CEN13FA338

The airline transport pilot (ATP) had volunteered to deliver the airplane to a maintenance facility and had made the arrangements for the flight, including preflight planning. The commercial pilot chose to ride along with the ATP to gain flight experience and familiarity with the airplane. After stopping to refuel, the airplane took off on the last leg of the cross-country flight that night. The commercial pilot reported that, about 10 minutes from their destination, the fuel gauge was reading "close to empty." About 5 minutes later, the engine lost power, at which time, the ATP took control of the airplane. The pilots attempted to deploy the ballistic parachute just before the forced landing; however, due to the low altitude, it did not fully deploy. The airplane impacted the ground hard, and the high surface winds dragged the airplane across rough and uneven terrain before it became entangled in a barbed wire fence. No fuel was found in the fuel pump or tank. An examination of the engine and fuel system revealed no mechanical anomalies that would have prevented the engine from producing power if fuel had been available. The fuel capacity information in the Pilot's Operating Handbook (POH) provided to the pilots and on the placard created by the ATP (based on the POH) was inaccurate. Although the manufacturer reported that it provided the correct POH to the owner when the airplane was delivered, the owner had the incorrect POH, and the investigation determined that several other owners of this airplane model had received the wrong POH upon delivery of their aircraft. The POH indicated that the airplane had 15 gallons total fuel capacity and 14.5 gallons usable fuel capacity. However, the airplane's actual total fuel capacity was 13.2 gallons and the usable fuel capacity was 12.7 gallons. The calculated fuel requirement for the accident leg of the flight would have been at least 13.2 gallons of fuel; thus, the engine stopped producing power due to fuel exhaustion. Even if the fuel capacity information had been accurate, visual flight rules night flights require a 45-minute fuel reserve, and that would not have been met on the accident leg. Thus, the ATP did not properly calculate the flight's fuel requirements. Further, he failed to adequately monitor the airplane's in-flight fuel consumption and recognize that the airplane was low on fuel. In addition, the airplane was not equipped to fly at night nor was it approved for night flight, yet the pilot planned the flight legs such that the airplane would be flying at night. The ATP's most recent application for a Federal Aviation Administration airman medical certificate had been denied; the commercial pilot did not know this before the accident. Although the ATP was acting in the capacity of the pilot-in-command , because his medical certificate had been denied, he was not qualified to serve in this role. The ATP had severe heart disease, hypertension, and a history of stroke, which increased hisrisk for a cardiac arrhythmia; however, the autopsy found no evidence of a recent heart attack. The ATP also had a history of depression, and toxicological tests were positive for therapeutic levels of the antidepressant medication citalopram, which has an acceptable side effect profile. It could not be determined if the pilot was impaired by cardiac symptoms or depression around the time of the accident; however, the circumstances of the accident make it unlikely. The manufacturer's instruction manual for the parachute stated that the minimum height for deploying the parachute ranged between 100 and 250 feet. However, the POH does not provide any information or guidance regarding the recommended altitude for deployment.

Fuel Capacity When the airplane was originally sold and delivered to the owner, a Pipistrel Pilot's Operating Handbook (POH) was included with the delivery. The POH applied to the ALPHA Trainer LSA equipped with the Rotax 912 engine and was marked as Revision 1 (March 19, 2012). This POH was printed on A4 paper and was bound with clear plastic page covers and a black spiral binding coil. At several points in the POH, including Performance Specifications, Chapter 1 – General, Chapter 2 – Aircraft and System Description, and Chapter 3 – Limitations, the full fuel capacity was written as 15 US gallons and the fuel capacity (usable – all flight conditions) was written as 14.5 US gallons. A Pipistrel POH, Revision 1 was located in the personal effects of the ATP in the wreckage of the airplane. Digital copies of several pages from the POH were provided to investigators including the cover page and several other pages reflecting fuel performance specifications. The POH serial number and registration number (for the accident airplane) had been hand written on the front page of the POH. This POH appeared to have been printed on 8 ½ inch by 11 inch paper. The fuel capacity reflected in this POH was identical to the fuel capacity in the POH for the accident airplane – 15 gallons total and 14.5 gallons usable. Pipistrel representatives reported that the airplane was delivered with revision 3 of the POH. It is unknown how or why the Revision 1 POH was supplied with the airplane at delivery and why the owner did not have the later revisions of the POH. In subsequent revisions of the POH, including Revision 4 which was provided to the NTSB by Pipistrel, the total fuel capacity was written as 13.2 US gallons, and the usable fuel capacity was written as 12.7 gallons. According to the owner of the accident airplane, fuel placards for the airplane's fuel filler cap did not arrive with the airplane when it was delivered. He said that the airline transport pilot had created a label/placard to affix near the fuel filler cap on the fuselage that indicated 15 gallons fuel capacity and 14.5 gallons usable. During the course of the investigation, it was also established that several owners had received the wrong revision of the POH with the fuel capacity error. As a result of this discovery, on August 8, 2013, Pipistrel notified all owners worldwide of the error and requested that they ensure the proper placard with fuel information was affixed adjacent to the fuel filler cap. On August 12, 2013, Pipistrel printed out and issued to all owners, the most recent POH revision with the correct fuel information. Fuel Burn Calculations According to both the Revision 1 and Revision 4 Pipistrel POH, the fuel flow at cruise speed is 3.6 gallons per hour. The Pipistrel POH does not provide fuel usage for engine start, taxi, and takeoff and climb. The following parameters were used by investigators to estimate the fuel requirements for the last leg of the accident flight based uponthis fuel flow rate: - 260 nm between KAID and KBGD - 72 knot average ground speed based upon GPS data - 3.6 gallons per hour - 3 hours and 40 minute flight (estimate) - 3 hours and 20 minutes (actual to the loss of engine power) Based upon the fuel flow information provided in the POH and the estimated flight time, the flight would have required no less than 13.2 gallons of fuel to complete the accident flight to its destination. It is estimated that the flight had used no less than 12.0 gallons of fuel at the time of engine power loss. Galaxy Rescue System – Ballistic Parachute The airplane was equipped with a Galaxy Rescue System (GRS) ballistic parachute. According to the Pipistrel POH, the system deploys in 0.4 to 0.7 seconds. After activation, the "canopy is open and fully inflated in about 3.2 seconds." The POH cites an engine failure over hostile terrain as one situation where the GRS should be deployed. The POH does not provide any information or guidance regarding a recommended altitude for deployment. The POH cautions of the dangers associated with impacting power lines while under the canopy; however, it does not provide any other cautions or warnings. It does state that, once the parachute has been deployed, there may "be a great unknown and great adventure for the crew." The instruction manual for the GRS, available on the GRS manufacturer's website at www.galaxysky.cz, stated that the minimum height for deploying the parachute ranged from 100 feet to 250 feet, depending on the configuration of the parachute design and the speed of the aircraft at the time of deployment. The manual further stated that the company could not guarantee that the occupants would not be injured after deployment or that the aircraft would not be damaged and stated that after deployment that the operator "may enter an unpredictable situation… ." The manual also provided a similar caution as the Pipistrel POH regarding power lines. Code of Federal Regulations The FAA defines pilot in command as "The person who: (1) Has final authority and responsibility for the operation and safety of the flight; (2) Has been designated as pilot in command before or during the flight; and (3) Holds the appropriate category, class, and type rating, if appropriate, for the conduct of the flight. 14 Code of Federal Regulations (CFR) Part 61.23 – Medical certificates: Requirement and duration (c) states in part "Operations requiring either a medical certificate or U.S. driver's license. (1) A person must hold and possess either a medical certificate issued under part 67 of this chapter or a U.S. driver's license when—… (ii) Exercising the privileges of a sport pilot certificate in a light-sport aircraft other than a glider or balloon;… (2) A person using a U.S. driver's license to meet the requirements of this paragraph must—(i) Comply with each restriction and limitation imposed by that person's U.S. driver's license and any judicial or administrative order applying to theoperation of a motor vehicle;(ii) Have been found eligible for the issuance of at least a third-class airman medical certificate at the time of his or her most recent application (if the person has applied for a medical certificate);(iii) Not have had his or her most recently issued medical certificate (if the person has held a medical certificate) suspended or revoked or most recent Authorization for a Special Issuance of a Medical Certificate withdrawn; and(iv) Not know or have reason to know of any medical condition that would make that person unable to operate a light-sport aircraft in a safe manner." 14 CFR Part 91.151 – fuel requirements for flight in VFR conditions states "(a)No person may begin a flight in an airplane under VFR conditions unless (considering wind and forecast weather conditions) there is enough fuel to fly to the first point of intended landing and, assuming normal cruising speed… (2) At night, to fly after that for at least 45 minutes." According to FAA records, the 2012 Pipistrel LSA SRA Alpha Trainer airplane (serial number 453 AT 912 LSA) had been manufactured by Pipistrel. It was registered with the FAA on a special airworthiness certificate for experimental light sport operations. A Rotax 912 UL2 engine rated at 80 horsepower at 5,800 rpm powered the airplane. The engine was equipped with a 2-blade, fixed pitch, wooden, Pipistrel propeller. The airplane was not equipped for night operations. A placard on the switch panel stated "NOT APPROVED FOR NIGHT FLIGHT" and the airplane did not have cockpit lightning. The airplane was maintained under a condition inspection program. A review of the maintenance records indicated that the airplane was inspected and a special airworthiness certificate was issued on January 10, 2013, by the FAA Indianapolis Flight Standards District Office. The condition inspection had been completed on January 4, 2013, at an airframe total time of 5.0 hours. The airplane had flown approximately 27.6 hours between the last inspection and the accident and had a total airframe time of 32.6 hours. A Garmin Aera 500 GPS was installed in the accident airplane. The GPS was sent to the National Transportation Safety Board (NTSB) Vehicle Recorders Lab in Washington D.C. for download. Flight track information, including time, latitude, longitude, altitude, ground speed, and heading was recovered from the unit for the accident flight. The flight departed Anderson, Indiana, and stopped in Mexico, Missouri, and El Dorado, Kansas. According to the data recovered from the GPS, the flight departed a location consistent with El Dorado, Kansas, around 2113. The flight track record was consistent with a relatively direct flight to KBGD. The altitude increased to 6,200 feet and ground speed varied throughout the flight but averaged 72 knots. At 0033:47, the airplane started to descend. At 0037:44, at an altitude of 2,765, the ground speed decreased to 15 knots consistent with the deployment of the ballisticparachute. The last line of data was recorded at 0038:13, at an elevation of 2,748 feet msl. On June 11, 2013, at 0038 central daylight time (CDT), a Pipistrel LSA SRL Alpha Trainer light sport airplane, N477PA, impacted terrain 22 miles north of Pampa, Texas, following a loss of engine power. The airline transport pilot was fatally injured and the commercial pilot was seriously injured. The airplane sustained substantial damage. The airplane was registered to Wisdom Aviation LLC., and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a positioning flight. Dark night visual meteorological conditions prevailed at the time of the accident, which operated without a flight plan. The flight originated from Anderson Municipal Airport – Darlington Field (KAID), Anderson, Indiana, on June 10, 2013, at 1336 and was en route to Hutchinson County Airport (KBGD), Borger, Texas. According to the owner, the airplane was being flown to Moriarty, New Mexico, to receive a repair on the composite material behind the main landing gear. He stated that the airline transport pilot had volunteered to take the airplane to New Mexico for the maintenance. The airline transport pilot intended to fly to Texas, stay overnight, and then continue to New Mexico the next day. According to the commercial pilot, he elected to ride along for the flight to gain flight experience and familiarity with the airplane. The decision was made to depart on June 10, as the commercial pilot had mandatory training he had to return for on June 13. During the flight, the commercial pilot sat in the left seat and the airline transport pilot sat in the right seat. The preflight inspection and engine start checklists were all performed by the airline transport pilot. Both pilots took turns flying. The commercial pilot stated that the airplane stopped in Mexico, Missouri, for fuel. During this stop the airline transport pilot had difficulty restarting the engine and had to call Pipistrel for assistance. The airline transport pilot removed the cowling from the engine to let it cool down and after 15 to 20 minutes they were able to restart the engine. The commercial pilot stated that the flight stopped in Eldorado, Kansas, for fuel. He estimated that they took on 10.9 gallons of fuel and that they departed Eldorado around 2115. He stated that, during the last leg of the flight, the airplane's ground speed (according to the Global Positioning System (GPS)) was between 75 and 85 knots. He further stated that the GPS calculated their flight at 3 hours and 30 minutes. He recalled that, about 0030, the fuel gauge was reading "close to empty" and they were 20 miles (10 minutes) from their destination airport. About 5 minutes later, the engine lost power, at which time, the airline transport pilot took control of the airplane. The commercial pilot recalled that the airline transport pilot turned on the emergency locator transmitter, dialed in 121.5 on theradio, and announced a Mayday. He did not recall anyone responding to their Mayday. The airline transport pilot attempted to glide the airplane to a nearby airstrip. When he realized that they would not make it to the airport, he and the commercial pilot discussed the necessity of deploying the ballistic recovery parachute. They agreed that it was time and the commercial pilot deployed the parachute. The commercial pilot estimated that they were between 3,500 and 3,100 feet mean sea level (msl) or 200 to 400 feet above ground level. About 5 to 10 seconds later, the airplane hit the ground. The commercial pilot recalled that the initial impact was "brutal" and that the nose of the airplane pitched up. Following the initial impact, he felt like the airplane was flipping and never really came to rest. Airline Transport Pilot The autopsy on the airline transport pilot was performed by the South Plains Forensic Pathology Lab on June 12, 2013, as authorized by the Roberts County Justice of the Peace. The autopsy concluded that the cause of death was blunt force injuries and the report listed the specific injuries. The pilot had an enlarged heart at 675 grams, (normal for a 205 pound man (the weight of the pilot) is 375 grams with a range from 285-495 grams) with concentric ventricular wall hypertrophy. He had 3-vessel coronary artery by-pass grafting to the native vessels, but patency of graft vessels was not described. The heart muscle had areas of fibrous scarring in the in the left ventricular free wall at the base of the heart which extended nearly to the apex. There was no evidence of changes consistent with new ischemia (heart attack). The examination of the brain did not identify any evidence of the remote stroke or new natural disease. During the autopsy, specimens were collected for toxicological testing to be performed by the FAA's Civil Aerospace Medical Institute (CAMI), Bioaeronautical Sciences Research Laboratory (CAMI Reference Number 201300099002). Testing for cyanide was not performed. No carbon monoxide was detected in the blood and no ethanol was detected in the vitreous. Citalapram, Metoprolol, valsartan, and metabolites of these drugs were detected in the liver. Metoprolol, 0.417 ug/ml of Citalopram, and 0.123 ug/ml of the Citalopram metabolite were detected in cavity blood. Citalopram is a prescription selective serotonin reuptake inhibitor (SSRI) antidepressant marketed as Celexa. The therapeutic range for the medication is from 0.0300 to 0.4000 ug/mL. Additionally, metoprolol and valsartan were detected in the cavity blood and liver. These are prescription medications used to treat high blood pressure and heart disease. At the time of his most recent medical certificate application, the pilot reported having had a pontine stroke in December 2006, diabetes, and depression. The pilot's stroke symptoms had reportedly resolved by March 2008. He was treated until March 2008 with escitalopram, an SSRI marketed as Lexapro, for thetreatment of depression. His high blood pressure was treated with valsartan and nifedipine. These are prescription high blood pressure medications marketed under the respective names Diovan and Adalat. He also reported that his diabetes was treated with metformin, a prescription oral antihyperglycemic drug used in the management of type 2 diabetes marketed as Glucophage. Commercial Pilot The commercial pilot was seriously injured in the accident and subsequently transported to a local hospital for medical treatment. Both blood and urine specimens were submitted for testing performed by CAMI, (CAMI Reference Number 201300099001). No carbon monoxide was detected in the blood and no ethanol was detected in the urine. Tests for cyanide were not performed. Testing of the blood revealed 0.044 ug/ml Hydrocodone and Ondansetron. Testing of the urine revealed 27 ug/ml Acetaminophen, Cetirizine, 0.12 ug/mL Dihydrocodeine, 3 ng/mL Fentanyl, 2.249 ug/mL Hydrocodone, 0.161 ug/mL Hydromorphone, 0.545 ug/ml Morphine, and Ondansetron Cetirizine is a sedating antihistamine used to treat allergies marketed as Zyrtec. The other medications noted are commonly prescribed in an emergency medical setting, during, and following surgery. The closest official weather observation station was Perry Lefors Field Airport (KPPA), Pampa, Texas, located 22 nautical miles south of the accident site. The elevation of the weather observation station was 3,245 feet msl. The routine aviation weather report (METAR) for KPPA, issued at 0035, reported, wind 190 degrees at 17 knots, gusting to 23 knots, visibility 10 miles, sky condition clear, temperature 25 degrees Celsius (C), dew point temperature 09 degrees C, altimeter 29.98 inches. According to the United States Naval Observatory, Astronomical Applications Department Sun and Moon Data, the sunset was recorded at 2059 CDT and the end of civil twilight was 2129 CDT. The Moon rose at 2149 CDT on June 9, 2013, and set at 2031 CDT on June 10, 2013. The phase of the Moon was waxing crescent with 8 percent of the Moon's visible disk illuminated. Airline Transport Pilot The airline transport pilot, age 64, held an airline transport pilot certificate with an airplane multiengine land rating. He also held a commercial pilot certificate with airplane single engine land, instrument airplane, and glider ratings, and a flight instructor certificate with airplane single and multiengine, instrument airplane, and glider ratings. The airline transport pilot was initially issued a first class airman medical certificate without limitations on March 31, 2008. Upon further review of his application, the Federal Aviation Administration (FAA) denied his airman medical certificate on May 2, 2008. The pilot appealed the denial and, on June 26, 2008, a final agency denial was issued. There were no further applications for special-issuance medical certificates following this denial. The commercial pilot stated that he was not aware of this. The pilot's wifeand the owner of the airplane both stated that the airline transport pilot's denied medical was common knowledge. At the time of medical certificate application, the airline transport pilot reported that he had logged 24,215 hours of flight time; 6 hours were logged in the previous 6 months. At the time of application for his commercial glider certificate, the pilot reported a total flight time of 25,000 hours, 22.7 of which had been logged in gliders. Investigators did not obtain recent flight information for day or night operations or for the make and model of the accident airplane. Commercial Pilot The commercial pilot, age 22, held a commercial pilot certificate with airplane single and multiengine land and instrument ratings issued on October 7, 2011. He was issued a first class airman medical certificate, without limitations, on January 7, 2010. The commercial pilot also held a flight instructor certificate with airplane single engine privileges issued on July 10, 2012. The commercial pilot successfully completed the requirements of a flight review upon issuance of his most recent pilot certificate. The commercial pilot's logbook was located in the wreckage and was recovered by the FAA. The logbook contained entries between August 16, 2012, and April 20, 2013. A review of the logbook indicated that the commercial pilot had logged no less than 388.6 hours total time; 377.5 hours in single engine airplanes and 11.1 hours in multiengine airplanes. The commercial pilot had not logged any flight time in the make and model of the accident airplane. The commercial pilot had logged 28 hours of night-flight experience; 3.4 hours of which (including 7 landings) had been logged within the previous 90 days. The wreckage was recovered to a facility in Greeley, Colorado, for storage and further examination. Investigators from the NTSB, Pipistrel, and Rotax examined the wreckage. The wreckage consisted of the fuselage, empennage, both wings, and the canopy. The wings and canopy were removed from the airplane during the recovery. The fuselage included the engine and propeller assembly, the fuel tank, both seats, and the instrument panel. The composite material on the bottom aft portion of the fuselage in addition to the engine cowling was torn and cracked. The instrument panel was not impact damaged. The fuel gauge read empty and the Hobbs meter showed 32.6. The Kollsman window was set to 30.03 inches. All other instruments indicated zero. The fuel tank was not impact damaged. The fuel lines were intact and approximately 1 tablespoon of fuel was observed at the bottom of the fuel tank. The fuel vent line separated and the fuel filter at the tank was clean and dry. Neither the rocket nor the cover for the parachute system were recovered. The canopy had several tears in the fabric on one side and was dirty. The risers were tangled and one area of Kevlar was abraded, as if it rubbed on something. The right wing assembly included the right flaperon. Theleading edge exhibited scratches and scrapes. There was a circular puncture on the inboard bottom portion of the wing and multiple small punctures on the upper skin of the wing. The right flaperon was unremarkable. The left wing assembly included the left flaperon. The leading edge exhibited scratches and scrapes. There were multiple punctures on the upper and lower wing skin. The outboard portion of the wing tip was fragmented. The outboard portion of the left flaperon was fragmented. The aileron push/pull tubes were continuous from the control stick to the aileron. The empennage included the vertical stabilizer and rudder. The empennage was separated from the fuselage, just aft of the fuel tank. The composite material was broken and cracked in multiple locations. The lower leading edge of the vertical stabilizer was crushed aft and broken. The rudder was separated partially at the top of the assembly. The horizontal stabilizer and elevator assembly was separated from the empennage and was located within the debris field. The right side of the elevator was cracked at midspan, and the left side of the elevator was intact. The composite material on the upper center portion of the horizontal stabilizer was torn. The elevator push/pull tube was continuous from the flight control stick in the cabin, aft to the point of separation. The tube was continuous from that point, aft through the empennage to the vertical stabilizer. The rudder cables were continuous from the cabin, aft to the point where they were cut for the purposes of recovery. The cables were continuous from the cut point, aft through the empennage to the rudder control. The engine remained attached to the fuselage at the engine mounts. The spark plugs were clean and 1/8 cup of fuel, yellow in color, was recovered from the carburetor bowl. Trace fuel was recovered from the engine drain, and a teaspoon of fuel was recovered from the second carburetor bowl. Both propeller blades were broken. For examination purposes, the impact-damaged fuel line was repaired, and fuel was added to the engine. The fuel system was primed, and the engine started without hesitation. The engine was run for several minutes at varying power settings. During the magneto check, the rpm dropped between 150 and 200 rpm. The accident site was located in hilly desert canyon terrain vegetated with short grass, sagebrush, and yucca plants, at a terrain elevation of 2,700 feet msl. The horizontal stabilizer and elevator assembly was located approximately 500 feet from the initial impact point. A debris field extended 1.7 miles from the initial impact point to the main wreckage. The main wreckage came to rest entangled in the metal post and wires of a barbed wire fence. The main wreckage consisted of the fuselage, engine, both wings, empennage, and the canopy. The empennage had separated partially and remained attached through the flight control connections. The canopy remained attached to the fuselage. The FAA inspectorswho responded to the accident scene reported that there was no fuel in the fuel pump or the fuel tank. The fuel tank was not impact damaged.