# NTSB CEN23FA016: Vans RV-12, N86GV, Chandler, TX, October 21, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: October 21, 2022, 14:30 local (19:30 UTC) - Place: Chandler, TX - Coordinates: 32.265383, -95.497824 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.2654&lon=-95.4978&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-climb to cruise: 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 FSDO - NTSB case key (mKey): 106174 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23FA016 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106174/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106174 - Page: https://openairdocs.org/ntsb/CEN23FA016 ## Probable cause The loss of control inflight for reasons that could not be determined. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Unknown/Not determined (probable cause); cases with it: [Vans RV-12, 2 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=0690009), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-climb to cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Vans RV-12, 5 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=0690009), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## 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](https://openairdocs.org/aircraft/N86GV), registered now, S/N 120384, built 2013 (OpenAirDocs) - Reported make and model: VANS AIRCRAFT INC RV-12 - Registry model: [Vans RV-12](https://openairdocs.org/model/vans-rv-12) (registry code 0690009) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 120384 - Year built: 2013 - Airframe hours: 203.1 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 79; injuries: fatal; 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 $ ## 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 20221021022299A](https://openairdocs.org/incident/20221021022299A), Oct 21, 2022: Vans Aircraft Inc RV-12, Chandler, TX, Destroyed, 1 fatal. Aircraft departed tyr @ 1423. Climbed to approx. 5475 feet at 79 knots, iaw ADS-B data. Aircraft then accelerrated to 93 knots, began a descending RH turn,… ## Docket (10 files) The files NTSB released with the investigation on October 3, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106174. 31.6 MB in all. - Airframe examination (item 1, PDF, 4 pages, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17265035&FileExtension=pdf&FileName=cen23fa016%20wrecakge%20exam-Rel.pdf - Photos (item 2, PDF, 2 pages, 583 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15995609&FileExtension=pdf&FileName=Photos%202-Rel.pdf - Map overlays (item 3, PDF, 2 pages, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15995905&FileExtension=pdf&FileName=Map%20Overlays-Rel.pdf - ADS-B data (item 4, CSV, 5 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15996011&FileExtension=csv&FileName=CEN23FA016%20-%20OV%20Track%20Data-Rel.csv - Records of conversation (item 5, PDF, 4 pages, 5 photos, 383 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17620792&FileExtension=pdf&FileName=Records%20of%20Conversation_Redacted-Rel.pdf - Rotech investigative notes (item 6, PDF, 5 pages, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15997228&FileExtension=pdf&FileName=N86GV%20Vans%20RV12%20Investigation%20Field%20Notes-Rel.pdf - Logbook entries (item 7, PDF, 2 pages, 24.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16836666&FileExtension=pdf&FileName=Logbook%20Entries_Redacted-Rel.pdf - Toxicology (item 8, PDF, 4 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17264486&FileExtension=pdf&FileName=Pilot%20Tox_Redacted-Rel.pdf - Medical factual memorandum for record (item 9, PDF, 6 pages, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17531753&FileExtension=pdf&FileName=CEN23FA016_MedicalFactualMemo-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16090668&FileExtension=pdf&FileName=Signed%20NTSB%20Release_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.