CEN17FA288

NTSB accident investigation · Zenith CH701SP · Laddonia, MO · July 27, 2017

Accident · FatalField investigationFinal report
Date
July 27, 2017, 04:52 local (09:52 UTC)
Place
Laddonia, MO
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N701XLZenith CH701SP
Defining event
Enroute: VFR encounter with IMC
Weather
Instrument (IMC) · Night
Status
Completed · report October 10, 2018
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Flight Standards District Office
FAA report
20170727015619A
Case key
95688

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 decision to take off at night and continue visual flight into instrument meteorological conditions. which resulted in the pilot becoming spatially disoriented and losing control of the airplane. Contributing to the accident were the pilot's degraded decision-making due to his use of a combination of impairing prescription drugs, and the pilot's lack of instrument and night flight experience.

Findings · 11

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.

Ceiling/visibility/precip: below VFR minimaEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomeSmith David B CH 701 SP: 1 caseAll aircraft: 184 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedSmith David B CH 701 SP: 1 caseAll aircraft: 1,269 casesProbable cause
Aircraft capability: instrument flight capabilityAircraft › Aircraft oper/perf/capability · Incorrect use/operationSmith David B CH 701 SP: 1 caseAll aircraft: 10 cases
Pressures/demands: personal pressureEnvironmental issues › Task environment · Contributed to outcomeSmith David B CH 701 SP: 1 caseAll aircraft: 5 cases

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

Although he had no night or instrument flight experience, the sport pilot departed in a non-instrument-certificated light sport airplane at night with an overcast ceiling and thunderstorms in the area. Radar data showed that the airplane proceeded on course for about 9 minutes and then entered a right descending turn that continued to ground impact, which was consistent with the pilot attempting to return to the departure airport and not paying attention to his altitude. Examination of the accident site revealed that the airplane struck open level farm land in a right wing-low, nose-low attitude. Examination of the engine and airframe did not reveal any evidence of preimpact anomalies that would have precluded normal operation. It is likely that the pilot continued visual flight into an area of instrument meteorological conditions, which resulted in the pilot experiencing a loss of visual reference and subsequent spatial disorientation. The pilot had a history of chronic insomnia treated with temazepam, a sedating benzodiazepine, and was regularly prescribed hydrocodone, an opioid analgesic. Toxicology testing detected these drugs and their metabolites in the pilot's system. The pilot was likely impaired by effects from his use of temazepam, and the impairing effects of temazepam were likely enhanced by the pilot's use of hydrocodone. It is likely that the pilot's decision-making was degraded due to his combined use of temazepam and hydrocodone.

Factual narrative

The experimental light sport airplane was constructed by a private individual in 2003, and later purchased by the pilot. It was powered by a 100-horsepower Rotax 912ULS engine, driving a 3-bladed Warp-Drive 70-inch fixed pitch composite propeller. A copy of the maintenance records contained entries from December 11, 2013, to May 1, 2017. A condition inspection was performed on the airframe and engine on May 1, 2017, with 1,142 flight hours recorded in the logbook. The airplane was not equipped nor certified for instrument flight rules (IFR) flight. On July 27, 2017, at 0452 central daylight time, a Zenith CH 701SP, N701XP, was destroyed when it impacted a bean field about 6.5 miles north of Laddonia, Missouri. The sport pilot and passenger were fatally injured. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Instrument meteorological conditions prevailed at the time of the accident, and no flight plan had been filed for the personal cross-country flight. The flight originated from Mexico Municipal Airport (MYJ), Mexico, Missouri, about 0440, and was en route to Whittman Regional Airport (OSH), Oshkosh, Wisconsin. According to the airport manager at MYJ, the airplane with the pilot and his passenger on board arrived late in the day on July 26, 2017. The pilot said he wanted to get an early morning start because he wanted to arrive at OSH when the control tower opened at 0700. A self-service fuel receipt charged to the pilot's credit card indicated that he purchased 17.8 gallons of fuel at 2038 on July 26. The manager said he believed the pilot and his passenger camped that evening next to the airplane. When the manager arrived at the airport the next morning, the airplane was gone. According to radar data provided by the U.S. Air Force/Civil Air Patrol, the airplane first appeared on radar at 0443:46 when it was about 5 miles east of MYJ. According to the data, the airplane's altitude varied between 2,000 and 2,800 feet above ground level (agl) as it maintained a northeast heading. The airplane then entered a right descending turn and had completed about 180° when radar contact was lost. The last radar return was at 0452:46, when the airplane was about 6.5 miles northeast of Laddonia, Missouri. A family member later reported that the airplane was missing and an Alert Notice (ALNOT) was issued on the evening of July 27. Search teams located the wreckage early on the morning of July 28. The Boone/Callaway County Medical Examiner's Office, Columbus, Missouri, performed an autopsy on the pilot. According to the autopsy report, death was attributed to "blunt force injuries." The toxicology screen on the pilot performed by St. Louis University's Toxicology Laboratory Berkeley, Missouri, revealed the presence of 0.040 gm% (40 mg/dl) ethanol, 0.11 micrograms/ml temazepam, 33 micrograms/ml acetaminophen, and 0.91 micrograms/ml sertraline. FAA's Bioaeronautical ScienceResearch Laboratory, Oklahoma City, Oklahoma, performed toxicology screening that revealed the presence of 10 (mg/dL, mg/hg) ethanol in urine, and 36 (mg/dL, mg/hg) ethanol in blood. Propanol, a metabolite of ethanol, was detected in blood and urine. The presence of propanol is consistent with postmortem alcohol production. The report noted that putrefaction had occurred, and the blood was unsuitable for carbon monoxide analysis. Also detected were 114.72 (ug/ml, ug/g) acetaminophen in urine; 0.007 (ug/mL, ug/g) dihydrocodeine in blood and 0.067 (ug/mL, ug/g) in urine; 0.144 (ug/ml, ug/g) hydrocodone in urine but not in blood; 0.054 (ug/mL, ug/g) hydromorphone in urine; 0.36 (ug/ml, ug/g) oxazepam in urine but not in blood; an unknown quantity of sertraline in urine and 1.23 (ug/mL, ug/g) in blood, and an unknown quantity of salicylate in urine. According to the pilot's medical records, the pilot had a history of chronic insomnia that was being treated with temazepam. (Oxazepam is a psychoactive metabolite of temazepam. Temazepam (Restoril) is "a sedating benzodiazepine available by prescription and intended for short-term treatment of insomnia." The drug carries several warnings, including "concomitant use of benzodiazepines, including temazepam and opioids, may result in profound sedation, respiratory depression, coma, and death." There is also a warning that the drug can cause "behavior changes, such as increased aggressivity, and patients using it may engage in complex behaviors while under its influence, such as 'sleep driving'" that they may later not recall. The pilot was also being treated for anxiety with sertraline, and had been regularly prescribed hydrocordone. Sertraline (Zoloft) is a prescription antidepressant that is not considered impairing. Hydrocodone, an opioid analgesic, is considered impairing and carries warnings about risks of central nervous system and respiratory depression, particularly when combined with benzodiazepines. In addition, the drug information warns that it "may impair the mental or physical abilities needed to perform potentially hazardous activities such as driving a car or operating machinery." There was no record that the pilot had obtained a preflight weather briefing. At 0414, MYJ reported a visibility of 1-1/2 miles in heavy rain, broken clouds at 1,100 feet, and overcast at 1,900 feet. At 0435, MYJ reported winds from 240° at 7 knots, visibility 7 miles in light rain, broken clouds at 600 feet and 1,200 feet, and overcast at 1,900 feet. The temperature-dew point spread was 1° (23/22). There was distant lightning in the north through east quadrants, and in the west quadrant. At 0455, MYJ reported winds from 230° at 7 knots, visibility 7 miles, with a thunderstorm and rain in the vicinity. There were scattered clouds at 600 feet, broken clouds at 3,300 feet, and overcast skies at 4,800 feet. The temperature-dew point spread was 1°, and there was distant lightning in the north through east quadrantsand in the west quadrant. According to Federal Aviation Administration (FAA) records, the pilot held a sport pilot certificate with a single-engine land rating. He was not instrument rated. A copy of the pilot's logbook contained entries from December 28, 2014, to July 19, 2017. The pilot's logbook entries were inconsistent: some of the entries were entered in tenths of an hour, and other entries were in minutes. The logbook revealed that the pilot had accrued the following flight experience: Pegasus powered parachute, 162.9 hours Cessna 150, 5.1 hours Piper PA-28, 5.0 hours Aeroprakt A22LS, 0.8 hours Zenith CH 701SP, 98.3 hours No night or instrument flight time had been logged. According to 14 CFR 61.315(c)(5), sport pilots are prohibited from flying at night. The accident site was located 6.5miles northeast of MYJ in open level farm land. Green position light lens fragments were found at the beginning of a ground scar that was 36 feet long and aligned on a magnetic course of 121°. At the end of the ground scar was a water-filled impact crater, followed by a debris path that extended 252 feet on a magnetic course of 130°, which was about the direction to MYJ. The crushed right wing and lesser damaged left wing were located farther down the debris path, preceded by a flap and aileron. The fuselage, cockpit, and empennage were located 84 feet from the impact crater and to the left of the debris path. The engine was located 210 feet from the impact crater.

Aircraft

Registration
N701XL
Reported as
Zenith CH701SP
Category
Airplane, amateur-built
Serial number
7-4618
Built
2003
Airframe hours
1,142
Engine
Rotax 912ULS, 100 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental light sport (Special)
Last inspection
Condition · May 1, 2017
Departed
KMYJ · Mexico, MO
Destination
KOSH · Oshkosh, WI
Equipment
None

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
41
Injuries
Fatal
Certificate
Sport Pilot
Airplane ratings
Single-engine land
Medical
Sport pilot
Last flight review
August 3, 2016
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
272 total · 98 in this make and model · 31 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Instrument (IMC) · Night
Wind
230° at 5 knots
Visibility
1.5 statute miles
Lowest ceiling
1,100 ft broken
Temperature
72 °F, dew point 72 °F
Altimeter
29.94 inHg
Observed at
KMYJ, 17 nm away

Docket · 7

The files NTSB released with the investigation on September 23, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 24.7 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.