ERA19FA183

NTSB accident investigation · Vans Vans RV 4 · Green Cove Springs, FL · May 29, 2019

Accident · FatalClass 3 · FieldFinal report
Date
May 29, 2019, 10:45 local (14:45 UTC)
Place
Green Cove Springs, FL
Injuries
1 fatal, 1 serious
Phase of flight
Maneuvering
Aircraft
N319RLVans Vans RV 4N203DDVans RV4
Defining events
Maneuvering-aerobatics: Midair collisionManeuvering-aerobatics: Midair collision
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
Case key
99503

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 failure of each pilot to maintain separation from the other airplane during intentional maneuvers within close proximity of each other.

Findings · 4

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.

N203DD · Vans RV4

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

According to the pilot of the yellow airplane, the purpose of the flight was to check the accuracy of his airspeed indicator while flying alongside the red airplane. After completing the airspeed indicator check, the pilots of both airplanes began to conduct flight maneuvers that the pilot of the yellow airplane referred to as a “tail chase.” After a few minutes of maneuvering and one visual lead change to the red airplane, both airplanes were on a southerly heading. The pilot of the yellow airplane called off the “tail chase” and made a gradual left turn, then a few banked heading changes to the northeast before settling on an easterly heading in a gradual descent. He stated that, while descending, he suddenly saw the red airplane directly in front of him, nose-to-nose. The airplanes collided, and he saw the red airplane descend to the ground. The pilot of the yellow airplane noted that his airplane was vibrating violently and he made a forced landing in a pasture. Examination of the wreckage area revealed that the red airplane came to rest 4 miles northwest of the departure airport. The yellow airplane came to rest 2 miles east-northeast of the red airplane and about 5 miles north of the departure airport. Examination of the yellow airplane revealed red paint transfer marks on a 6-inch-deep, 17-inch-wide semicircle on the leading edge of the left wing. There were also red paint transfers on the lower outboard section of the right-wing leading edge. Examination of the red airplane revealed yellow paint transfers on the lower part of the rudder. A 3-ft tire skid mark was found on top of the empennage and ended at the vertical stabilizer. Examination of the flight controls and engines of both airplanes did not reveal any anomalies that would have precluded normal operation. Toxicological testing of tissue samples from the pilot of the red airplane indicated that he had taken some cough and cold medications. From the levels of the substances observed in tissue samples, it could not be determined if, or to what extent, the pilot may have been impaired by them. The pilots of the airplanes were intentionally maneuvering their airplanes within close proximity to each other. After losing sight of each other, the pilots then unintentionally maneuvered the airplanes such that they approached each other nearly head-on and collided.

Factual narrative

On May 29, 2019, about 1045 eastern daylight time, a red experimental amateur-built Vans RV-4, N319RL, was destroyed and a yellow experimental amateur-built Vans RV-4, N203DD, sustained substantial damage when they were involved in an accident near Green Cove Springs, Florida. The pilot of the yellow airplane was seriously injured, and the pilot of the red airplane was fatally injured. Both airplanes were operated as Title 14 Code of Federal Regulations Part 91 personal flights. The local flights both originated from Haller Airpark (7FL4), Green Cove Springs, Florida, about 1030 in day visual meteorological conditions; neither flight was operated on a flight plan. According to the pilot of the yellow airplane, the purpose of the flight was to check the accuracy of his airspeed indicator; he had asked his acquaintance, the pilot of the red airplane, to fly alongside his airplane. After departure, he checked his airspeed indicator with the pilot of the red airplane, and everything appeared normal. He said that they decided to engage in a maneuver they often performed called a “tail chase,” which consisted of taking turns flying in trail through various turns, dives, and climbs. After a few minutes of maneuvering and one visual lead change to the red airplane, both airplanes were on a southerly heading. The pilot of the yellow airplane called off the “tail chase” and made a gradual left turn. He made a few banked heading changes to the northeast before settling on an easterly heading in a gradual decent. He stated that during the descent, he suddenly saw the red airplane appear at his “twelve o-clock” position at a distance of 50 ft, coming directly at him. He said he was so close that he could see the other pilot in his cockpit. He said that before either pilot could react, the airplanes collided, with the red airplane slightly lower than his airplane. After the collision, the pilot of the yellow airplane looked back and saw the red airplane falling in two pieces to the ground. He said that he knew his propeller was out of balance because his airplane began to vibrate violently, so he conducted a forced landing in a pasture. Examination of the wreckage area revealed that the red airplane came to rest 4 miles northwest of 7FL4. The yellow airplane came to rest 2 miles east-northeast of the red airplane and about 5 miles north of 7FL4. During the wreckage examination of the yellow airplane, red paint transfer marks were found on a 6-inch-deep, 17-inch-wide semicircle on the leading edge of the left wing. There were also red paint transfers on the lower outboard section of the right wing leading edge. Examination of the main landing gear revealed the left main gear strut was broken but still attached to the fuselage. The left main landing gear wheel was broken on the hub and remained attached to the axle. There was a skid mark on the tire, and the strut fairing and wheel pant were missing. Examination of the propeller revealed both blades were bent,and one blade displayed a 2-inch semicircular gouge on the leading edge of the blade. Examination of the flight controls revealed continuity from all flight controls to their respective control surfaces. Examination of the engine revealed valvetrain continuity to the accessory section and compression. Spark was observed on all ignition leads. Trace amounts of fuel were observed in the fuel system, and the fuel system was breached. During the wreckage examination of the red airplane, yellow paint transfers were found on the lower part of the rudder. A 3-ft tire skid mark was found on top of the empennage and ended at the vertical stabilizer. The vertical stabilizer was fragmented and broken away from the fuselage. Pieces of the vertical stabilizer skin and rudder were located at the wreckage site. The upper section of the rudder was fragmented, and only the lower part of the rudder remained attached at the attachment fitting and the rudder control cables. The horizontal stabilizers and the elevators were broken, fragmented, and remained partially attached by the skin of the fuselage. The airplane impacted the ground nose first and was accordion-crushed aft. All control surfaces were accounted for at the accident site. Flight control continuity was established to the push-pull tubes. The control tubes revealed overstress breaks within the fuselage and wings. Examination of the engine revealed the crankshaft was impact damaged and bent. The propeller remained attached to the crankshaft flange and showed signs of rotational scoring. Valvetrain continuity was observed, but compression in the cylinders could not be obtained due to the bent crankshaft. The engine accessories, magnetos, vacuum pump, and fuel pump were crushed aft. The ignition system wiring was destroyed. No fuel was noted in the fuel system due to impact damage. The instrument panel was destroyed. The Office of the Medical Examiner, Jacksonville, Florida, performed an autopsy on the pilot of the red airplane. His cause of death was blunt impact injuries. Toxicology testing performed at the Federal Aviation Administration Forensic Sciences Laboratory found 21 mg/dL ethanol in muscle, no ethanol in liver, dextrorphan in liver and muscle, dextromethorphan in liver and muscle, and chlorpheniramine in liver and muscle. Dextromethorphan is a nonsedating cough suppressant (its metabolite is dextrorphan). Chlorpheniramine is a sedating antihistamine used to temporarily relieve symptoms of allergies and colds. Product packaging for chlorpheniramine includes the warning that drowsiness may occur and to use caution when driving a motor vehicle or operating machinery. Dextromethorphan and chlorpheniramine are often sold in combination in over-the-counter cough and cold remedies. Ethanol can be produced after death by microbial activity; the identified ethanol was likely from sources other than ingestion. The pilot of the yellow airplane survived the accident. No postaccident toxicology wasobtained.

Aircraft · 2

Registration
N319RL
Reported as
Vans Vans RV 4 (Undesignat)
Category
Airplane, amateur-built
Serial number
1807
Built
2008
Engine
Lennon/Woolley exprimental O-360 A1B, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Departed
7FL4 · Green Cove Springs, FL
Destination
7FL4 · Green Cove Springs, FL
Equipment
None

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.

Registration
N203DD
Reported as
Vans RV4 (Undesignat)
Category
Airplane, amateur-built
Serial number
2285
Built
2000
Engine
exprimental O-360-A1A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Departed
7FL4 · Green Cove Springs, FL
Destination
7FL4 · Green Cove Springs, FL
Equipment
Handheld GPS

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N319RL
Age
74
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Single
Restraint
5-point
Toxicology
Performed
Flight hours
3,800 total
Role
Pilot, aircraft N203DD
Age
77
Injuries
Serious
Certificates
Commercial, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
January 30, 2018
Seat
Center
Restraint
5-point
Flight hours
20,071 total · 1,968 in this make and model · 9,342 as pilot in command · 18 in the last 90 days · 5 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 63 °F
Altimeter
30.00 inHg
Observed at
K28J, 13 nm away

Docket · 7

The files NTSB released with the investigation on June 10, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.0 MB in all.

FAA reports on this event · 2

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.