# NTSB ERA20FA025: Vans RV 4, N425JW, Middleburg, FL, October 31, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: October 31, 2019, 17:30 local (21:30 UTC) - Place: Middleburg, FL - Coordinates: 30.0125, -81.779998 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.0125&lon=-81.7800&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA, Lycoming - NTSB case key (mKey): 100515 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20FA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100515/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100515 - Page: https://openairdocs.org/ntsb/ERA20FA025 ## Probable cause Impact with power lines for reasons that could not be determined based on available evidence. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Whitcomb Jack RV-4, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=05623MB), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Whitcomb Jack RV-4, 1 case](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=05623MB), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Use of equip/info](https://openairdocs.org/ntsb-findings/02063000): Personnel issues › Task performance · Pilot; cases with it: [Whitcomb Jack RV-4, 1 case](https://openairdocs.org/ntsb-findings/02063000/cases.md?model=05623MB), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02063000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) (defining event); cases with it: [Whitcomb Jack RV-4, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05623MB), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N425JW-2020-06-11), registration cancelled 2020-06-11, S/N 1908, built 1993 (OpenAirDocs) - Reported make and model: Vans RV 4 (Undesignat) - Registry model: [Whitcomb Jack RV-4](https://openairdocs.org/model/whitcomb-jack-rv-4) (registry code 05623MB) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 1908 - Year built: 1993 - Airframe hours: 835.7 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: fatal; 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 ## 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 20191031020549A](https://openairdocs.org/incident/20191031020549A), Oct 31, 2019: Whitcomb Jack RV-4, Middleburg, FL, Destroyed, 1 fatal. 10.31.2019. Assigned case while serving accident telephone standby duty for the orlando FSDO. At approximately 5:30PM aircraft N425JW, a vans RV-4 aircraft,… ## Docket (8 files) The files NTSB released with the investigation on November 16, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100515. 18.6 MB in all. - Memorandum-conversation with pilot's son (item 1, PDF, 1 page, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12871119&FileExtension=pdf&FileName=Memorandom-%20conversation%20with%20son-Rel.pdf - Memorandum-conversation with pilot at airport (item 2, PDF, 1 page, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12870542&FileExtension=pdf&FileName=Memorandom-conversation%20with%20pilot%20at%20airport-Rel.pdf - Excerpts from maintenance and pilot logbooks (item 3, PDF, 3 pages, 13.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9938384&FileExtension=pdf&FileName=Logbooks_Redacted-Rel.pdf - Investigative photos (item 4, PDF, 8 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9938375&FileExtension=pdf&FileName=Investigative%20Photo%27s-Rel.pdf - Toxicological report (item 5, PDF, 1 page, 336 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9939158&FileExtension=pdf&FileName=TOX1_Redacted-Rel.pdf - Memorandom-medical case review (item 6, PDF, 2 pages, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12870532&FileExtension=pdf&FileName=Memorandom_Medical%20Case%20Review-Rel.pdf - Statement of party representatives to NTSB investigation (item 7, PDF, 1 page, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9939523&FileExtension=pdf&FileName=party%20form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 8, PDF, 1 page, 427 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9939207&FileExtension=pdf&FileName=N425JW%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.