# NTSB ERA19FA183: Vans Vans RV 4, N319RL, Green Cove Springs, FL, May 29, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: May 29, 2019, 10:45 local (14:45 UTC) - Place: Green Cove Springs, FL - Coordinates: 29.957777, -81.727218 - Nearby events: https://openairdocs.org/map.md?lat=29.9578&lon=-81.7272&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining events: [Maneuvering-aerobatics: Midair collision](https://openairdocs.org/ntsb-events/250); [Maneuvering-aerobatics: Midair collision](https://openairdocs.org/ntsb-events/250) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 99503 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19FA183 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99503/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99503 - Page: https://openairdocs.org/ntsb/ERA19FA183 ## Probable cause (aircraft 1) The failure of each pilot to maintain separation from the other airplane during intentional maneuvers within close proximity of each other. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause), aircraft 1; cases with it: [Lennon Rockwell Gene VANS RV-4, 1 case](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=05621X6), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) - [Planning/preparation: flight planning/navigation](https://openairdocs.org/ntsb-findings/02061025): Personnel issues › Task performance · Pilot (probable cause), aircraft 1; cases with it: [Lennon Rockwell Gene VANS RV-4, 1 case](https://openairdocs.org/ntsb-findings/02061025/cases.md?model=05621X6), [All aircraft, 179 cases](https://openairdocs.org/ntsb-findings/02061025/cases.md) - [Planning/preparation: flight planning/navigation](https://openairdocs.org/ntsb-findings/02061025): Personnel issues › Task performance · Pilot (probable cause), aircraft 2; cases with it: [Dougherty John G RV4, 1 case](https://openairdocs.org/ntsb-findings/02061025/cases.md?model=0560664), [All aircraft, 179 cases](https://openairdocs.org/ntsb-findings/02061025/cases.md) - [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause), aircraft 2; cases with it: [Dougherty John G RV4, 1 case](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=0560664), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-aerobatics: Midair collision](https://openairdocs.org/ntsb-events/250) (defining event), aircraft 1; cases with it: [Lennon Rockwell Gene VANS RV-4, 1 case](https://openairdocs.org/ntsb-events/250/sequence.md?model=05621X6), [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470), aircraft 1; cases with it: [Lennon Rockwell Gene VANS RV-4, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05621X6), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Maneuvering-aerobatics: Midair collision](https://openairdocs.org/ntsb-events/250) (defining event), aircraft 2; cases with it: [Dougherty John G RV4, 1 case](https://openairdocs.org/ntsb-events/250/sequence.md?model=0560664), [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470), aircraft 2; cases with it: [Dougherty John G RV4, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=0560664), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis (aircraft 1) 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 (aircraft 1) 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 1 - Registration: [N319RL](https://openairdocs.org/deregistered/N319RL-2020-08-02), registration cancelled 2020-08-02, S/N 1807, built 2008 (OpenAirDocs) - Reported make and model: Vans VANS RV 4 (Undesignat) - Registry model: [Lennon Rockwell Gene VANS RV-4](https://openairdocs.org/model/lennon-rockwell-gene-vans-rv-4) (registry code 05621X6) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 1807 - Year built: 2008 - Engines: 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 ## Aircraft 2 - Registration: [N203DD](https://openairdocs.org/deregistered/N203DD-2020-08-27), registration cancelled 2020-08-27, S/N 2285, built 2000 (OpenAirDocs) - Reported make and model: Vans RV4 (Undesignat) - Registry model: [Dougherty John G RV4](https://openairdocs.org/model/dougherty-john-g-rv4) (registry code 0560664) (OpenAirDocs) - Registry engine: [Lycoming O-360-A1A](https://openairdocs.org/engine/lycoming-o-360-a1a) (registry code 41594, 4 cycle) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 2285 - Year built: 2000 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N319RL; age 74; injuries: fatal; 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 - Pilot, aircraft N203DD; age 77; injuries: serious; 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 ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20190529011422A](https://openairdocs.org/incident/20190529011422A), May 29, 2019: Lennon Rockwell Gene VANS RV-4, Green Cove Spri, FL, Destroyed, 1 fatal. *Note: original FSDO notification referenced tail number N313RL. The correct tail number is N319RL. On may 29, 2019, at approximately 10:45 (local time),… - [Accident 20190529008532A](https://openairdocs.org/incident/20190529008532A), May 29, 2019: Dougherty John G RV4, Green Cove Spri, FL, Substantial damage. *Note: original FSDO notification referenced tail number N313RL. The correct tail number is N319RL. On may 29, 2019, at approximately 10:45 (local time),… ## Docket (7 files) The files NTSB released with the investigation on June 10, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99503. 20.0 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 6.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11707106&FileExtension=pdf&FileName=NTSB%206120_1%20David%20Dollarhide_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot N203DD (item 2, PDF, 1 page, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11707466&FileExtension=pdf&FileName=Memorandum%20of%20Record%20FA183AB%20Dollarhide-Rel.pdf - Maintenance records (item 3, PDF, 2 pages, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11907224&FileExtension=pdf&FileName=Dollorhide%20logbooks%20excerpts_Redacted-Rel.pdf - Toxicological report (item 4, PDF, 2 pages, 529 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11877273&FileExtension=pdf&FileName=Toxicology%20N319RL_Redacted-Rel.pdf - Photo array (item 5, PDF, 7 pages, 6.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11905567&FileExtension=pdf&FileName=Photo%20Array%20FA183AB-Rel.pdf - Evidence control form (item 6, PDF, 3 pages, 369 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11907850&FileExtension=pdf&FileName=Evidence%20Control%20Form%20FA183AB_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 3 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11882636&FileExtension=pdf&FileName=N203DD%20_%20N319RL%20Wreckage%20Release%20Form%2001%2027%2021_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.