# NTSB CEN20LA168: Yakovlev YAK 52, N27YK, Palmyra, IL, May 2, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: May 2, 2020, 16:00 local (21:00 UTC) - Place: Palmyra, IL - Coordinates: 39.408889, -89.99028 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.4089&lon=-89.9903&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: 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 3 - NTSB office: Central Region - Parties: FAA - NTSB case key (mKey): 101228 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA168 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101228/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101228 - Page: https://openairdocs.org/ntsb/CEN20LA168 ## Probable cause A loss of control during a low-altitude aerobatic maneuver. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Yakovlev YAK 52, 1 case](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=9830220), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Yakovlev YAK 52, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=9830220), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Yakovlev YAK 52, 4 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=9830220), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Yakovlev YAK 52, 1 case](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=9830220), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Yakovlev YAK 52, 5 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=9830220), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis Witnesses saw the airplane approach the airport and perform a low-altitude pass 20 to 30 ft above the runway. The airplane then pitched up, climbed about 200 feet, and entered a roll. During the roll, the airplane’s nose dropped, and the airplane descended and impacted the ground in a steep, nose-down attitude. One of the witnesses was familiar with the pilot and had seen the pilot perform similar maneuvers previously. A review of the pilot’s logbooks revealed one entry about three years before the accident flight that suggested some aerobatic training in the accident airplane; however, the extent of the pilot’s aerobatic training could not be determined. Postaccident examination of the airplane revealed no evidence of anomalies; however, impact damage prevented complete examination of the flight control system. Based on autopsy findings, the pilot did not appear to have any natural disease that would be a factor in this accident; however, his toxicology was positive for the anticoagulant warfarin. This medication, while non-impairing, is used to prevent complications of atrial fibrillation or prevent several cardiovascular conditions, such as heart attack and stroke, which can cause sudden incapacitation. This would be especially true for aerial maneuvers that would result in changes in gravitational forces that could trigger heart arrhythmias. The pilot’s FAA third-class medical certificate expired 10 years before this accident, and his current medical status and the reason he was taking warfarin are unknown. Given the operational findings of this accident, the pilot’s use of the medication warfarin and the possible medical conditions for which warfarin was prescribed were unlikely factors in the accident. Ethanol detected in the pilot’s vitreous fluid was likely from sources other than ingestion and did not contribute to the accident. Based on the available information, the circumstances of the accident are consistent with a loss of control during a low-altitude aerobatic maneuver. ## Factual narrative On May 2, 2020, about 1600 central daylight time, a Yakovlev YAK-52 airplane, N27YK, was destroyed when it was involved in an accident near Palmyra, Illinois. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. A witness north of Zelmer Memorial Airpark Inc (5K1), Palmyra, Illinois, saw the airplane descend toward the airport at high speed, “way too fast to be landing.” He lost sight of the airplane as it descended behind a tree line. A few moments later, he saw the airplane climb into sight 200 to 300 ft above ground level (agl) about 1.5 miles away, start to roll, and descend steeply into the ground. A pilot witness observed the airplane make a low pass over the airport around 20 to 30 ft agl. He stated that the airplane pitched up 5 to 10° to about 100 to 200 ft agl when it was past the end of the runway and made a slow roll to the left. As the airplane rolled inverted, he did not think the pilot had enough altitude to perform the maneuver. He lost sight of the airplane as it descended and passed about 270° of roll. His wife captured the low pass on video, but did not record the airplane climbing away from the ground or the roll maneuver. Another witness was mowing his yard when he saw the airplane traveling to the west at low altitude. It began a roll “to the south” and then “nose-dived” steeply toward the ground about 1/2 mile from his location. One of the witnesses, who was not a pilot, said he was familiar with the accident pilot and he had seen the pilot perform “barrel rolls” over property owned by a family member of the pilot. He said that the pilot was usually a couple hundred feet higher above the ground when he saw him perform those maneuvers. An on-scene examination of the wreckage was conducted by a Federal Aviation Administration (FAA) inspector. The airplane impacted an open field about 1/2 mile south of 5K1. The wreckage was located 10 to 15 ft from the initial impact point. The impact crater was 12 to 18 inches deep and the direction of travel from the impact crater to the wreckage was about 240°. The wreckage was highly impact damaged. Both wooden propeller blades were fragmented and impact-separated at the propeller hub. The landing gear were found in the retracted position. The tail section and empennage aft of the rear cockpit were almost completely severed from the fuselage and folded underneath the inverted wreckage. The control cables and associated turn buckles were in place. The flight controls could not be moved, and flight control continuity could not be verified due to the extent of impact damage. Review of the pilot’s logbook, which contained entries beginning in July 1995, revealed that the pilot began recording flights in the accident airplane in April 2017. The only entry pertaining to aerobatics instruction was contained in the first logbook entry associated with the accident airplane, an instructional flight for which the remarksincluded, “rolls.” The last flight recorded in the logbook was on April 17, 2019. The pilot’s most recent third-class medical certificate was issued on August 28, 2008, at which time he reported he was taking no medications. The pilot completed the requirements for operation under BasicMed on February 25, 2019. The Macoupin County Coroner’s Office, Brighton, Illinois, performed an autopsy of the pilot and determined the cause of death to be blunt force injuries. Toxicology testing performed for the coroner’s office detected ethanol at 0.01 grams per deciliter (gm/dL) in the pilot’s vitreous fluid. No ethanol was detected in the pilot’s blood by the FAA Forensic Sciences Laboratory. The FAA laboratory also detected the anticoagulant medication, warfarin, in liver and blood. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. It acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Ethanol is water soluble, and after absorption it quickly and uniformly distributes throughout the body’s tissues and fluids. The distribution pattern parallels water content and blood supply of the tissue. Ethanol can be produced after death by microbial activity. Warfarin is a medication used to treat or prevent blood clots (thromboemboli) or prevent their complications in conditions such as atrial fibrillation or cardiac valve replacement. The medication is given to reduce the risk of sudden death, heart attacks, and strokes. Warfarin increases a person’s chance of major bleeding especially with a fall or accident; a person taking warfarin receives frequent laboratory testing to make sure the concentration balances the risks of bleeding and clotting. Warfarin is not an impairing medication, but the medication and conditions for which it is prescribed would require an observation period by the FAA. ## Aircraft - Registration: [N27YK](https://openairdocs.org/deregistered/N27YK-2021-03-06), registration cancelled 2021-03-06, S/N 9611905, built 1996 (OpenAirDocs) - Reported make and model: Yakovlev YAK 52 (No Series) - Registry model: [Yakovlev YAK 52](https://openairdocs.org/model/yakovlev-yak-52) (registry code 9830220) (OpenAirDocs) - Registry engine: [Vedeneyev M14P](https://openairdocs.org/engine/vedeneyev-m14p) (registry code 63601, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 9611905 - Year built: 1996 - Airframe hours: 1137.8 - Engines: Vedeneyev M14P 360 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Aerobatic - Last inspection: Annual, August 3, 2019 - Airport: 5K1, Zelmer Memorial Airpark Inc ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: basicmed; last flight review September 20, 2017; seat: front; toxicology performed; flight hours: 3,147 total, 25 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 57 °F - Altimeter: 29.26 inHg ## 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 20200502007459A](https://openairdocs.org/incident/20200502007459A), May 2, 2020: Yakovlev YAK 52, Palmyra, IL, Destroyed, 1 fatal. Narrative: a witness stated he saw a blue low wing single engine airplane make a low pass down runway 18 at Zelmer airport in Palmyra, Illinois. After passing… ## Docket (8 files) The files NTSB released with the investigation on March 3, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101228. 43.8 MB in all. - Record of FAA notes (item 1, PDF, 2 pages, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11657848&FileExtension=pdf&FileName=Memorandum%20of%20Record%20-%20FAA%20Notes-Rel.pdf - Witness statements (item 2, PDF, 6 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11658423&FileExtension=pdf&FileName=Binder%20Witnesses_Redacted-Rel.pdf - Flyover video (item 3, MOV, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11658764&FileExtension=MOV&FileName=Witness%20Video-Rel.MOV - Photos (item 4, PDF, 4 pages, 4 photos, 6.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11851545&FileExtension=pdf&FileName=Photo%20Array%20CEN20LA168-Rel.pdf - Maintenance records (item 5, PDF, 2 pages, 2 photos, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11853712&FileExtension=pdf&FileName=MX%20Records_Redacted-Rel.pdf - Toxicological report (item 6, PDF, 1 page, 635 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11905023&FileExtension=pdf&FileName=CEN20LA168%20Tox_1_Redacted-Rel.pdf - Memorandum for record - medical information (item 7, PDF, 1 page, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11907322&FileExtension=pdf&FileName=Memorandum%20of%20Record%20-%20Medical%20and%20Pathological%20Information-Rel.pdf - Pilot logbooks (item 8, PDF, 21 pages, 28.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13315808&FileExtension=pdf&FileName=Pilot%20Logbooks%20CEN20LA168_2_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.