CEN11FA346

NTSB accident investigation · Hansen IB C Cassutt III M · Erie, CO · May 22, 2011

Accident · FatalField investigationFinal report
Date
May 22, 2011, 10:50 local (16:50 UTC)
Place
Erie, CO
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N420FHHansen IB C Cassutt III M
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report March 28, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20110522009259A
Case key
79165

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's incapacitation due to a cardiac event.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

During the initial takeoff on the airplane's maiden flight, witnesses observed the airplane climb to about 300 feet above ground level, turn left, descend and impact the ground. A postaccident examination of the airplane and engine did not reveal any anomalies. An autopsy revealed that that the pilot's left anterior descending artery had up to 70-percent stenosis with 100-percent stenosis in many of the branches. With a lack of control-type injuries to the pilot's extremities, the medical examiner concluded that it was possible that the pilot experienced a sudden cardiac death shortly after takeoff.

Factual narrative

HISTORY OF FLIGHT On May 22, 2011, approximately 1050 mountain daylight time, an amateur built Cassutt III M airplane, N420FH, impacted terrain while maneuvering after takeoff near Erie, Colorado. The private pilot was fatally injured. The airplane sustained substantial damage and a post-crash fire ensued. The airplane was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a flight test. Visual meteorological conditions prevailed for the flight, which was being operated without a flight plan. The local flight was originating at the time of the accident. The accident flight was the airplane's first flight or maiden flight. A witness observed the airplane takeoff from the airport, climb to about 300 feet, and enter a sudden left turn. The airplane was then observed to descend towards the ground and impact terrain. PERSONNEL INFORMATION The pilot, age 64, held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. A third class airman medical certificate was issued on December 9, 2009, with the limitation that the pilot must have glasses available for near vision. On his medical application, the pilot reported using Atenolol to control his high blood pressure. At the time of the last medical application, the pilot reported having logged 1,975 hours with 35 hours in the previous six months. AIRCRAFT INFORMATION The Cassutt is a low-wing, fixed gear airplane, serial number NAC 2009-1, was built by the accident from plans, and was completed in 2011. It was powered by a 100 horsepower experimental engine, which drove a Sterba 58x64 2-bladed wood propeller. The airplane employed a steel tubing frame, covered with fiberglass, fabric, and laminated plywood. The airplane’s airworthiness certificate and experimental operating limitations were issued on May 16, 2011. METEOROLOGICAL INFORMATION At 1049, the automated weather observation facility at the Rocky Mountain Metropolitan Airport (BJC), Broomfield, Colorado, reported wind 240 degrees at 12 knots gusting to 19 knots, visibility 40 miles, few clouds at 7,000 feet, broken layers at 15,000 and 20,000, temperature 64 degrees Fahrenheit, dew point 28 degrees Fahrenheit, and a barometric pressure of 29.88 inches of Mercury. WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that the airplane collided with trees located 350 yards west-northwest of the runway's departure end. Downed tree limbs and impact marks on aspen trees revealed an impact angle of approximately 50 degrees nose down. A two foot deep crater contained fragments of the airplane's composite materials as well as portions of the wooden propeller. The airplane was found inverted, approximately eight feet from the impact crater. A post-crash fire consumed most of the airplane's coverings. All airplane components were found at the accident scene. A portion of the right wing composite casing was found separated from theright wing and was entangled in aspen trees. The spruce wing spar remained attached to the fuselage and displayed thermal damage. Flight control continuity was established from the cockpit controls to the flight control surfaces. The aileron push-pull rod ends displayed overload fractures. The engine received extensive thermal damage. Both magnetos were impact and fire damaged; neither magneto could produce a spark. Engine continuity and compression was confirmed by rotating the propeller by hand. The oil screen contained a tiny amount of particulates, consistent with a new engine. All fuel screens were found to be clean. No anomalies were found with either the airframe or the engine. MEDICAL AND PATHOLOGICAL INFORMATION On May 23, 2011, an autopsy was performed on the pilot by the Weld County Office of the Corner/Medical Examiner as authorized by the Weld County Coroner. Of note, the medical examiner discovered that the heart’s left anterior descending artery had up to 70-percent stenosis with 100-percent in many of the branches. The medical examiner concluded that the pilot’s heart disease may have contributed to the plane crash. He noted that “[i]t is possible that sudden cardiac death occurred shortly after takeoff and that led to the crash, as there are no definitive control type injuries to the extremities.” The manner of death was ruled an accident. The Federal Aviation Administration FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology on specimens from the pilot. The report noted that following findings: 0.821 (ug/mL, ug/g) Atenolol detected in Blood (peripheral) Atenolol detected in Urine The United States National Library of Medicine listed atenolol as a medical used alone or in combination with other medications to treat high blood pressure. The medication is also used to prevent angina (chest pain) and improve survival after a heart attack. Atenolol works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure.

Aircraft

Registration
N420FH
Reported as
Hansen IB C Cassutt III M
Category
Airplane, amateur-built
Serial number
NAC 2009-1
Engine
Experimental O-200 A, 100 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Flight test · Part 91
Operator
Hansen Ib
Registered owner
Hansen Ib
Airworthiness certificate
Special, Experimental (Special)
Departed
KEIK · Erie, CO
Destination
KEIK · Erie, CO
Airport
KEIK · Erie Municipal, runway 33, 4,700 × 60 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Front
Toxicology
Performed
Flight hours
1,975 total

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 12 knots, gusting 19
Visibility
40 statute miles
Lowest ceiling
15,000 ft broken
Temperature
64 °F, dew point 28 °F
Altimeter
29.87 inHg
Observed at
KBJC, 8 nm away

Docket · 7

The files NTSB released with the investigation on February 17, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.