [lbf]), and the two rear risers could withstand a maximum shock/load of 13.3 kN (2,990 lbf) each. The representative added that the data were for the anchors and risers and that data for the actual anchor-to-airframe attachment would have to be provided by the airplane manufacturer.

The GRS also included a drogue parachute to assist in main parachute deployment. The parachute manufacturer representative further stated that, although the engine should be off during parachute deployment, it did not have a significant effect on the parachute deployment. Rather, airplane speed and weight had a greater effect on the parachute deployment and performance.

According to a representative of the airplane manufacturer, the first in-flight deployment of the parachute on the make and model airplane was on the accident airplane during the accident flight. During certification, one test deployment was performed on the ground. The representative further stated that they could not perform additional testing on the front anchor attachment because the design had been changed about 8 years before the accident. The current design (Skyleader 600) included two front anchors rather than one. The manufacturer no longer had any airplanes with a single front anchor to test.

METEOROLOGICAL INFORMATION

Orange County Airport (OMH), Orange, Virginia, was located about 9 miles west of the accident site. The 1635 recorded weather at OMH included calm wind, visibility 10 miles, and scattered clouds at 11,000 ft.

WRECKAGE INFORMATION

The wreckage was located in open terrain at an elevation of about 400 ft. The airplane was found upside down and complete with the exception of some smaller pieces that were found nearby. When the airplane was righted, significant fore-to-aft crushing damage was noted to the nose section and to both wings.

The airplane was subsequently moved to a temporary storage facility where it was laid out, and the presence of all flight control surfaces was confirmed, as was control continuity from each flight control surface to the cockpit controls.

At the accident scene, the drogue parachute was found in a nearby field, and the main parachute was found in trees about 100 yards east of the wreckage. At the temporary storage facility, the parachute's fabric canopy was spread out and observed to be undamaged. The two individual risers that had been attached to wing anchors were found separated near their respective anchors with the wire ends broomstrawed, consistent with overload separation. The other two risers were found still attached to their shared single anchor; however, that anchor was itself separated from the airframe. The cockpit parachute activation handle, located on the pilot's side of the instrument panel, appeared to have been pulled (system was activated.)

An engine monitoring system (EMS), electronic flight information system (EFIS), and engine control unit (ECU) were retained and forwarded to the NTSB Vehicle Recorder Laboratory. Attempted data download from the units revealed that the EMS and EFIS did not record any data; however, data were successfully downloaded and plotted from the ECU. Review of the data revealed that the ECU recorded about the last 20 minutes of the accident flight. About 11 minutes before the end of the data, the engine rpm averaged about 2,000, consistent with the last approach and landing. Subsequently, the engine rpm averaged between 4,000 and 5,000 to the end of the data.

Metallurgical examination of the two separated risers revealed overstress features. Additionally, pull-testing of the separated risers revealed that they exceeded their design specification by about 1,000 lbf. Metallurgical examination of the separated anchor revealed that it had been bolted into aluminum bulkhead skin that was approximately 0.022-inch thick. Although the anchor and seven of its eight bolts remained intact, the surrounding aluminum skin of the airplane had separated, consistent with overstress. There were no longerons, stringers, or bathtub fittings to transfer the parachute deployment loads into the airframe. The airplane manufacturer was unable to provide any data or testing of the amount of shock force the surrounding aluminum skin could withstand (for more information, see the Materials Laboratory Factual Report and Structures Group Chairman's Factual Report in the public docket for this investigation).

MEDICAL AND PATHOLOGICAL INFORMATION

The State of Virginia Office of Chief Medical Examiner, Manassas, Virginia, conducted autopsies on the pilot and flight instructor. The autopsy reports noted the cause of death for both pilots as "blunt force trauma."

The FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of specimens from the pilot and flight instructor. The results for the flight instructor were negative for alcohol and drugs. The results for the pilot were as follows:

"Carvedilol detected in Liver

Carvedilol detected in Blood

Doxazosin detected in Liver

Doxazosin detected in Blood

2.099 (ug/mL, ug/g) Doxepin detected in Liver

0.451 (ug/mL, ug/g) Doxepin detected in Blood

Methadone detected in Liver

Nordoxepin detected in Liver

Nordoxepin detected in Blood

0.592 (ug/mL, ug/g) Quetiapine detected in Liver

Quetiapine NOT detected in Blood

Blood unsuitable for analysis of Methadone."

According to the pilot's personal medical records, his chronic medical conditions included obstructive sleep apnea, high blood pressure, elevated cholesterol, heart disease, chronic obstructive pulmonary disease, and benign prostatic hypertrophy; these were all reportedly controlled, and the treatments are generally considered not to be impairing. In addition, he had an unspecified clotting disorder treated and controlled with apixaban. Because of the clotting disorder and bleeding into his muscles, he had severe myositis ossificans (bone formation in the muscle tissue), which resulted in limited range of motion and chronic pain treated with the impairing opioid medications methadone and oxycodone. The pilot had a remote history of strokes and heart disease, but no abnormal findings were documented on recent neurological and cardiac examinations. Further, the autopsy did not identify any significant natural disease in the heart or brain. Finally, he had a history of insomnia and depression treated with the impairing medications seroquel and doxepin. Although there was no evidence of depression on recent examinations, both psychoactive medications had been prescribed specifically for their sedating effects.

Title 14 CFR Part 61.23(c)(1) allows sport pilots to use a valid and current U.S. driver's license in lieu of a medical certificate. However, further review of 61.23(c)(2)(iv) revealed that the sport pilot must "Not know or have reason to know of any medical condition that would make that person unable to operate a light-sport aircraft in a safe manner."

ADDITIONAL INFORMATION

According to the manufacturer, the airplane's basic empty weight was 819.82 lbs. Review of fueling records revealed that on the day of the accident, 9.1 gallons of fuel were added to the airplane, and its total fuel capacity was 16.9 gallons (101.4 lbs). Review of autopsy reports revealed that the pilot weighed 270 lbs and that the flight instructor weighed 170 lbs, which resulted in a total airplane weight of 1,361.22 lbs, or 82.22 lbs above the airplane's maximum takeoff weight of 1,279 lbs. The airplane had flown about 1 hour before parachute deployment, and a fuel consumption rate of 5 gallons per hour corresponded to an airplane weight about 50 lbs above its maximum takeoff weight of 1,279 lbs at the time of parachute deployment.

The airplane manufacturer and FAA Office of Accident Investigation, Recommendation and Analysis Division were notified about the overstress failure of the airplane structure to which the front anchor attached. A search of FAA data revealed fifteen other U.S.-registered Skyleader 500 airplanes.

NTSB Probable Cause

The pilots' loss of control that necessitated the activation of the parachute system and the airplane manufacturer's inadequate design of the front parachute anchor attachment structure, which resulted in a failure of the parachute after it was deployed in flight and precluded the pilots from safely recovering from the spin.