Citra, FL, USA
N709RD
WREN RONNIE D TITAN II
The pilot and passenger departed a private airport in an experimental amateur-built airplane. A witness who knew the pilot described the pilot as flying “aggressively” and observed the airplane complete a barrel roll, and then enter into an aerodynamic stall and spin into a swamp. The witness also advised that it sounded as if the engine was brought back or went back to idle power. Postaccident examination of the accident site and wreckage revealed that there was no debris path, the wreckage was partially submerged, and the odor of fuel was present, along with a fuel sheen on the surface of the water. Flight control continuity was established. The throttle control was in the closed (idle) position and damage to two of the three propeller blades showed no leading-edge gouges or chordwise scratches that would indicate that the propellers were operating under high power at impact. The third propeller blade was submerged in the swamp and could not be examined. The engine was also submerged in the swamp, was not recovered, and could not be examined. Review of weight and balance information indicated that the airplane was likely being operated in excess of the kit manufacturer’s published gross weight. The weight would have resulted in a higher stalling speed, which would have made the airplane more difficult to control in the barrel roll and more difficult to recover once the stall and spin had begun. The pilot was employed as an airline pilot. He was on medical leave for depression, anxiety, and a head injury. The pilot’s toxicology was positive for ethanol. The consistency of ethanol levels across multiple postmortem specimens, including vitreous fluid, indicated that the pilot likely had consumed ethanol before the accident. Based on the ethanol concentrations he likely experienced degradation of judgment and deficits in coordination, psychomotor skills, perception, and attention. In addition, the pilot’s toxicology results detected delta-9-THC and its metabolites 11-hydroxy-THC and carboxy-delta-9-THC. Research shows poor and inconsistent correlation between the degree of impairment and delta-9-THC blood levels in living persons. Interpretation of levels in postmortem cavity blood is further complicated by cavity blood’s potential for contamination. Thus, the pilot’s delta-9-THC results could not be used to determine if specific impairing effects were present. In addition, the pilot’s toxicology results detected other central nervous system depressant medications including quetiapine and gabapentin, both of which can adversely interact with one another, in addition to ethanol, to worsen impairment—most commonly in the form of drowsiness, difficulty concentrating, and confusion. According to the Federal Aviation Administration (FAA) medical case review, the pilot had a significant history of depression and anxiety. Depression can impact risk perception; specifically, some depressed persons will avoid risk to avoid anxiety, while others may engage in risky behavior without consideration of the consequences. One month before the accident, a psychologist assessed the pilot via formal neurocognitive testing and recommended him for consideration of Special Issuance medical certification. The pilot’s psychiatrist assessed the pilot’s condition to be “stable.” Thus, whether the pilot’s psychiatric condition contributed to the accident could not be determined. The pilot’s autopsy detected mild coronary artery disease with low grade stenoses and a flabby myocardium. Due to his mild heart disease, the pilot was at a slightly increased risk of a sudden distracting, impairing, or incapacitating cardiac event, including angina, arrhythmia, or heart attack; however, there is no forensic evidence that such an event occurred. The circumstances of the accident with the pilot actively controlling the airplane through an aerobatic maneuver is generally inconsistent with a sudden incapacitating event. Thus, it is unlikely that the pilot’s heart disease contributed to the accident. In summary, the airplane’s overweight condition, and the pilot’s use of ethanol, delta-9-THC, gabapentin, and quetiapine before the accident, likely contributed to the accident. The contribution of the pilot’s mental health to the accident could not be determined.
HISTORY OF FLIGHTOn September 17, 2022, about 1847 eastern daylight time, an experimental amateur-built Titan Tornado II airplane, N709RD, was substantially damaged when it was involved in an accident near Citra, Florida. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. On the day of the accident, the pilot and passenger departed Patch O Blue Airport (FD02), Orange Springs, Florida about 1835. According to ADS-B track data provided by the FAA, the airplane made a left turn after takeoff and climbed to about 900 ft above mean sea level while circling back towards FD02, where it appeared to make an approach to the airport. Track data was lost briefly, but then reappeared on the other side of the airport, with the airplane making a left climbing turn and circling back toward the point of departure as it continued to climb. As the airplane climbed and circled to the left within about a 1-mile area, it reached an altitude of just over 3,000 ft. The airplane then began to descend with varying ground speeds until the last track data showed a more significant descent rate. Track data was lost at 1846:47 when the airplane was at 2,200 ft, traveling at a groundspeed of 67 kts on a heading of 227°, about 2.0 miles south of the point of departure. PERSONNEL INFORMATIONThe pilot had served as a naval aviator for 18 years. After retiring from the United States Navy, he was employed as an airline pilot for about 23 years. According to FAA records, the pilot held an airline transport pilot certificate, with a rating for airplane multi-engine land, with commercial privileges for airplane single-engine land, and glider. He possessed type ratings for B-737, B-757, B-767, BD500, and DC-9, and a flight engineer certificate with a rating for turbojet-powered aircraft. He also held sport pilot endorsements for airplane single-engine sea and weight-shift-control land. The pilot also held a flight instructor certificate for multi-engine and instrument airplanes, a flight instructor sport endorsement for weight-shift-control aircraft, and possessed a repairman certificate for weight-shift-control aircraft. At the time of the accident, he was on medical leave and did not possess a medical certificate. No pilot logbooks were recovered or provided. According to FAA records, as of August of 2022, he had accrued about 12,100 total flight hours, of which about 36 hours were in the previous 6 months. AIRCRAFT INFORMATIONThe accident aircraft was a high-wing experimental amateur-built airplane that was assembled from a kit. According to FAA records, the airplane was issued a special airworthiness certificate on October 26, 2006. During the investigation, no maintenance records were recovered or provided. AIRPORT INFORMATIONThe accident aircraft was a high-wing experimental amateur-built airplane that was assembled from a kit. According to FAA records, the airplane was issued a special airworthiness certificate on October 26, 2006. During the investigation, no maintenance records were recovered or provided. WRECKAGE AND IMPACT INFORMATIONExamination of the accident site revealed that the airplane struck trees and came to rest inverted in a swamp within a heavily wooded area on a magnetic heading of about 270°. Further examination revealed that there was no debris path, the wreckage was partially submerged, and the odor of fuel was present along with a fuel sheen on the surface of the water. Examination of the airplane revealed that most of the airplane’s structure was on site. The tail boom was twisted and displayed a fracture around its circumference near the attach point on the fuselage. The wings were partially separated from the fuselage. Control continuity was established from the flight control surfaces to the breaks in the system, and from the breaks in the system to the flight controls in the cockpit. The throttle control was in the closed (idle) position, the cabin door locking mechanism was in the closed position. The fuel filter was free of debris and both it and the fuel line from the fuel tank contained fuel that was clear and bright. Examination of the 3-blade pusher-type propeller revealed that one blade was separated from the hub near the blade root consistent with damage from the impact sequence. Examination of the separated blade did not reveal any evidence of leading-edge gouging or chordwise scratching. Examination of one blade that was visible above the water and had remined attached to the hub also did not reveal the presence of leading-edge gouging or chordwise scratching. The remaining blade was unable to be examined as it was buried in muck below the surface of the water. The engine was also unable to be examined as it was buried in muck below the surface of the water. The wreckage was not recovered. ADDITIONAL INFORMATIONWitness Interview On December 8, 2022, during an interview with an FAA inspector, a witness (who also was a pilot and lived near the accident pilot) stated he was standing on his property when he heard the airplane and when he looked, he thought the pilot was flying over the treetops about 1,500 ft and a mile away from his location. He believed that the pilot (who had a passenger onboard) appeared to be flying a bit aggressively, maybe to show off. As he watched, he observed the airplane enter what he believed was an intentional barrel roll to the left. He was surprised as he did not believe that the airplane was certificated for aerobatics. As the airplane did the left barrel roll, it rolled a full 360º and at the completion of the barrel roll was in a nose-down pitch attitude, followed by a nose-up pitch attitude. The airplane then entered a spin to the left and after 4 or 5 rotations during the spin, it sounded as if the engine was brought back or went back to idle power. He waited for full power to be reapplied but then lost sight of the airplane, as the airplane spun below the tree line. He did not see or hear anything fall off the airplane during the barrel roll. He did hear the engine power being in what he thought was full idle after the barrel roll was completed. 14 CFR 91.303 - Aerobatic Flight According to 14 CFR Part 91.303, aerobatic flight means an intentional maneuver involving an abrupt change in an aircraft's attitude, an abnormal attitude, or abnormal acceleration, not necessary for normal flight. 14 CFR 91.307 - Parachutes and Parachuting Both the pilot and the passenger were not wearing parachutes. According to 14 CFR 91.307, Unless each occupant of the aircraft is wearing an approved parachute, no pilot of a civil aircraft carrying any person (other than a crewmember) may execute any intentional maneuver that exceeds— (1) A bank of 60 degrees relative to the horizon; or (2) A nose-up or nose-down attitude of 30 degrees relative to the horizon. FAA Advisory Circular AC 61-67C - Stall and Spin Awareness Training According to AC 61-67C, the first step in recovering from an upright spin is to close the throttle completely to eliminate power and minimize the loss of altitude. If the particular aircraft spin recovery techniques are not known, the next step is to neutralize the ailerons, determine the direction of the turn, and apply full opposite rudder. When the rotation slows, briskly move the elevator control forward to approximately the neutral position. Some aircraft require merely a relaxation of back pressure; others require full forward elevator control pressure. Forward movement of the elevator control will decrease the angle of attack (AOA). Once the stall is broken, the spinning will stop. Neutralize the rudder when the spinning stops to avoid entering a spin in the opposite direction. When the rudder is neutralized, gradually apply enough aft elevator pressure to return to level flight. Too much or abrupt aft elevator pressure and/or application of rudder and ailerons during the recovery can result in a secondary stall and possibly another spin. If the spin is being performed in an airplane, the engine will sometimes stop developing power due to centrifugal force acting on the fuel in the airplane's tanks causing fuel interruption. It is, therefore, recommended to assume that power is not available when practicing spin recovery. As a rough estimate, an altitude loss of approximately 500 ft per each 3-second turn can be expected in most small aircraft in which spins are authorized. Greater losses can be expected at higher density altitudes. MEDICAL AND PATHOLOGICAL INFORMATIONAccording to FAA records, the 64-year-old pilot’s last aviation medical examination was on August 25, 2022. At that time, he reported a medical history including depression and generalized anxiety as well as high blood pressure. He reported using the medications quetiapine, lisinopril, escitalopram, and gabapentin. In February of 2022, the pilot sustained a fall and a mild closed head injury resulting in headaches, neck pain, vision problems, and mood liability. At the time of his last aviation medical examination, the pilot was still in therapy for complications from his head injury. The aviation medical examiner (AME) deferred his medical certification decision to the FAA due to the pilot’s ongoing therapy and his use of quetiapine and gabapentin. Before his last aviation medical examination, the pilot underwent formal neurocognitive testing. Based on the results, the psychologist recommended re-authorization of his special issuance medical certification. In addition, the pilot had a psychiatric visit and the psychiatrist reported the pilot was psychiatrically stable. At the time of the accident, FAA review of the pilot’s application for medical certification was pending. According to the pilot’s autopsy report, his cause of death was multiple blunt force injuries, and his manner of death was accident. He was noted to have mild coronary artery disease with 30-40% stenosis of the distal left anterior descending coronary artery and the mid-portion of the right coronary artery as well as moderate atherosclerotic disease of the abdominal aorta. A flabby myocardium was also noted. The remainder of the autopsy examination did not identify other significant natural disease. Postmortem toxicological testing of one cavity blood specimen detected delta-9-THC at 38 ng/mL, carboxy-delta-9-THC at more than 500 ng/mL, and 11-hydroxy-THC at more than 100 ng/mL. In additional specimens, delta-9-THC was detected in cavity blood at 22.1 ng/mL and in urine at 15.8 ng/mL. Carboxy-delta-9-THC was detected in cavity blood at 87.8 ng/mL and in urine at 277 ng/mL. 11-hydroxy-THC was detected in cavity blood at 8.9 ng/mL and in urine at 739.4 ng/mL. Ethanol was detected in a cavity blood specimen at 0.055 g/dL, in vitreous fluid at 0.063 g/dL, and in urine at 0.069 g/dL. Citalopram was detected in cavity blood at 79 ng/mL and was not detected in urine. N-desmethylcitalopram was detected in cavity blood at 51 ng/mL and was not detected in urine. Quetiapine was detected in cavity blood at 13 ng/mL and urine at 17 ng/mL. Norquetiapine was detected in cavity blood at 13 ng/mL and urine at 421 ng/mL. Gabapentin was detected in cavity blood at 1835 ng/mL and urine at 88,944 ng/mL. TESTS AND RESEARCHWeight and Balance According to the kit manufacturer, the airplane was designed to a +6g /-4g load limit at 1,000 pounds gross weight. A review of the kit manufacturer’s weight and balance data and the accident airplane’s weight and balance data submitted to the FAA by the original builder indicated that the accident aircraft’s empty weight of 624 pounds was higher than the published kit manufacturer’s standard empty weight of 440 pounds, which would have resulted in a reduction of useful load by 184 pounds. Further review also indicated that the kit manufacturer’s acceptable Center of Gravity (CG) forward limit was 73” aft of datum and the acceptable CG aft limit was 79” aft of datum. Calculations using the kit manufacturer’s published weight and balance data, and the accident airplane’s weight and balance data submitted to the FAA by the original builder, along with the pilot’s actual weight of 187 pounds and the passenger’s actual weight of 180 pounds, indicated that the airplane at the time of the accident was within the lateral CG limits but over the kit manufacturer’s published gross weight. Calculations with just the pilot and passenger onboard, with no fuel, indicated that the airplane would have only been 9 pounds below the published gross weight. Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25C) According to the Pilot’s Handbook of Aeronautical Knowledge, compliance with the weight and balance limits of any aircraft is critical to flight safety. Operating above the maximum weight limitation compromises the structural integrity of an aircraft and adversely affects its performance. Two of the listed deficiencies of an overloaded aircraft were reduced maneuverability and a higher stalling speed.
The pilot’s exceedance of the airplane’s critical angle of attack and failure to maintain airspeed while recovering from an aerobatic maneuver, which resulted in an aerodynamic stall and loss of control. Contributing to the accident was the pilot’s use of ethanol and other depressant medications, and his decision to operate the airplane outside of the published weight limitations.
Source: NTSB Aviation Accident Database
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