Culpeper, VA, USA
N168EX
Extra Flugzeugbau GMBH 300
During an airshow, the experienced aerobatic pilot was demonstrating a series of five snap rolls along a 45-degree "down line." The airplane completed two left-turning rolls at an approximately 45-degree descent angle, but, during the third roll, the trajectory changed toward a vertical descent. Following that, three additional left rolls were completed in an approximately vertical-descent trajectory. After recovering from the last, and unplanned, sixth roll, the airplane stabilized in an estimated 45-degree nose-down, 20-degree left-wing-down attitude. The airplane continued to descend, and, as it neared the ground, the airplane's nose began rising so that the airplane was almost level when it impacted terrain. The pilot was transported to a nearby medical center where she died about 11 hours after the accident. An on-site examination of the airplane and engine revealed no preimpact mechanical anomalies. Postmortem toxicological testing of the pilot revealed the presence of morphine, consistent with amounts administered after the accident. Testing also indicated the presence of phentermine, a prescription stimulant drug in the same class as amphetamines, and fluoxetine, a prescription antidepressant often known by the trade name Prozac. The amounts found during testing indicated that both drugs had been present before the accident at levels much higher than would be expected for routine dosing. On her most recent airman medical certificate application, less than 5 months prior to the accident, the pilot did not indicate the use of phentermine or fluoxetine, or any visits to healthcare providers during the previous 3 years. Routine doses of fluoxetine are not thought to affect performance, and the effects of its overuse are unknown. The use of phentermine may result in physical and psychological dependence. Despite the use of higher-than-normal doses of phentermine, the pilot was not observed prior to the flight to have any symptoms consistent with stimulant overdose, which indicates tolerance to the effects of the drug and suggests the possibility of substance dependence. Overuse of, or a dependence on, phentermine may adversely affect a pilot’s judgment or psychomotor performance. Given the challenging nature of the maneuver being performed during the accident flight, even a slight impairment would have been sufficient to contribute to the accident.
HISTORY OF FLIGHT On October 14, 2006, about 1300 eastern daylight time, an Extra Flugzeugbau GMBH 300, N168EX, was destroyed when it impacted terrain at Culpeper Regional Airport (CJR), Culpeper, Virginia. The certificated commercial pilot was fatally injured. Visual meteorological conditions prevailed, and the airplane was not operating on a flight plan. The local air show flight was being conducted under 14 Code of Federal Regulations Part 91. According to a Federal Aviation Administration (FAA) inspector who had been attending the show, the pilot had been performing aerobatic maneuvers for 6 to 7 minutes along runway 4/22 when the accident occurred. At the time of the accident, the pilot was performing multiple snap rolls on a 45-degree down line, and during the maneuver, the inspector heard the announcer state that the airplane was in "the fourth turn of a five-turn demonstration." The inspector also noted the altitude of the airplane in reference to the ground and shouted "NO", as he "did not believe the aircraft could make another turn and clear the ground." Another witness observed the airplane "descending rapidly straight towards the ground at a point approximately one-third of the way down runway 22." He estimated that it was "approximately 30-40 feet agl [above ground level] [when] the pilot attempted to pull out of the downward angle and regain level flight." A third witness noted that the pilot "was just about to finish her maneuver when she seemed to be accelerating towards the ground." He "only caught the last few seconds, [but] noticed that she snapped the wings level and contacted the ground (grassy area east of runway 22) on all three wheels, a 3-point landing." The airplane "continued on the grass and it seemed that the right wing started to lift, then the aircraft started to tumble..." A fourth witness "[became] concerned that the airplane seemed to be very low when the rotations stopped. The airplane stopped rotation but was still descending and angled slightly towards the runway. There was a quick roll to the left and pitch up shortly followed by the left wing impacting the ground. I believe the airplane cartwheeled once before going out of sight as there is a ground depression on the other side of the runway." A review of video footage revealed that the airplane completed two left-turning rolls at an approximately 45-degree descent angle, but during a third roll, the trajectory changed toward a vertical descent. Following that, three additional left rolls were also completed in an approximately vertical-descent trajectory. After recovering from the last roll, the airplane stabilized in an estimated 45-degree nose-down, 20-degree left-wing-down attitude. The airplane continued to descend, and as a distant tree line came into the camera's view, the airplane's nose began rising, to where it was nose-level when the airplane impacted the ground. The airplane then disappeared into a depressed area behind the runway. PERSONNEL INFORMATION The pilot, age 56, held a commercial pilot certificate with airplane single engine land, and instrument airplane ratings. She also held a flight instructor certificate for airplane single engine land. The pilot's logbook was not recovered. On the application for her latest FAA second class medical certificate, dated May 30, 2006, the pilot indicated that she had 5,200 hours of flight time, with 150 hours in the previous 6 months. A family member, as well as online biographical information about the pilot, indicated that she had performed aerobatic maneuvers such as the one during the accident sequence for many years. Biographical information also indicated that she had over 3,000 hours of aerobatic flight experience. There were no reports of unusual behavior by the pilot prior to the accident flight. An individual who had spoken to her at the previous night's banquet described her as "normal," with "nothing in her demeanor to cause any concern." Another person, who saw the pilot at the morning flight safety briefing, also described the pilot as "normal," and a third person, who observed the pilot walk through her routine prior to her flight, described her as "very focused in preparation for her performance." AIRCRAFT INFORMATION The airplane was manufactured in 2003, and was powered by a Lycoming AEIO-540-series engine. According to maintenance records, the latest annual inspection was completed on March 10, 2006, at 333.5 hours since new. AIRPORT INFORMATION Runway 4/22 was 4,002 feet long and 75 feet wide. Airport elevation was 313 feet. Northwest of the first half of runway 22 was a parking apron, and across the runway from that was an open area where the acrobatics took place. METEROLOGICAL INFORMATION Weather, reported at an airport 20 nautical miles to the northeast, at 1253, included clear skies, visibility 10 statute miles, winds from 280 degrees true at 11, gusting to 16 knots, temperature 14 degrees Celsius (C), dew point -4 degrees C. WRECKAGE AND IMPACT INFORMATION An examination of the accident site revealed a 950-foot wreckage path that began about 200 feet to the east of the runway, then continued along a general path of 240 degrees magnetic, and ended at the main wreckage, about 50 feet from the runway's edge. Initial ground scars along the wreckage path correlated to the airplane's three landing gear and the left wingtip. All flight control surfaces were accounted for at the scene. Left wing remnants were found along the wreckage path, while most of the right wing came to rest next to the main fuselage. The main fuselage was on its right side at the time of examination; however, witnesses reported that it had initially come to rest inverted and was rolled to rescue the pilot. The fuselage was charred in the cockpit area, and the only indicating gauge was the altimeter, which was indicating zero feet. Flight control continuity was confirmed from the cockpit to the rudder and elevator. The propeller was shattered, and there was no evidence of mechanical engine failure. Video footage also revealed constant engine power throughout the accident sequence. The airplane had been inspected by FAA personnel prior to the air show for currency of inspections and any visual defects, none of which were noted. MEDICAL AND TOXICOLOGICAL INFORMATION After the accident, the pilot was taken to the University of Virginia Medical Center, Charlottesville, Virginia, where she succumbed to her injuries about 11 hours after the accident. On October 16, 2006, an autopsy was performed on the pilot at the Office of the Chief Medical Examiner, Richmond, Virginia. Cause of death was determined to be "thermal and inhalational injuries." Toxicological testing of iliac blood obtained in conjunction with the autopsy revealed the presence of fluoxetine (0.5 mg/L) and phentermine (0.59 mg/L). Additional toxicological testing was performed by the FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma. Results indicated: - 1.151 ug/ml (ug/g) phentermine in blood - Phentermine detected in the liver - 0.775 ug/ml (ug/g) fluoxetine detected in blood - 62.732 ug/ml (ug/g) fluoxetine detected in liver - 0.392 ug/ml (ug/g) norfluoxetine detected in blood - 30.963 ug/ml (ug/g) norfluoxetine detected in liver - 0.255 ug/ml (ug/g) morphine detected in blood - 0.521 ug/ml (ug/g) morphine detected in liver Records of the pilot's post-accident hospitalization reviewed by the National Transportation Safety Board Medical Officer noted the administration of at least 7 liters of fluid, multiple units of red blood cells and plasma, and morphine. The Medical Officer also reviewed the pilot's medical records maintained by the FAA Aerospace Medical Certification Division. The pilot's most recent medical certificate application noted "No" to the question "Do You Currently Use Any Medication," and "No" to "Visits to Health Professional Within Last 3 Years." On the physical examination conducted in conjunction with the application, the pilot's height was noted as 69 inches, weight 133 pounds, blood pressure 140/74, and resting pulse 84.
The pilot’s disorientation while performing an aerobatic maneuver, which resulted in the airplane’s inadvertent impact with the ground. Contributing to the accident was the pilot’s overuse of prescription medication.
Source: NTSB Aviation Accident Database
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