CEN23FA016

NTSB accident investigation · Vans RV-12 · Chandler, TX · October 21, 2022

Accident · FatalClass 3 · FieldFinal report
Date
October 21, 2022, 14:30 local (19:30 UTC)
Place
Chandler, TX
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N86GVVans RV-12
Defining event
Enroute-climb to cruise: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
FAA FSDO
FAA report
20221021022299A
Case key
106174

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The loss of control inflight for reasons that could not be determined.

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.

Performance/control parametersAircraft › Aircraft oper/perf/capability · Unknown/Not determinedVans RV-12: 2 casesAll 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 pilot departed the airport for an unknown destination. ADS-B data captured the accident flight as it departed from the runway and climbed to about 5,500 ft mean sea level (msl). It then entered a descending right turn with increasing speed and impacted shallow water on the bank of a lake. Examination of the airframe and engine did not reveal any preimpact anomalies that would have precluded normal operation. A gear marking in the engine case was consistent with the engine producing power at the time of the accident. The pilot had a documented history of angioplasty and hypertension, and toxicological evidence indicated he had used medications consistent with treating cardiovascular disease. He likely was at increased risk of a sudden impairing or incapacitating cardiovascular event. An autopsy was conducted on the pilot; however, due to the condition of the remains, a thorough examination could not be conducted. It could not be determined if an impairing condition or natural disease contributed to the accident. Some, or all, of the ethanol detected by toxicological testing may have been from postmortem production; however, the limited results also do not exclude the possibility of ethanol consumption or related impairment. Additionally, the pilot’s toxicology results indicate that he had used multiple medications (including hydrocodone, citalopram, zolpidem, gabapentin, and amitriptyline) that are potentially impairing and/or potentially indicative of other medical conditions (such as depression, chronic pain, or medication-treated diabetes) that could have impairing effects on performance. The airplane’s descending right turn, along with the near-vertical impact signatures, were consistent with an inflight loss of control from which the pilot was unable to recover.

Factual narrative

Several people interacted with the pilot before his departure; none reported any unusual behavior. According to records on file with the FAA, the pilot purchased the airplane in August, 2021. On October 21, 2022, about 1430 central daylight time, a Vans RV-12 airplane, N86GV, was substantially damaged when it was involved in an accident near Chandler, Texas. The pilot was fatally injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Before the flight, ADS-B data captured the airplane as it flew from the area of Round Rock, Texas, towards the Tyler Pounds Regional Airport (TYR), Tyler, Texas. At the airport, the pilot added 3.9 gallons of fuel to the airplane to be fully fueled. ADS-B data captured the accident flight as it departed from runway 22 at TYR about 1423 for an unknown destination. The data showed the airplane climbed to about 5,500 ft msl and entered a descending right turn with increasing speed. The airplane impacted shallow water on a bank of Lake Palestine. An autopsy was conducted by American Forensics, Mesquite, Texas, as authorized by the Justice of the Peace, Henderson County, Texas. Due to the condition of the pilot’s remains, a thorough autopsy to evaluate for natural disease could not be performed. The autopsy ruled the cause of death to be extensive blunt force trauma. The manner of death was ruled an accident. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified ethanol at 0.054 g/dL in one blood specimen and 0.022 g/dL in another blood specimen, at 0.049 g/hg in kidney tissue, and at 0.075 g/hg in muscle tissue. Hydrocodone and its metabolites dihydrocodeine and hydromorphone were detected in blood and liver tissue. Citalopram and its metabolite n-desmethylcitalopram was detected in blood and lung tissue. Zolpidem and gabapentin were detected in blood and liver tissue, as were amitriptyline and its metabolite nortriptyline. Glipizide, atorvastatin, valsartan, carvedilol, and clopidogrel also were detected in blood and liver tissue. Tamsulosin was detected in liver tissue. Sildenafil was detected in blood. The samples submitted for testing were marked putrefied. Of the substances identified in toxicology testing, there were several medications which would have required a Special Issuance or were completely unacceptable for use by pilots. By FAA medical standards, the side effects, alone and combined, posed a hazard to flight safety and may have contributed to the accident. A review of the pilot’s medical history revealed that he did not hold an FAA medical certificate at the time of the accident. The pilot’s prior Authorization for Special Issuance of Medical Certification for a history of angina, angioplasty, and medication-controlled hypertension had expired. According to Federal Aviation Administration (FAA) records, the pilot’s last FAA medical certificate was issued on August 12, 1999, and was not valid after2001. Under the provisions of Title 14 CFR 61.23, the pilot was operating the light sport airplane using his driver’s license. A complete pilot logbook was not recovered for the pilot. In 2018, the pilot submitted flight experience of 1,717 total hours to his insurance carrier. In 1999, on the pilot’s last application for an FAA medical certificate, he reported his total flight experience of 800 hours. Impact signatures were consistent with a near-vertical impact. The engine was separated from the airframe during recovery from the lake. Examination of the airframe revealed nearly symmetrical accordion crushing on both wings. The engine compartment was crushed rearward toward the cockpit and wing spar. Buckling and crushing was noted along the empennage. All primary flight controls were accounted for at the accident site. The left aileron was partially torn near the outboard hinge. The right aileron remained attached to the right wing. The rudder remained attached to the vertical stabilizer. The stabilator was crushed and deformed. Flight control continuity could not be established due to the extent of the impact damage. An examination of the engine did not detect any preimpact anomalies. Disassembly of the gearbox indicated that a gear within the gearbox had made contact with the crankcase, which resulted in a rotational smearing of metal.

Aircraft

Registration
N86GV
Reported as
Vans RV-12
Category
Airplane, amateur-built
Serial number
120384
Built
2013
Airframe hours
203.1
Engine
Rotax 912ULS, 100 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Blackwell Jimmie A
Registered owner
Blackwell Jimmie A
Airworthiness certificate
Special, Experimental light sport (Special)
Last inspection
Condition · August 26, 2022
Departed
KTYR · Tyler, TX
Airport
None
Equipment
ADS-B

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
79
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Last flight review
June 28, 2022
Seat
Left
Toxicology
Performed
Flight hours
800 total

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 11 knots, gusting 18
Visibility
10 statute miles
Lowest ceiling
None
Temperature
86 °F, dew point 54 °F
Altimeter
29.89 inHg
Observed at
KTYR, 7 nm away
METAR
KTYR 211953Z 21011G18KT 10SM CLR 30/12 A2989 RMK AO2 SLP117 T03000117 $

Docket · 10

The files NTSB released with the investigation on October 3, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 31.6 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.