CEN15FA022

NTSB accident investigation · CGS Hawk Arrow II Slsa · Lonoke, AR · October 20, 2014

Accident · FatalField investigationFinal report
Date
October 20, 2014, 17:37 local (22:37 UTC)
Place
Lonoke, AR
Injuries
1 fatal, 1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N916HCGS Hawk Arrow II Slsa
Defining event
Approach-VFR pattern base: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report July 25, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
Flight Standards
FAA report
20141020020039A
Case key
90286

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 loss of airplane control while turning onto the base leg of the traffic pattern due to his failure to maintain sufficient speed and/or overbanking, which resulted in the airplane impacting trees. Contributing to the pilot's fatal injuries was his fall from a tree after exiting the airplane.

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCGS HAWK ARROW II SLSA: 1 caseAll aircraft: 9,295 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedCGS HAWK ARROW II SLSA: 1 caseAll aircraft: 1,269 casesProbable cause

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

The commercial pilot and passenger reported that, after a 45-minute local flight in the light sport airplane, the pilot entered the traffic pattern at the nontowered airport. While the airplane was on the left base leg of the traffic pattern, the pilot flew past the extended runway centerline and banked sharply left. The airplane subsequently nosed over and impacted trees near the approach end of the runway and then came to rest suspended in a tree about 25 ft above the ground. The passenger disconnected his seat restraints and climbed down a tree without incident. The pilot disconnected his seat restraints and attempted to climb down a tree but fell to the ground. After transport to a local hospital, the pilot died due to multiple traumatic injuries. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. One week before the accident, the pilot accomplished a flight review in the accident airplane following a 4-year period of not flying; the review included six landings at the accident airport. The flight instructor who conducted the review characterized the accident airplane as having a high drag profile, which led it to easily "get slow" in the traffic pattern, which the pilot was sometimes slow to recognize, especially during base turns. The flight instructor recommended a mid-power setting to compensate for the drag profile, but the pilot frequently reverted to idle power during his base turns. Given the passenger and flight instructor statements, the pilot likely did not maintain sufficient airspeed and/or overbanked to correct for overshooting final, which resulted in his loss of airplane control. At his last medical examination, the pilot reported that he was taking citalopram to treat depression and metoprolol to treat blood pressure, and toxicology tests detected these medications in his blood and urine. He was also being treated for hypertension, leg swelling, glaucoma, and cholesterol. However, there was no evidence suggesting that any of the pilot's medical problems or the medications he was using to treat them contributed to the accident or his fall from the tree.

Factual narrative

The CGS Aviation Hawk Arrow II, a light sport airplane, was issued an airworthiness certificate on May 6, 2013. The airplane was equipped with an HKS 700E twin-cylinder, 60-horsepower engine. The last annual inspection was performed on the airplane was January 1, 2014, with a total of 97.8 hours. On October 20, 2014, at 1737 central daylight time, a CGS Aviation Hawk Arrow II airplane, N916H, impacted trees during approach for landing at the Country Air Estates Airport (1AR9), Lonoke, Arkansas. The pilot was fatally injured and the passenger sustained minor injuries. The aircraft was substantially damaged. The aircraft was registered to and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions prevailed for the local flight, which departed without a flight plan. The front seat passenger stated that after a local 45 minute flight, the pilot (flying from the rear seat) entered a left base to Runway 18 at 1AR9. While in a left turn towards final, the passenger noticed the airplane fly past extended centerline for the runway, bank steeply to the left, and then nose over. The airplane impacted trees near the approach end of Runway 18 and came to rest in a tree, about 25 ft above ground level (agl). The passenger disconnected from his seat restraints and climbed down a tree. The pilot disconnected himself from his seat restraints and attempted to climb, but fell to the ground. After transport to a local hospital, the pilot passed away. On October 21, 2014, an autopsy was performed on the pilot by the State Crime Laboratory in Little Rock, Arkansas. The cause of death was multiple traumatic injuries. Toxicology testing performed by the FAA's Bioaeronautical Research Laboratory identified citalopram, its metabolite N-desmethylcitalopram, and metoprolol in blood and urine. At the time of his last medical examination, the pilot reported treatment with prescription medications including citalopram for depression, lisinopril and metoprolol for blood pressure, spironolactone for hypertension, aspirin to prevent future heart attacks, furosemide (a diuretic) for leg swelling, latanoprost eye drops for glaucoma, and niacin for cholesterol. At 1753, the weather observation station at Adams Field Airport, Little Rock, Arkansas, located about 13 miles southwest of the accident site, reported wind 230 degrees at 5 knots, visibility 10 miles, few clouds at 15,000 ft agl, scattered clouds at 25,000 ft agl, temperature 21 degrees C, dew point negative 12 degrees C, and altimeter setting 30.02. The pilot, age 75, held a commercial pilot certificate with airplane single engine land, rotorcraft helicopter, gyroplane, and sport ratings. He also held flight and ground instructor certificates. The pilot reported flight experience of 4,300 total flight hours and 0 hours in last six months during his exam for a third class medical certificate, dated December 19, 2013. Theaviation medical examiner (AME) did not issue a medical certificate during this exam, as the pilot was appealing a previous denial. The AME deferred issuance to the Aerospace Medical Certification Division of the Federal Aviation Administration (FAA), who on August 8, 2014, referred the case to the Medical Appeals Branch of the FAA, for final adjudication. The case was pending at the time of the accident. The pilot's medical history included alcohol dependence in recovery since 2004, cirrhosis, anxiety/depression, splenomegaly with chronic anemia and thrombocytopenia, chronic kidney disease, hypertension, arrhythmia, and glaucoma. The pilot's medical history also included coronary artery disease treated with coronary artery bypass grafting (CABG) in 2009, as well as an aortic valve replacement in 2009, following an episode of endocarditis. The pilot received medical certification denials from the FAA in 2010 and 2012, based on his history of CABG, neurocognitive deficits, unreported anxiety/medication use, and falsification of his medical applications. In the course of appealing these denials, the pilot underwent three neuropsychological evaluations. These evaluations placed the pilot's cognitive skills in the 30-50th percentile, as compared with other men of his age and education. The evaluations placed him at or below the 10th percentile, as compared to a sampling of the pilot community. On October 14, 2014, the pilot accomplished a flight review in the accident airplane. The local flight's duration was 1.4 flight hours and included six landings at 1AR9. The flight review was the only flight recorded in the pilot's logbook since 2010. The flight instructor who administered the flight review characterized the accident airplane as having a high drag profile in the pattern and that it was "easy to get slow". The flight instructor stated the pilot was sometimes slow to recognize a decaying airspeed in the pattern. This tendency was most prevalent during base turns, as the pilot preferred to glide with engine power set to idle. The flight instructor recommended a mid-power setting, but the pilot frequently reverted to setting idle power during the base turn. The airplane impacted into an area of trees located about 25 yards from large, open fields. Following recovery to a hangar at 1AR9, examination of the airplane revealed flight control continuity, with no anomalies of the flight control surfaces. The airplane was secured for an engine test run utilizing fuel onboard the airplane from the time of the accident. The engine started and ran normally for about 20 minutes. The engine was cycled several times between idle and full power, with no power interruptions or hesitations observed. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Aircraft

Registration
N916H
Reported as
CGS Hawk Arrow II Slsa (NO SERIES)
Category
Airplane
Serial number
HAII-316-700E-T
Built
2013
Airframe hours
97
Engine
HKS 700E, 60 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Private Individual
Registered owner
Private Individual
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
Condition · January 1, 2014 · 97 hours before
Departed
1AR9 · Lonoke, AR
Destination
1AR9 · Lonoke, AR
Airport
1AR9 · Country Estates Airport, runway 18, 3,800 × 100 ft, grass/turf

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
75
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Last flight review
October 14, 2014
Seat
Rear
Toxicology
Performed
Flight hours
4,300 total · 2 in this make and model · 2 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 54 °F
Altimeter
30.02 inHg
Observed at
KLIT, 13 nm away

Docket · 4

The files NTSB released with the investigation on June 30, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 771 KB 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.