CEN14FA140

NTSB accident investigation · Hillam Scott L Rans S 10 · Shepherd, TX · February 16, 2014

Accident · FatalField investigationFinal report
Date
February 16, 2014, 13:11 local (19:11 UTC)
Place
Shepherd, TX
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N3000VHillam Scott L Rans S 10
Defining event
Maneuvering-aerobatics: Aircraft structural failure
Weather
Visual (VMC) · Day
Status
Completed · report September 15, 2014
Report
Approved by Office Director
NTSB office
Central Region
Parties
Flight Standards District Office
FAA report
20140216000849A
Case key
88803

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 noncertificated pilot’s improper decision to attempt aerobatic maneuvers that exceeded the airplane’s design limitations, which resulted in the subsequent in-flight breakup of the airplane. Contributing to the accident was the pilot’s lack of aerobatic flight instruction.

Findings · 3

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

A ground witness reported that the pilot made a radio transmission announcing his intention to perform a rolling maneuver. He and another ground witness stated that they then saw the airplane roll through an inverted position and then transition into a steep, high-speed dive. The left wing separated from the fuselage, and the airplane continued in a near-vertical descent until ground impact. Postaccident examination revealed that the left front wing spar had fractured near the left wing root due to overload. No records were found indicating that the noncertificated pilot had received dual flight instruction for aerobatics, and the pilot's friend reported that he did not think that the pilot had ever received any aerobatic flight training. A review of the pilot's journal revealed that he had recently attempted solo aerobatics in the accident airplane, which resulted in high-speed spiral dives at airspeeds higher than the never exceed speed for the airplane. The pilot likely attempted an aerobatic maneuver that exceeded the airplane's design limitations, which resulted in the subsequent in-flight breakup of the airplane. Toxicological reports revealed the presence of amlodipine, a blood pressure medication, in the urine and liver, and autopsy results indicated that the pilot had hypertension; however, it is unlikely that the hypertension or the medication used for its treatment contributed to the accident. Tramadol and its metabolite, which are analgesics, were also present in the urine and liver. Insufficient evidence was available to determine whether the pilot's use of tramadol contributed to his decision to perform aerobatic maneuvers without training or impaired his ability to complete the maneuver successfully.

Factual narrative

On January 11, 2014, the pilot wrote the following information in a journal: "… Flew S10 and tried to roll it, aileron only, about 95 mph (miles per hour) with horizon just a little low. Hard left aileron, plane inverted then went into dive upside down and spiraling. Thought I maybe was too slow so I tried again at about 105 mph, this time I was spiraling real fast upside down in a dive, even with throttle back off and as I was pulling it out this time I noticed my airspeed was 180 mph. I gradually started pulling it out, pulled 4 ½ Gs, and was down to about 600 feet. " Never exceed speed (Vne) for the Rans S10 airplane is 130 miles per hour. According to a friend, the pilot had recently started to attempt aerobatic maneuvers while solo. The pilot told him that the elevator of the airplane tended to "flutter" at higher speeds. After one flight, the pilot told him that he intended to fly less than 125 miles per hour, due to elevator flutter. His friend did not think the pilot had ever taken dual aerobatic flight training. The Rans S10 kit airplane, equipped with a Rotax 912 engine, was built by the previous owner and received an airworthiness certificate on May 31, 2002. The accident pilot purchased the airplane on June 20, 2003. A review of logbooks indicated the airplane had been flown about 390 hours, with no inspections recorded since the purchase in 2003. On February 16, 2014, about 1311 central standard time, a Scott L. Hillam Rans S10 airplane, N3000V, impacted terrain following an inflight breakup near Shepherd, Texas. The pilot, the sole occupant, was fatally injured and the airplane was destroyed. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions existed at the time of the accident and no flight plan was filed. The local flight departed the Lake Water Wheel Airport (XS99), Shepherd, Texas about 1245. According to a ground witness, the pilot made a radio transmission announcing his intention to perform a rolling maneuver. Multiple ground witnesses observed the airplane roll through an inverted position and then transition into a steep dive. During the dive, the witnesses noticed the elevator move back and forth rapidly, followed by a wing separating from the fuselage. The airplane subsequently impacted the ground at a steep angle. On February 18, 2014, an autopsy was performed on the pilot at a Forensic Medical Management Services facility in Beaumont, Texas. The examination determined the cause of death to be due to multiple traumatic injuries. The Federal Aviation Administration's Civil Aeromedical Institute in Oklahoma City, Oklahoma, performed toxicology tests on the pilot, but no blood was available for testing. The tests were negative for ethanol in muscle or brain. Amlodipine, tramadol, and tramadol's primary metabolite O-desmethyltramadol were identified in urine and liver. Salicylate was identified inurine. Amlodipine is a blood pressure medication marketed under the brand name Norvasc. Its presence and the thickness of the heart wall (1.5cm) on autopsy were consistent with the pilot having hypertension. Tramadol, an analgesic that carries an FDA warning about sedation, is marketed under the brand name Ultram and is potentially impairing, but without a blood level, its effects on the pilot cannot be determined. Salicylate is a metabolite of aspirin, a non-sedating analgesic. The weather observation station at Cleveland Municipal Airport (6R3), Cleveland, Texas, located about 9 miles southwest of the accident site, reported the following conditions at 1315: wind 160 degrees at 5 knots, visibility 10 miles, broken clouds at 3,600 feet above ground level (AGL), temperature 24 degrees Celsius (C), dew point 16 degrees C, altimeter setting 30.06. The pilot, age 77, began flying ultralight aircraft in 1983 and recorded 764 flight hours in his logbook as of February 26, 2007. A review of the Federal Aviation Administration (FAA) database revealed the pilot did not hold a pilot or medical certificate. The pilot did possess a valid driver's license and was a member of the United States Ultralight Association. The airplane impacted in an open field and came to rest in an inverted position. The left wing was located about 200 yards north of the main wreckage. All flight control surfaces, with the exception of the left aileron, were found intact with the main wreckage and flight control continuity was confirmed to the rudder, elevator, and right aileron. The empennage was twisted. The left front wing spar fractured near the left wing root. An examination of the spar did not reveal any evidence of pre-existing fatigue fracture propagation and contained 45 degree shear-lips, consistent with an overload failure. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Aircraft

Registration
N3000V
Reported as
Hillam Scott L Rans S 10
Category
Airplane, amateur-built
Serial number
0996178-S
Built
2002
Airframe hours
390
Engine
Bombardier ROTAX (ALL), 100 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Goldsmith James I
Registered owner
Goldsmith James I
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · June 20, 2013
Departed
XS99 · Shepherd, TX
Destination
XS99 · Shepherd, TX

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
77
Injuries
Fatal
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
764 total · 229 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
160° at 5 knots
Visibility
10 statute miles
Lowest ceiling
3,600 ft broken
Temperature
75 °F, dew point 61 °F
Altimeter
30.05 inHg
Observed at
6R3, 9 nm away

Docket · 4

The files NTSB released with the investigation on September 2, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.4 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.