Aircraft: Lancair IV. Injuries: 1 Fatal. Location: Winnsboro, La. Aircraft damage: Destroyed.
What reportedly happened: The purpose of the flight was to calibrate the fuel system on the homebuilt aircraft. Several witnesses on the ground heard an increase in engine rpm consistent with the pilot adding power to perform a go-around, then heard the engine lose power. The nose pitched up, then dropped. The airplane crashed beyond the departure end of the runway.
The damage to the airplane and the resultant ground scars were consistent with the airplane being in a stalled condition at the time of impact.
An examination of the fuel system revealed that the fuel selector was stiff and difficult to rotate. Further examination revealed that the O-rings on the fuel selector valve’s internal spindle were swollen past the plane of the shaft of the spindle, preventing easy rotation.
The pilot was aware of the fuel selector valve anomaly, however, a service bulletin addressing the problem with the fuel selector O-rings had not yet been complied with.
The fuel blighting evidence at the accident site and the quantity of fuel found in the right fuel tank suggest that the right wing contained fuel at the time of impact.
Investigators determined that, based on the circumstances of the accident, it is most likely the engine lost power due to fuel starvation during the go-around with the fuel selector valve positioned to the left tank, and the pilot became distracted when he tried to switch fuel tanks and lost control of the airplane.
Toxicological testing during the autopsy revealed the presence of antidepressant and cardiac medications in the pilot’s system. The blood level of the antidepressant medication was higher than usual therapeutic levels, indicating a high dose and prolonged use. The antidepressant comes with the warning that it may impair mental and/or physical abilities required for the performance of potentially hazardous tasks. In addition, depression is associated with significant cognitive degradation.
A review of the pilot’s medical records revealed an extensive history of psychiatric and cardiac issues and subsequent difficulties obtaining a medical certificate for flight. Before the pilot’s most recent medical certification exam, he provided the medical examiner with documentation indicating that he was no longer taking antidepressants. Required standardized neuropsychological testing placed the pilot at average, below average, or mildly impaired when compared with other (somewhat younger) pilots.
Investigators noted that based on the levels of antidepressant medication in the pilot’s system, the pilot likely knowingly misreported his medication use to the FAA when he applied for his medical certificate, and the pilot’s underlying depression, personality disorder, cognitive issues, and medication use likely contributed to his unwillingness to address the airplane’s fuel selector valve problem. In addition, these conditions would have adversely affected his ability to maintain control of the airplane in an emergency.
Probable cause: The pilot’s failure to maintain control of the airplane after a loss of engine power during a go-around. Contributing to the accident was the difficult-to-operate fuel selector valve and the pilot’s continued operation of the airplane with a known mechanical anomaly. Also contributing to the accident was the pilot’s depression, personality disorder, cognitive issues, and medication use, which adversely affected his ability to maintain control of the airplane during the emergency and likely affected his decision not to address the airplane’s fuel selector valve problem.
NTSB Identification: CEN12FA611
This August 2012 accident report is provided by the National Transportation Safety Board. Published as an educational tool, it is intended to help pilots learn from the misfortunes of others.
He just needed Jesus………….