Aviation Accident Summaries

Aviation Accident Summary ANC04LA093

Palmer, AK, USA

Aircraft #1

N898DH

Hudson Hiperbipe SNS-7

Analysis

The solo private pilot was departing in a recently built experimental/homebuilt airplane. A witness reported that just after the airplane became airborne, it climbed to about 200 to 300 feet above the runway. As it approached the departure end, it initially turned about 90-degrees to right of the runway centerline, immediately followed by a tight 360-degree turn to the left, circling the departure end of the runway. As the airplane continued the tight 360-degree left turn, the wings rolled and continued to roll until the airplane was inverted. The nose of the airplane abruptly pitched down, and the airplane descended into a large stand of trees at the departure end of the runway, followed by a large plume of black smoke. The wood and fabric-covered airplane was destroyed by a combination of impact forces and a postimpact fire. A postaccident investigation revealed that the accident pilot had been diagnosed with Type II diabetes about 12 years prior, and was using self-administered insulin injections to control his diabetes. A review of the pilot's FAA Airman Medical Records Center located in Oklahoma City, dating back to July 1, 1980, revealed no disclosure of his use of medications or any diagnosis of diabetes. The aviation medical examiner that issued the pilot his most recent third-class medical certificate was not the pilot's personal physician that was treating him for diabetes. The pilot's primary care physician prescribed Humalog 75/25 insulin for treatment of diabetes. Humalog 75/25 insulin has a very rapid onset of glucose-lowering action, and the manufacturer recommends that the dose be given within 15 minutes before eating a meal to avoid hypoglycemia (low blood glucose), a condition which can lead to behavioral changes, confusion, fatigue, seizures, and loss of consciousness. The pathologist that conducted the postmortem examination noted that the pilot's stomach was empty. Postmortem toxicology tests revealed the presence of glucose in the pilot's urine, suggesting that his blood glucose was likely over 180 mg/dL at some time between his awakening and the time of the accident (normal levels are typically between 80 and 120 mg/dL).

Factual Information

HISTORY OF FLIGHT On August 18, 2004, about 0810 Alaska daylight time, a wheel-equipped experimental/homebuilt, Hudson Hiperbipe SNS-7 airplane, N898DH, was destroyed by impact and postimpact fire when it collided with tree-covered terrain following a loss of control during initial takeoff climb from the Wolf Lake Airport, Palmer, Alaska. The airplane was being operated as a visual flight rules (VFR) local area personal flight under Title 14, CFR Part 91, when the accident occurred. The certificated private pilot, the sole occupant, received fatal injuries. Visual meteorological conditions prevailed, and no flight plan was filed. The flight originated about 0810 from the Wolf Lake Airport. During on-scene interviews with the National Transportation Safety Board (NTSB) investigator-in-charge (IIC) on August 18, a witness located at the Wolf Lake Airport reported that the airplane departed runway 24, and climbed to about 200 to 300 feet above the ground. The witness reported that as the airplane approached the departure end of the runway, it initially turned about 90-degrees to right of the runway centerline, immediately followed by a tight 360-degree turn to the left, circling the departure end of the runway. The witness said that as the airplane continued the tight 360-degree left turn, the wings rolled and continued to roll until the airplane was inverted. The nose of the airplane abruptly pitched down, and it descended into a large stand of trees at the departure end of the runway, followed by a large plume of black smoke. Search and rescue personnel from the Alaska State Trooper's, Palmer/Mat-Su Fire Department, and various residents, responded to the accident site and discovered the airplane was fully engulfed in fire. DAMAGE TO AIRCRAFT The wood and fabric-covered airplane was destroyed by a combination of impact forces and a postimpact fire. PERSONNEL INFORMATION The pilot held a private pilot certificate with an airplane single-engine land, and an instrument rating. The most recent third-class medical certificate was issued to the pilot on November 1, 2002, and contained no limitations. No personal flight records were located for the pilot, and the aeronautical experience listed on page 3 of this report was obtained from a review of the Federal Aviation Administration (FAA) records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. On the pilot's application for medical certificate, dated November 1, 2002, the pilot indicated that his total aeronautical experience consisted of about 5,000 hours, of which 50 were accrued in the previous 6 months. During a telephone conversation with the NTSB IIC on October 27, 2004, the pilot's wife reported that her husband had been diagnosed with Type II diabetes about 12 years prior, but added that he was able to control his diabetes by using self-administered insulin injections. She characterized her husband's control and monitoring of his diabetes as very "militaristic" at times. The pilot's wife noted that on the day of the accident, her husband awoke early and left the house, before the rest of the family. She said that her husband's normal morning routine included eating breakfast, checking his blood sugar, and administering a dose of insulin. She reported that she was unaware if her husband had administered himself any insulin or eaten breakfast before leaving the house on the morning of the accident. A review of the pilot's FAA applications for Airman Medical Certificate on file at the Airman and Medical Records Center located in Oklahoma City, dating back to July 1, 1980, revealed no disclosure of his use of medications or any diagnosis of diabetes. On the pilot's most recent application for medical certificate, dated November 1, 2002, in section "17" of the application (FAA form 8500-8), indicated "no" in response to "Use of any medications (prescription or nonprescription)." Additionally, in response to the pilot's medical history questions, specifically question number 18k, "Diabetes," was indicated "no" to the question about diabetes. The aviation medical examiner (AME) that issued the pilot his most recent third-class medical certificate was not the pilot's personal physician that was treating him for his diabetes. The NTSB medical officer reviewed the medical records obtained from the accident pilot's primary care physician. According to the medical records obtained, the accident pilot had been under treatment for type II diabetes mellitus. The pilot is noted to have hypoglycemia (low blood sugar) at various times. An entry on 10/1/02: "hypoglycemic during hunting trip" An entry on 5/15/03: "morning blood glucoses highest of day 80-140 - lowest prior to lunch - no hypoglycemic symptoms" An entry on 2/13/04: "consistently low at lunch" An entry on 4/29/04: "still low at lunchtime." On June 8, 2004, the last entry in the accident pilot's primary care medical records notes, in part: "...home blood glucoses very affected currently by long [work] hours. Adhering to current regimen...blood glucose 137, hemoglobin A1c 7% ...Assessment: Diabetes Mellitus Type I... Still working on [Super] Cub in garage..." The medical records also revealed that the pilot's primary care physician prescribed Humalog 75/25 insulin for treatment of the pilot's diabetes. According to the NTSB medical officer, Humalog 75/25 insulin has a very rapid onset of glucose-lowering action, and the manufacturer recommends that the does be given within 15 minutes before eating a meal to avoid hypoglycemia. A copy of the NTSB medical officer's factual report is included in the public docket for this accident. At the time of the accident, the pilot was employed as an aviation mechanic, working for Wick Air, Inc., a local FAA approved aircraft repair facility located in Palmer. According to the president of Wick Air, a local physician who had hired Wick Air to complete the initial construction of the experimental/homebuilt airplane owned the accident airplane. Wick Air's president noted that the accident pilot performed a majority of the work on the accident airplane, and when the work was completed, he conducted all of the initial test flights required by the FAA. AIRCRAFT INFORMATION Construction of the experimental/homebuilt airplane was officially completed on August 15, 2004, having successfully completed all of the required initial test flights. All work was reportedly completed in accordance with FAA Advisory Circular AC90-89A, which requires a minimum of 40 hours of test flight time before an FAA special airworthiness certificate can be issued. At that time, the airplane and engine had accumulated a total time in service of 40.8 hours. According to the aircraft logbook entries, the final test flight, and all previous test flights, were certified by the accident pilot's signature. MEDICAL AND PATHOLOGICAL INFORMATION A postmortem examination of the pilot was conducted under the authority of the Alaska State Medical Examiner, 4500 South Boniface Parkway, Anchorage, Alaska, on August 19, 2004. The cause of death was attributed to smoke and soot inhalation. The Federal Aviation Administration (FAA) Civil Aero medical Institute (CAMI) conducted a toxicological examination on September 23, 2004, and was negative for drugs or alcohol. However, the examination revealed the presence of 5450 gm/dl of glucose in the pilot's urine. The physician that conducted the postmortem examination noted in the section that describes the decedents gastrointestinal exam, in part: "The stomach is empty..."

Probable Cause and Findings

The pilot's failure to maintain control of the airplane, which resulted in an uncontrolled descent and subsequent in-flight collision with trees. A factor associated with the accident was a low altitude maneuver preformed by the pilot just after takeoff.

 

Source: NTSB Aviation Accident Database

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