# NTSB CEN19FA134: Alliant Destiny 2000, N65481, New Era, MI, May 4, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 2 · Field · Final report - Date: May 4, 2019, 10:42 local (14:42 UTC) - Place: New Era, MI - Coordinates: 43.564445, -86.418052 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.5644&lon=-86.4181&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 2 - NTSB office: Central Region - Parties: Federal Aviation Administration, Federal Aviation Adminstration, Rotech Flight Safety - NTSB case key (mKey): 99368 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA134 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99368/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99368 - Page: https://openairdocs.org/ntsb/CEN19FA134 ## Probable cause The pilot's failure to maintain aircraft control while maneuvering that resulted in collapse of the canopy and an uncontrolled descent into terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Alliant DESTINY 2000, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=0590103), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Experience/qualifications: recent experience w/ equipment](https://openairdocs.org/ntsb-findings/02031045): Personnel issues › Experience/knowledge · Pilot; cases with it: [Alliant DESTINY 2000, 1 case](https://openairdocs.org/ntsb-findings/02031045/cases.md?model=0590103), [All aircraft, 31 cases](https://openairdocs.org/ntsb-findings/02031045/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Alliant DESTINY 2000, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=0590103), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Alliant DESTINY 2000, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=0590103), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Alliant DESTINY 2000, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=0590103), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The accident flight was the pilot's first flight in 8 months in the powered parachute. Witnesses saw the aircraft turning at low altitude when the canopy collapsed and the aircraft entered a spiraling descent to ground contact. Two of the witnesses stated that the engine sound changed before the canopy collapse. Postaccident examination of the aircraft revealed no mechanical anomalies that would have precluded normal operation, and wind conditions near the accident site were reported between 1 and 5 mph. Review of the pilot's logbook indicated that his most recent flight review was conducted about 9 years before the accident. Toxicology testing of the pilot revealed the presence of tramadol, which the pilot was taking to treat arthritis. Although both tramadol and underlying arthritis severe enough to warrant the use of opioid analgesics are potentially impairing, it could not be determined whether the pilot's arthritis or effects from his use of tramadol contributed to the accident. Information provided on the aircraft's stability cited the powered parachute … can be flown erratically relative to power so to upset normal flight. [However] this isn't catastrophic if altitude is sufficient. The pilot most likely did not maintain proper power and aircraft control in the turn to keep the canopy inflated resulting in its collapse and the aircraft's subsequent uncontrolled descent into terrain. ## Factual narrative The last condition inspection in the aircraft logbook was dated April 26, 2013. Subsequent maintenance entries were dated April 2015, July 2016, April 2018, and April 2019, all of which were routine owner-performed maintenance as changing the oil, oil and air filters, and spark plugs. The April 8, 2019 entry included installation of new fuel lines. The canopy's data tag fields for model, serial number, and date of manufacture were blank. The powered parachute with the Chiron canopy had a maximum cruise speed of 25 to 30 mph (22 to 26 kts) and speeds to 45 mph (39 kts) in a diving turn. Information provided on the aircraft's stability cited the powered parachute with the Chiron canopy can be flown erratically relative to power so to upset normal flight. [However] this isn't catastrophic if altitude is sufficient. On May 4, 2019, about 1042 eastern daylight time, an experimental light-sport Alliant Aviation Destiny 2000 powered parachute, N65481, was destroyed when it was involved in an accident near New Era, Michigan. The pilot sustained fatal injuries. The aircraft was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The accident flight was the pilot's first flight of the year in the powered parachute. Witnesses stated that they saw the aircraft flying low when it turned and the canopy collapsed. The aircraft then entered a spiraling descent and impacted the ground. Two of the witnesses stated that the engine sound changed before the canopy collapsed. A witness who responded to the accident site saw the aircraft on its side leaking fluid. Download of a GPS unit recovered from the wreckage began recording at 10:25:56 and ended at 10:41:36 on the day of the accident. At 10:40:36, the aircraft's speed was 26 knots and the true magnetic heading was 349.6 degrees. The heading then changed from northwest to southeast. At 10:41:25, the speed was 33 knots and the true magnetic heading was 174.6 degrees. The autopsy of the pilot was performed by Final Diagnosis, Inc, Tampa, Florida. The cause of death was blunt impact to the torso. Toxicology testing at the FAA Forensic Sciences Laboratory revealed 441 (ng/mL, ng/g) tramadol in blood; 1,081 (ng/mL, ng/g) tramadol in liver; 94 (ng/mL, ng/g) desmethyltramadol in blood; and desmethyltramadol in liver. Tramadol is an opioid analgesic available by prescription as a Schedule IV narcotic (desmethyltramadol is its metabolite). In addition to increasing the risk of seizures, tramadol carries the warning, " may impair the mental and or physical abilities required for the performance of potentially hazardous tasks such as driving a car or operating machinery. The patient using this drug should be cautioned accordingly." The usual therapeutic range (levels that would be expected to cause effects) for tramadol is 50-500 ng/ml. According to the pilot's wife, the pilot had been prescribed tramadol for the treatment of arthritis. At 1039, the Tea Time weather station in New Era, Michiganrecorded wind from the north/northeast at 1 mph gusting to 5 mph. At 1044, the weather station recorded wind from the west/northwest at 1 mph gusting to 5 mph. A review of the pilot's logbook revealed that the last entry was dated September 9, 2018. The logbook contained one flight review endorsement, which was dated June 12, 2010. Although the pilot did not hold a flight instructor certificate, there were regular logbook entries made for "dual given" in the accident aircraft. Examination of the wreckage revealed ground scarring limited to the area beneath the powered parachute frame. The left side of the frame exhibited greater damage that the right side and was consistent with a left-banking impact with terrain. The canopy did not exhibit any tears externally or internally. All the canopy lines were connected to the frame. Flight control continuity from the parachute to the flight controls was confirmed. The engine was test run on the airframe using an external supply tank of automotive gasoline and the installed battery. The test run revealed no anomalies. ## Aircraft - Registration: [N65481](https://openairdocs.org/deregistered/N65481-2020-10-03), registration cancelled 2020-10-03, S/N 3C0533, built 2002 (OpenAirDocs) - Reported make and model: ALLIANT AVIATION DESTINY 2000 (No Series) - Registry model: [Alliant DESTINY 2000](https://openairdocs.org/model/alliant-destiny-2000) (registry code 0590103) (OpenAirDocs) - Registry engine: [Rotax 582SER](https://openairdocs.org/engine/rotax-582ser) (registry code 55556, 2 cycle) (OpenAirDocs) - Category: Powered parachute - Serial number: 3C0533 - Year built: 2002 - Engines: Rotax 582 reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Pilot - Registered owner: Pilot - Airworthiness certificate: Special, Special light-sport (Special) - Last inspection: Condition, April 26, 2013 - Departed: Rothbury, MI - Destination: Rothbury, MI - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: fatal; sport pilot; last flight review June 12, 2010; seat: front; toxicology performed; flight hours: 269 total, 269 in this make and model, 0 in the last 90 days, 0 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 55 °F, dew point 39 °F - Altimeter: 30.02 inHg - Observed at: KFFX, 20 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20190504016439A](https://openairdocs.org/incident/20190504016439A), May 4, 2019: Alliant Aviation DESTINY 2000, New Era, MI, Substantial damage, 1 fatal. The aircraft, a powered parachute, stalled in flight. As a result of the aerodynamic stall, the aircraft impacted open field terrain in benona township,… ## Docket (11 files) The files NTSB released with the investigation on October 9, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99368. 101 MB in all. - Police report excerpt (item 1, PDF, 1 page, 904 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9333211&FileExtension=pdf&FileName=Witnenss%20Report%20MASTER_Redacted-Rel.pdf - Record of examination (item 2, PDF, 1 page, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9332012&FileExtension=pdf&FileName=RECORD%20OF%20EXAMINATION%20MASTER-Rel.pdf - GPS factual report (item 3, PDF, 2 pages, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9332021&FileExtension=pdf&FileName=GPS%20Factual%20Report-Rel.pdf - GPS tabular data (item 4, CSV, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9332091&FileExtension=csv&FileName=Attachment%201%20-%20Accident%20flight%20tabluar%20data-Rel.csv - Meteorological information (item 5, PDF, 4 pages, 400 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10085863&FileExtension=pdf&FileName=Weather-Rel.pdf - Aircraft logbook (item 6, PDF, 10 pages, 17.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10086919&FileExtension=pdf&FileName=Aircraft%20Logbook%20MASTER_Redacted-Rel.pdf - Aircraft information article (item 7, PDF, 21 pages, 912 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10087728&FileExtension=pdf&FileName=Destiny%20Powered%20Parachutes-Rel.pdf - Pilot logbook (item 8, PDF, 69 pages, 78.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9326344&FileExtension=pdf&FileName=Pilot%20Logbook%20Master_Redacted-Rel.pdf - FAA toxicological report (item 9, PDF, 1 page, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9332941&FileExtension=pdf&FileName=Tox%20Master-Rel.pdf_Redacted.pdf - Photo log (item 10, PDF, 1 page, 930 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9334148&FileExtension=pdf&FileName=Photo%20Log-Rel.pdf - Wreckage release (item 11, PDF, 1 page, 756 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9333227&FileExtension=pdf&FileName=Wrecakge%20Release%20MASTER_Redacted-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.