# NTSB CEN11FA346: Hansen IB C Cassutt III M, N420FH, Erie, CO, May 22, 2011 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 22, 2011, 10:50 local (16:50 UTC) - Place: Erie, CO - Coordinates: 40.016387, -105.054168 - Nearby events: https://openairdocs.org/map.md?lat=40.0164&lon=-105.0542&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 28, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 79165 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11FA346 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/79165/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=79165 - Page: https://openairdocs.org/ntsb/CEN11FA346 ## Probable cause The pilot's incapacitation due to a cardiac event. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Impairment/incapacitation: cardiovascular](https://openairdocs.org/ntsb-findings/02012050): Personnel issues › Physical · Pilot (probable cause); cases with it: [Hansen IB C CASSUTT III M, 1 case](https://openairdocs.org/ntsb-findings/02012050/cases.md?model=1970152), [All aircraft, 69 cases](https://openairdocs.org/ntsb-findings/02012050/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Hansen IB C CASSUTT III M, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=1970152), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Hansen IB C CASSUTT III M, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=1970152), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Hansen IB C CASSUTT III M, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=1970152), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Post-impact: Fire/smoke (post-impact)](https://openairdocs.org/ntsb-events/170); cases with it: [Hansen IB C CASSUTT III M, 1 case](https://openairdocs.org/ntsb-events/170/sequence.md?model=1970152), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## 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](https://openairdocs.org/deregistered/N420FH-2017-06-08), registration cancelled 2017-06-08, S/N NAC 2009-1, built 2010 (OpenAirDocs) - Reported make and model: HANSEN IB C CASSUTT III M - Registry model: [Hansen IB C CASSUTT III M](https://openairdocs.org/model/hansen-ib-c-cassutt-iii-m) (registry code 1970152) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: NAC 2009-1 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: fatal; 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 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20110522009259A](https://openairdocs.org/incident/20110522009259A), May 22, 2011: Hansen Ib C CASSUTT III M, Erie, CO, Destroyed, 1 fatal. On may 22, 2011 at 0954 MDT a cassutt iiim, N420FH an experiemental amateur-built impacted the ground during climbout from the tri county airport (eik) while… ## Docket (7 files) The files NTSB released with the investigation on February 17, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=79165. 1.3 MB in all. - Toxicological Report (item 1, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357280&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo: Wreckage (item 2, .PDF, 413 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357281&FileExtension=.PDF&FileName=Photo%3A%20Wreckage-Master.PDF - Photo: Right wing in trees (item 3, .PDF, 389 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357282&FileExtension=.PDF&FileName=Photo%3A%20Right%20wing%20in%20trees-Master.PDF - Photo: Engine (item 4, .PDF, 307 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357284&FileExtension=.PDF&FileName=Photo%3A%20Engine-Master.PDF - Miscellaneous: Atenolol (item 5, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360744&FileExtension=.PDF&FileName=Miscellaneous%3A%20Atenolol-Master.PDF - Witness Statements: excerpt from Erie PD report (item 6, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360785&FileExtension=.PDF&FileName=Witness%20Statements%3A%20excerpt%20from%20Erie%20PD%20report-Master.PDF - Miscellaneous: KBJC Weather (item 7, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360790&FileExtension=.PDF&FileName=Miscellaneous%3A%20KBJC%20Weather-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.