ERA20FA025

NTSB accident investigation · Vans RV 4 · Middleburg, FL · October 31, 2019

Accident · FatalClass 3 · FieldFinal report
Date
October 31, 2019, 17:30 local (21:30 UTC)
Place
Middleburg, FL
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N425JWVans RV 4
Defining event
Enroute-cruise: Collision with terr/obj (non-CFIT)
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA, Lycoming
FAA report
20191031020549A
Case key
100515

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

Impact with power lines for reasons that could not be determined based on available evidence.

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.

Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedWhitcomb Jack RV-4: 1 caseAll aircraft: 1,310 cases
Not determinedNot determined › Not determined · Unknown/Not determinedWhitcomb Jack RV-4: 1 caseAll aircraft: 2,247 casesProbable cause
Use of equip/infoPersonnel issues › Task performance · PilotWhitcomb Jack RV-4: 1 caseAll aircraft: 111 cases

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 a family member, the pilot intended to conduct a brief local flight. A witness at the departure airport reported that he heard an airplane take off. He did not identify the airplane; however, about 10 minutes later the airport experienced a complete electrical power outage. The airplane was located in a clearing in a heavily wooded area. The wreckage and accident site were consistent with the airplane impacting powerlines before impacting terrain. Most of the airplane was destroyed by postcrash fire. The engine was examined, and no anomalies were noted. The pilot had recent diagnoses of several cardiovascular conditions that would increase his risk for an acute cardiovascular event, including severe mitral valve regurgitation, ventricular enlargement, and heart failure; however, there were no autopsy findings or radio communication to determine if the pilot experienced a cardiac event. Post-mortem toxicology detected the impairing medication gabapentin in liver tissue and urine, but it could not be determined if the concentration was at therapeutic or impairing levels; therefore, whether the pilot’s medical conditions or his use of medication contributed to the accident could not be determined. Given the lack of available evidence, the reason for the airplane’s impact with power lines could not be determined.

Factual narrative

On October 31, 2019, about 1730 eastern daylight time, an experimental, amateur-built Vans RV-4, N425JW, was destroyed when it was involved in an accident near Middleburg, Florida. The airline transport pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot’s son, the pilot intended to conduct a brief flight before participating in family events later in the day. A witness at Haller Airpark (7FL4), Green Cove Springs, Florida stated that he was working in his hangar when he heard an airplane take off about 1720. He did not identify the airplane; however, about 10 minutes later the airport experienced a complete electrical power outage. According to the Office of the Medical Examiner, Jacksonville, Florida, the cause of the pilot’s death was multiple blunt injuries, and the manner of death was accident. With the exception on an enlarged heart (537 grams), there was no evidence of any significant natural disease identified. The Federal Aviation Administration (FAA) Forensic Sciences Laboratory toxicology testing detected the impairing medication gabapentin in the pilot’s liver tissue and urine (56 micrograms per milliliter [µg/mL]). Gabapentin (commonly marketed as Neurontin) is an antiseizure medication that is also used to treat chronic nerve pain and postherpetic neuralgia (shingles). It carries a warning that it “may cause dizziness, somnolence and other symptoms and signs of central nervous system depression” and patients should be advised not to operate complex machinery “until they have gained sufficient experience on gabapentin to assess whether gabapentin impairs their ability to perform such tasks.” The airplane was located in a construction clearing in a heavily wooded area. Power lines were observed on the ground near the wreckage. The wreckage path began where the power lines had been located and continued for about 450 ft on a 270° heading. A post-accident fire consumed the airplane. The main wreckage was inverted and oriented on a 320° heading. The wings were separated from the fuselage, and only about 4 feet of the wing tips remained. The wooden propeller was fragmented, and power line impression marks were found on the propeller blades. The vertical stabilizer was located about 230 ft from the main wreckage. Parts from the engine cowling, rudder, and canopy were found scattered in the wreckage path. The cockpit, instrument panel, and firewall were all destroyed by postimpact fire. The engine accessory case was consumed by fire; the magnetos, fuel pump, vacuum pump, and oil filter were destroyed. The engine crank case and cylinders were intact. The top spark plugs were removed, and a lighted borescope was used to examine the cylinder walls, exhaust, intake valves and piston heads. No anomalies were noted. The propeller was rotated by hand and thumb compression was established on all cylinders. Valve train continuity was established throughoutthe engine by observing movement of the rocker arms and rear accessory case gears. The carburetor was removed and disassembled with no anomalies noted.

Aircraft

Registration
N425JW
Reported as
Vans RV 4 (Undesignat)
Category
Airplane, amateur-built
Serial number
1908
Built
1993
Airframe hours
835.7
Engine
Lycoming O-360-A1A, 180 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · January 9, 2019
Departed
7FL4 · Green Cove Springs, FL
Equipment
Unknown

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
72
Injuries
Fatal
Certificates
Airline transport, Flight engineer
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
BasicMed, With waivers/limitations
Seat
Front
Toxicology
Performed
Flight hours
17,868 total · 652.2 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 8 knots
Visibility
10 statute miles
Lowest ceiling
4,100 ft broken
Temperature
84 °F, dew point 72 °F
Altimeter
29.96 inHg
Observed at
K28J, 23 nm away

Docket · 8

The files NTSB released with the investigation on November 16, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 18.6 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.