CEN15LA195

NTSB accident investigation · Quad City Challenger - II · Chippewa Falls, WI · April 11, 2015

Accident · FatalLimited investigationFinal report
Date
April 11, 2015, 11:32 local (16:32 UTC)
Place
Chippewa Falls, WI
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N30796Quad City Challenger - II
Defining event
Approach-VFR pattern downwind: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report March 6, 2017
Report
Approved by Office Director
NTSB office
Central Region
Parties
Flight Standards District Office
FAA report
20150411003489A
Case key
91015

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 cardiovascular event, which resulted in a loss of control and subsequent impact with terrain.

Findings · 1

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.

Impairment/incapacitation: cardiovascularPersonnel issues › Physical · PilotAll aircraft: 69 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

While the airplane was on the downwind leg of the traffic pattern at the pilot's home airport, witnesses observed it enter into a steep dive that continued to ground contact in an open field. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The recreational pilot's medical history included coronary artery disease treated with multivessel bypass surgery. The autopsy documented severe coronary artery disease and damage to the heart muscle; including myocarditis (inflammation of the heart muscle), which placed the pilot at severe risk of a cardiac arrhythmia (irregular heart rhythm) and incapacitation. Based on the autopsy findings and the pilot's medical history, he most likely became incapacitated due to a cardiovascular event secondary to his severe heart disease and recent myocarditis.

Factual narrative

The airplane was a two-seat tandem, high-wing, pusher configuration. FAA records indicated the pilot manufactured the airplane and received a special airworthiness certificate on May 17, 2002. The airplane was equipped with a Rotax 503 engine and a Tennessee, Inc. wooden propeller. Maintenance logbooks were not available to the investigation. On April 11, 2015, at 1132 central daylight time, an experimental Quad City Challenger II airplane, formerly registered as N30796, impacted terrain while on visual pattern downwind at the Rosenbaum Field Airport (3WI9), near Chippewa Falls, Wisconsin. The airplane was substantially damaged and the pilot sustained fatal injuries. The airplane, with an expired registry, was operated by the pilot 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 at an unknown time. Several witnesses observed the airplane making a turn near the mid-field downwind position at 3WI9. The airplane subsequently began a steep dive, which continued until ground impact. The airplane caught fire following ground impact. A review of primary care and cardiology records from January 2012 until April 2015 revealed the pilot had a history of coronary artery disease treated with multi-vessel bypass surgery, high blood pressure, elevated cholesterol, and hypothyroidism. He also had diet controlled type 2 diabetes with peripheral neuropathy resulting in difficulty with balance and walking, as well as major depressive disorder with mild symptoms controlled with fluoxetine. The pilot's latest cardiologist evaluation on October 6, 2014 documented that the pilot was stable from a cardiac standpoint and remained asymptomatic. The cardiologist documented that the pilot was not following a proper cardiac diet. The records did not document a recent exercise stress test or electrocardiogram. During his last primary care appointment, which occurred two days prior to the accident, the pilot's height and weight measured 70 inches and 251 pounds. The primary care physician documented that the pilot had no chest pain or discomfort and no shortness of breath and his high blood pressure was "well controlled". The pilot's medications included atenolol and lisinopril (medications to control blood pressure), levothyroxine (a thyroid replacement medication), fluoxetine (an antidepressant medication), atorvastatin (a cholesterol lowering medicine), tamsulosin (a medication to treat enlarged prostate), naproxen (medication to control pain and swelling), and aspirin (medication used to control pain, inflammation and fever also used to decrease the risk of recurrent heart attacks). According to his wife, the pilot underwent heart bypass surgery in September 2008. Two months prior to the accident, the pilot had been sick with upper respiratory issues and a sinus infection and he had taken a while to recover. She stated the pilotwas just starting to feel well and energetic the week of the accident. On April 14, 2015, an autopsy was performed on the pilot by the Sacred Heart Hospital in Eau Claire, Wisconsin. The cause of death was blunt force injuries. The autopsy identified an enlarged heart, severe multi-vessel coronary artery disease (greater than 80 percent occlusion of all vessels) with coronary artery bypass grafts and complete occlusion of two bypass vessels, evidence of an old heart attack with scarring of the ventricular septum and active inflammation of heart muscle of the anterolateral wall of the left ventricle. The FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma performed toxicology tests on the pilot. Toxicology did not identify carbon monoxide or ethanol in cavity blood. Testing detected atenolol in liver and cavity blood, atorvastatin in liver, fluoxetine in cavity blood and liver, and its metabolite norfluoxetine in cavity blood and liver. At 1156, the weather observation station at Chippewa Valley Regional Airport (EAU), Eau Claire, Wisconsin, located about 9 miles southwest of the accident site, reported the following conditions: wind 250 degrees at 11 knots, with gusts to 17 knots, 10 miles visibility, clear skies, temperature 15 degrees C, dew point 1 degree C, altimeter setting 30.14 inches of mercury. The pilot, age 77, held a recreational pilot certificate with airplane single engine land rating and a repairman experimental aircraft builder certificate. The pilot's logbook indicated he had flown 416 total hours as of May 5, 2006, with nearly all of his flight time accomplished in the accident airplane. Recent logbooks were not available for the investigation. According to his wife, the pilot had flown a few times over the past 12 months. The pilot's most recent Federal Aviation Administration (FAA) medical certification exam, dated May 10, 2004, did not identify any abnormal findings and the examiner issued a third-class medical certificate with the following limitation: must wear lenses for distant - possess glasses for near vision. This medical certificate expired for all classes on May 31, 2006. The accident site was located in a level, open farm field located about ½ mile to the east of the runway. The airplane impacted the field with a nose low attitude, which created a 2 ft deep crater, and came to rest about 40 ft from the initial impact point. A post-crash fire consumed much of the fuselage and tail. FAA examination of the airplane confirmed flight control continuity to all flight controls and engine crankshaft continuity was confirmed via rotation of the propeller. The wooden propeller was fragmented down to its hub. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation.

Aircraft

Registration
N30796
Reported as
Quad City Challenger - II
Category
Airplane, amateur-built
Serial number
CH-2-0501-2088
Built
2002
Engine
Rotax 503, 50 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Departed
3WI9 · Chippewa Falls, WI
Destination
3WI9 · Chippewa Falls, WI
Airport
3WI9 · Rosenbaum Field Airport, runway 18, 2,600 × 100 ft, grass/turf
Equipment
None

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
77
Injuries
Fatal
Certificate
Recreational
Airplane ratings
Single-engine land
Seat
Front
Restraint
Lap only
Toxicology
Performed
Flight hours
416 total · 402 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 11 knots, gusting 17
Visibility
10 statute miles
Lowest ceiling
None
Temperature
59 °F, dew point 34 °F
Altimeter
30.13 inHg
Observed at
KEAU, 9 nm away

Docket · 3

The files NTSB released with the investigation on January 19, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.2 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.