DFW08LA157

NTSB accident investigation · Lucas D E/ Lucas K A AcroSport II · St Charles, MO · June 1, 2008

Accident · FatalLimited investigationFinal report
Date
June 1, 2008, 11:00 local (16:00 UTC)
Place
St Charles, MO
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N114KTLucas D E/ Lucas K A AcroSport II
Defining event
Maneuvering-low-alt flying: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report May 6, 2010
Report
Approved by Office Director
Parties
FAA St Louis FSDO
FAA report
20080601838949A
Case key
68147

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 failure to maintain control during an attempted low pass maneuver.

Findings · 3

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.

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 told several people that he intended to do a flyby over the model airplane flying field. Later that morning, when the accident airplane was about a mile away from the model airplane flying field, several witnesses observed it flying straight and level at less than 100 feet above the ground. The airplane pitched up, rolled right and impacted the ground vertically, heading in the opposite direction. One witness observed the airplane flying inverted when the nose pitched up, suddenly performing what the eyewitness described as an aileron roll, then sharply rolled nose down toward the ground. The pilot did not have a previous history of aerobatic flight at low altitude. The pilot had a previous history of frequent episodes of abnormal heart rhythm resulting in markedly elevated heart rate (220 beats per minute), palpitations, and neck discomfort. He had severe coronary artery disease discovered on autopsy, which would have reduced his tolerance to such a high heart rate. Additionally, the pilot was on a prescription antidepressant that could increase his risk for seizure, and had been regularly using a prescription narcotic with the potential for impairment. He had not revealed his history of abnormal heart rhythm or his use of an antidepressant and a narcotic medication to the Federal Aviation Administration. While the circumstances of the accident suggest the possibility of incapacitation, potentially due to an abnormal heart rhythm or seizure, the investigation was unable to determine whether the pilot became incapacitated at the time of the accident.

Factual narrative

History of flight

On June 1, 2008, about 1100 central standard time (CST), a Lucas D E/Lucas K A Acro Sport II, N114KT, was substantially damaged during impact with terrain, following a loss of control while maneuvering. The private pilot, who was the sole occupant, was fatally injured. The amateur built airplane was registered to and operated by the pilot. Visual meteorological conditions prevailed and a flight plan had not been filed for the 14 Code of Federal Regulations Part 91 personal flight. The flight had departed the Creve Coeur Airport (1H0) in St. Louis, Missouri on a local area flight.

The pilot told several people that he intended to do a flyby over the model airplane flying field. Later that morning, when the accident airplane was about a mile away from the model airplane flying field several witnesses observed it flying straight and level at less than 100 feet above the ground. The airplane pitched up, rolled right and impacted the ground vertically, heading in the opposite direction. One witness observed the airplane flying inverted when the nose pitched up, suddenly performing what the eyewitness described as an aileron roll then sharply rolled nose down toward the ground. First responders found the wreckage after several witnesses had made calls to 911 emergency.

Personnel information

A review of Federal Aviation Administration (FAA) airman records revealed the pilot held a private certificate with a rating for airplane single engine land.

The pilot held a third class medical certificate, with waivers or limitations, which was issued on June 21, 2007.

An examination of the pilot's logbook and the airplane maintenance logbook indicated he had an estimated total pilot flight time of 331 hours of which 130 hours was in the accident airplane. He had logged 20 hours in the last 90 days, and 3 in the last 30 days.

An examination of the pilot’s logbook and statements from several persons that knew him did not show any previous history of aerobatic flight at low altitude.

Aircraft information

The airplane was a Lucas D E/Lucas K A Acro Sport II, serial number 28, equipped with a Lycoming IO-360-A3B6D engine. The Acro Sport II design is an amateur built, short wing-span biplane of conventional tail dragger configuration, with open cockpits and “spatted” main undercarriage. Its structure is a fabric-covered steel tube fuselage with a wood wing structure.

At the time of the accident, the airplane had accumulated 162.4 hours total time, with an engine total time of 162.4. The aircraft maintenance logs showed the most recent condition inspection had been completed on June 12, 2007 at 120.2 hours total time.

Meteorological information

The weather reported at the Spirit of St. Louis Airport (SUS) at 1053 CST (5 miles southwest of the accident site) reported a calm wind, 10 miles visibility, few clouds at 25,000 feet, temperature 79 degrees Fahrenheit, dew point 66 degrees Fahrenheit, and an altimeter setting of 29.97 inches of Mercury.

Communications

According to the FAA, the St. Louis Terminal Radar Approach Control (TRACON) had no record of radar contacts or communications contacts with the accident airplane.

Wreckage and impact information

The Federal Aviation Administration (FAA) inspectors that responded to the accident scene reported that the airplane was destroyed on impact, with extensive damage from the propeller spinner aft to the rear of the aft cockpit. The smell of fuel was present at the scene, but there was no post crash fire.

The recording “G” meter in the rear cockpit indicated forces of 8.7 positive and 3.0 negative. The FAA inspectors reported that rudder and elevator control continuity was established from the control surfaces up to the aft cockpit. Because of crash damage they were unable to further determine control continuity.

Medical and pathological information

The Saint Louis University Health Sciences Center completed an autopsy. The cause of death was listed as: Immediate Cause: Massive Trauma of Head, Chest, Abdomen and Extremities.

The FAA Toxicology and Accident Research Laboratory performed toxicological testing of specimens of the pilot with the following results: NO CARBON MONOXIDE detected in Blood, NO CYANIDE detected in Blood, NO ETHANOL detected in Urine, AZACYCLONOL detected in Urine, AZACYCLONOL detected in Liver, BUPROPION detected in Blood, BUPROPION detected in Urine, BUPROPION METABOLITE detected in Urine, DIHYDROCODEINE detected in Blood, 0.012 (ug/mL, ug/g) DIHYDROCODEINE detected in Urine, 0.019 (ug/ml, ug/g) HYDROCODONE detected in Blood, 0.093 (ug/ml, ug/g) HYDROCODONE detected in Urine, LOSARTAN detected in Urine, LOSARTAN detected in Liver, QUININE detected in Urine, and QUININE detected in Liver.

The pilot had noted on his most recent application for airman medical certificate, dated 6/21/2007, a history of asthma requiring only intermittent treatment, allergies, high blood pressure treated with losartan/hydrochlorothiazide, and use of the cholesterol-lowering medication atorvastatin and the antihistamine fexofenadine. No other conditions or medications were noted on that application.

The pilot’s personal medical records documented a history of chronic knee pain, chronic back pain treated with surgery and hydrocodone/acetaminophen (used once a day on average), depressive symptoms treated with bupropion extended release 150 mg twice a day, and a history of frequent abnormal heart rhythms. An electrophysiologist documented in 2002 that the pilot had a “…history of recurrent episodes of supraventricular tachycardia … rate of approximately 220 beats per minute. … six to seven year history of recurrent episodes … three or four times a year … associated with moderate to strenuous activities … abrupt onset of palpitations and fullness in his neck … he will lie down and the palpitations will subside after 1 to 5 minutes. … can be somewhat dangerous for him … discussed the treatment options ...” A 2004 primary care physician’s note indicated “…Episodic supraventricular tachycardia. The patient has not had any episodes recently. He has seen [an electrophysiologist] for an opinion, but for the time being he is not interested in pursuing that option…”

The autopsy report on the pilot noted “Arteriosclerotic Heart Disease: Coronary artery, right, severe [75% occlusion] atherosclerosis.” The report also noted that the blood for toxicology testing was “from the chest.”

Tests and research

The wreckage was moved to a storage facility. An FAA inspector examined the engine and the airframe and found no evidence of preexisting anomalies with either.

Aircraft

Registration
N114KT
Reported as
Lucas D E/ Lucas K A AcroSport II
Category
Airplane, amateur-built
Serial number
28
Airframe hours
162
Engine
Lycoming IO-360-A3B6D, 200 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Annual · June 12, 2007 · 42 hours before
Departed
1H0 · St Louis, MO
Destination
1H0 · St Louis, MO
Airport
1H0 · Creve Coeur Airport

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
52
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Rear
Toxicology
Performed
Flight hours
331 total · 130 in this make and model · 20 in the last 90 days · 3 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 66 °F
Altimeter
29.96 inHg
Observed at
KSUS, 5 nm away

Docket · 18

The files NTSB released with the investigation on February 10, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 7.5 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.