Marysville, OH, USA
N930LA
Evektor-Aerotechnik AS Sportstar Plus
The sport pilot departed on a cross-country flight without a flight plan and there was no record of a weather briefing for the route of flight with forecasted instrument meteorological conditions (IMC). Recorded radar data showed that as the airplane approached the area of IMC, it changed heading and altitude and tracked southward, which was then followed by a descending turn with increasing airspeed. The airplane impacted a field in a nose-down attitude. The pilot was taking three different medications to treat his diabetes, which would have increased his risk for impairment due to excessively low blood sugar. He had been using a medication for respiratory symptoms combining a narcotic and an antihistamine, both of which have potentially impairing effects. He also may have taken another medication containing the same antihistamine. He had been using a stimulant typically prescribed for weight loss and a sedative previously prescribed for insomnia. He was at high risk for, and had previously been noted to possibly have, obstructive sleep apnea, which can cause severe fatigue and resultant impairment. The pilot may have been impaired or distracted by symptoms of his medical conditions or by effects of medications used to treat those conditions. The extent to which such possible impairment or distraction may have contributed to the accident is unclear. The crash severity precluded the determination of the existence or absence of substantive pre-existing disease, or the determination regarding when medications may have most recently been used. The pilot did not have a Federal Aviation Administration airman medical certificate, nor was he required to for a sport pilot certificate. Postaccident examination of the airplane revealed no anomalies that would have precluded normal operation.
HISTORY OF FLIGHT On March 5, 2010, at 0857 eastern standard time, a special light sport Evektor-Aerotechnik AS Sportstar Plus, N930LA, impacted terrain near Marysville, Ohio. Instrument conditions prevailed at the time of the accident. The Code of Federal Regulations Part 91 flight was not operating on a flight plan. The sport pilot and one passenger were fatally injured. The flight originated from Greenwood Municipal Airport (HFY), Indianapolis, Indiana, at 0716 and was en route to New Castle Municipal Airport (UCP), New Castle, Pennsylvania. According to an employee of a fixed base operator at HFY, the pilot pulled up in his Jeep and asked about the self-serve fuel pumps. The employee told the pilot that the self-serve pumps were being worked on and was then asked by the pilot to “top off” the airplane. The employee added 3.8 gallons of 100 low lead (100LL) fuel to the left fuel tank and did not see the airplane again. A fuel service form dated March 4, 2010, at 1345 showed the airplane was serviced with 3.8 gallons of 100LL. The pilot’s flight instructor stated that the pilot had “mentioned” that he was going to fly to Pennsylvania, but he never gave a reason for the trip. The pilot did not reserve the airplane through the Greenwood Flying Club’s on-line scheduling system, but two other club members had done so for the day of the accident. The two other members separately reserved the airplane at 1000 and at 1100 or 1130. The airplane was not at the airport when either of the two other pilots arrived for their flights. The flight instructor thought it was “strange” that the pilot had not scheduled the airplane because he was “really good” at reserving it. There were no records of the pilot contacting Flight Service or the Direct User Access Terminal Service on March 4, 2010 or March 5, 2010, to obtain weather information or to file a flight plan. An Alert Notice (ALNOT) for an overdue aircraft was issued at 1444 due to a family concern. The route of flight was direct to UCP with an expected arrival time of 1030. PERSONNEL INFORMATION The pilot was issued a sport pilot certificate on November 5, 2008, after he had passed his airman exam using an Evektor Sportstar. The pilot’s total flight time at the time of the examination was 86.5 hours. The pilot’s logbook entries were dated from June 7, 2007, to March 1, 2010. The March 1, 2010, entry shows a flight in an EVSS, N30LA that was 1.0 hours in duration from HFY to HFY and four landings. The entry also showed that of the 1.0 hours of flight time, 1.0 hours was actual instrument time with the printed first name of the pilot’s flight instructor. The entry’s remarks stated, “practice & maneuvers.” The pilot’s total flight time at the time of this last entry was 186.1 hours, of which 1.0 hours were in actual instrument conditions. AIRCRAFT INFORMATION The airplane was an Evektor-Aerotechnik AS Sportstar Plus, serial number 20070930, which was certified as a Light Sport Aircraft on November 1, 2007. The airplane was powered by a Rotax 912ULS, serial number 5648799 engine. The airplane was registered to the Greenwood Flying Club LLC on July 1, 2009. The airplane logbooks were not found by the National Transportation Safety Board (NTSB) Investigator-In-Charge (IIC), Federal Aviation Administration (FAA), or recovery personnel nor were any aircraft logbooks received by the NTSB IIC. A mechanic who had worked on the airplane stated that he had the invoices and maintenance entries, which were about two years old, for the airplane. He stated that he had never seen the airplane logbooks, but when he completed maintenance work on the airplane, he would provide an adhesive backed entry. The mechanic stated that he remembered having performed a maintenance inspection of the airplane but not one that was current. The mechanic later provided a list of maintenance entries dated February 10, 2008 to November 13, 2009, and invoices. The November 13, 2009, entry states that an annual condition inspection was completed at a total time of 509.0 hours. A second entry with this date states that a 100-hour condition inspection was completed and the engine was “found to be in a condition for safe flight…” METEROLOGICAL INFORMATION AIRMET Sierra update 3 was issued at 0708 for instrument flight rule (IFR) conditions that included Ohio for an area from 20 nautical miles (nm) southwest of Erie, Pennsylvania, to 20 nm west northwest of Bellaire, Ohio, to 30 nm south of Appleton, Ohio, to Rosewood, Ohio, to 40 nm south southeast of Detroit, Michigan, to 20 nm southwest of Erie, Pennsylvania. The advisory was for ceilings below 1,000 feet and/or visibility below 3 statute miles (sm) and mist; conditions ending at 1000. The Union County Airport (MRT), Marysville, Ohio, AWOS-3 recorded the following observations: From 0454 – 0634, the visibility was 10 sm and the sky condition was clear. At 0654 the visibility was unchanged and the sky condition was scattered at 400 feet above ground level (agl). At 0714, the visibility was unchanged and the sky condition was broken at 400 feet agl. At 0834, visibility - 1 sm, sky condition - overcast 200 feet agl At 0854, visibility - 4 sm, sky condition - overcast 200 feet agl The Port Columbus International Airport (CMH), Columbus, Ohio, located about 25 nm southeast of MRT recorded the following observations: At 0827, visibility - 9 sm, sky condition – overcast 600 feet agl At 0851, visibility - 8 sm, sky condition – overcast 600 feet agl The CMH terminal area forecast (amendment) issued at 0547 was for temporary conditions from 0600 – 0900, for visibility - 3 sm, mist, sky condition – broken 300 feet agl. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was located about 4.1 nm on a 145.4 degrees magnetic bearing from MRT on a snow covered agricultural field. The wreckage path was approximately 280 feet in length and oriented on an east/west heading. Near the eastern edge of the wreckage path, a ground scar was present that contained pieces of the propeller with impressions consistent with the right wing and a portion of left wing leading edges. The right wing impression was on the east side and left wing impression was on the west side of the propeller pieces and were orientated approximately perpendicular to a northerly heading. A separated piece of the left wing was near the ground scar. The left and right wing sections were separated from the fuselage and were resting inverted about 100 feet west of the propeller pieces. Both sides of the wing were bent rearwards into a V-shape with the right wing tip facing an approximately northerly heading. The engine was separated from fuselage and was located between the propeller pieces and the wing. The fuselage with its attached empennage was resting upright about 10 feet west of the wing. The wing leading edges displayed inward crushing at an estimated 80-90 degrees. Examination of the flight controls confirmed flight control continuity. Examination of the airplane instrument system revealed no anomalies. The engine was shipped to Rotech Flight Safety Ltd. where it underwent a disassembly examination under the supervision of a National Transportation Safety Board Investigator. The examination revealed no evidence that would have precluded normal engine operation. The pilot’s logbook was found within a bag found along the debris path of the airplane. MEDICAL INFORMATION The FAA’s Final Forensic Toxicology Fatal Accident Report for the pilot reported the following: chlorpheniramine detected in lung and kidney, 0.14 (ug/ml, ug/g) hydrocodone detected in lung, 0.089 (ug/ml, ug/g) hydorcodone detected in kidney, irbesartan detected in lung and kidney, phentermine detected in lung and kidney, 0.275 (ug/ml, ug/g) temazepam detected in kidney, and 0.142 (ug/ml, ug/g) temazepam detected in lung. A review of the pilot’s personal medical records indicated a history of multiple medical conditions, including diabetes, kidney disease, high blood pressure, high cholesterol, insomnia, possible obstructive sleep apnea, possible glaucoma, LASIK surgery, cataract surgery, and nasal allergies, among others. Records indicated that medical care had been received by the pilot from a Veterans Affairs (VA) Medical Center, a non-VA primary care physician, a non-VA endocrinologist, a non-VA kidney specialist, and a non-VA ophthalmologist, among others. Records noted the use of multiple medications, including glyburide (5 mg twice a day), sitagliptin (50 mg per day), and exenatide (10 mcg subcutaneously twice a day) for diabetes; niacin (1,000 mg per day) and ezetemibe/simvastatin (10 mg/40 mg per day) for cholesterol, irbesartan/hydrochlorothiazide (300/12.5 mg daily) for high blood pressure; and a prior prescription for temazepam (30mg) for use at night. None of the records reviewed indicated any prescriptions for phentermine. The pilot’s most recent (as of September 30, 2009) weight was noted as 258 pounds and his height was 71 inches. An exercise stress test performed in January 2006 did not identify any abnormalities. The medical records also noted that the pilot was seen by a non-VA primary care physician with symptoms of cough and shortness of breath on October, 20, 2009, and a prescription was filled in the pilot’s name for an extended release hydrocodone/chlorpheniramine syrup from that physician on October 13, 2009, with refills on December 13, 2009 and on March 4, 2010, the day prior to the accident. The March 4, 2010 refill of the hydrocodone/chlorpheniramine syrup was found in the wreckage, along with a nasal decongestant spray, a nasal steroid spray, and a separate bottle of over-the-counter chlorpheniramine tablets. The bottle of hydrocodone/chlorpheniramine syrup was labeled with the brand name (Tussionex) of the compound, and did not note that chlorpheniramine was a component. Information printed on the back and side of the bottle included: “Shake well before using,” “Do not drink alcoholic beverages when taking this medication,” “May cause blurred vision,” “Taking more than recommended may cause breathing problems,” and “May make you drowsy/dizzy, especially with alcohol. Use care with car-machines.” The autopsy report on the pilot noted that “the majority of the internal organs are severely lacerated and displaced from their normal anatomic positions.” TESTS AND RESEARCH A printed page from NavMonster.com, dated March 4, 2010, was recovered from the accident site and showed a route from HFY to UCP with a distance of 273 nm, an initial true course of 070 degrees, and an estimated time en route of 2 hours 16 minutes at a speed of 120 knots (no winds). Radar data of a “possible track” for the airplane with a squawk code of 1200 showed that about 0846, the airplane was about 11 nm west of MRT at an altitude of 5,400 feet along an easterly track. About 0853, the airplane was about 0.8 nm northeast of MRT at an altitude of 3,300 feet along an easterly-southeasterly track. About 0854, the airplane was 3.5 nm east-southeast at an altitude of 1,800 feet the decreased to 1,100 feet over a period of 10 seconds along a southerly track. About 2 minutes later, the track became southwesterly and returned to a southerly track. A Global Positioning System (GPS) receiver recovered from the wreckage recorded its last four data points about 4 nm southeast of MRT beginning at an altitude of 1,719 feet, a ground speed of 100 knots, and a track of 173.5 degrees. The remaining three GPS data points showed an altitude decrease to 1,423 feet, the ground speed varied from 102-131 knots, and a track that increased from 179.6 to 227.7 degrees.
The pilot's improper decision to initiate and continue a flight into instrument meteorological conditions that led to spatial disorientation and a loss of control during cruise flight.
Source: NTSB Aviation Accident Database
Aviation Accidents App
In-Depth Access to Aviation Accident Reports
