# NTSB ERA22FA391: Aeronca 7AC, N1478E, Jacksboro, TN, August 29, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: August 29, 2022, 12:50 local (16:50 UTC) - Place: Jacksboro, TN · Off airport property - Coordinates: 36.335478, -84.159532 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.3355&lon=-84.1595&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 105818 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22FA391 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105818/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105818 - Page: https://openairdocs.org/ntsb/ERA22FA391 ## Probable cause The pilot's exceedance of the airplane’s critical angle of attack during takeoff, which resulted in an aerodynamic stall and loss of control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Aeronca 7AC, 7 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2110102), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aeronca 7AC, 43 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2110102), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Aeronca 7AC, 9 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2110102), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Aeronca 7AC, 17 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2110102), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Aeronca 7AC, 44 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2110102), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis According to a friend, the pilot had not flown for 20 years, and purchased the accident airplane the day before the accident flight. The pilot’s friend witnessed and recorded video of the accident takeoff, which revealed that the airplane became airborne and entered a slow speed, nose-high climb that continued into a left turn. The airplane then pitched nose-down and began descending while the engine could be heard operating smoothly and continuously to ground contact. The airplane was found in a nose-down position in a field near the runway with significant damage to the engine and cockpit area. All primary flight control surfaces remained attached, and the empennage was bent upward and forward but remained partially attached. The wreckage examination did not reveal evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Toxicology testing detected diphenhydramine in the pilot’s cavity blood and urine. The concentration of diphenhydramine in cavity blood was reported qualitatively, indicating a level below the laboratory reporting threshold. Given the potential for postmortem redistribution and contamination in cavity blood, it is unlikely that the pilot’s use of diphenhydramine contributed to the accident. The takeoff described by the witness and video appeared consistent with entry into a low altitude aerodynamic stall. The distribution of the wreckage and relatively low energy signatures exhibited by the wreckage at the accident site were also consistent with an aerodynamic stall. Based on this information, it is likely that the pilot exceeded the airplane’s critical angle of attack during the initial climb, which resulted in an aerodynamic stall, loss of control, and impact with terrain. ## Factual narrative On August 29, 2022, about 1250 eastern daylight time, an Aeronca 7AC, N1478E, was destroyed when it was involved in an accident near Jacksboro, Tennessee. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to a friend of the pilot, the pilot purchased the airplane the day before the accident. He flew the airplane from Alabama to Tennessee, and this flight was the pilot’s first in 20 years. She described that on the day of the accident, he wanted to "take it up for a flight." The friend stated that the airplane took off "real early" and the airplane did not use much of the runway. After takeoff, the airplane made a sharp turn to the left and descended below the tree line. She contacted local authorities and waited for their arrival. Review of video footage recorded by the pilot’s friend showed the airplane became airborne and entered a slow speed, nose-high climb that continued into a left turn. The airplane then pitched nose-down and began descending while the engine could be heard operating smoothly and continuously to ground contact. The Regional Forensic Center of Knox County performed the pilot’s autopsy, as authorized by the Campbell County Medical Examiner. According to the pilot’s autopsy report, his cause of death was multiple and massive blunt force injuries, and his manner of death was accident. The Federal Aviation Administration (FAA) Forensic Sciences Laboratory performed toxicological testing of postmortem specimens of the pilot. Diphenhydramine, clopidogrel, and amlodipine were detected in cavity blood and urine. Diphenhydramine is a sedating antihistamine medication widely available over the counter in multiple sleep aids and cold and allergy products. Diphenhydramine can cause cognitive and psychomotor slowing and drowsiness and often carries a warning that it may impair performance of tasks like driving and operating heavy machinery. The typical elimination half-life of diphenhydramine in plasma is about 3 to 14 hours. The FAA states that pilots should not fly within 60 hours of using diphenhydramine, to allow time for it to be cleared from circulation. Clopidogrel is a prescription medication that prevents clotting. It is used to treat patients with previous histories of heart attacks, including those who are managed medically and those who are managed with coronary revascularization, and to reduce the rate of subsequent heart attacks. It is also used to reduce the risk of recurrent strokes in patients who have had previous non-hemorrhagic strokes. Amlodipine is prescription medication commonly used to treat high blood pressure, chronic stable angina, and as part of the medical management of coronary artery disease. The airplane came to rest nose-down in a field adjacent to the runway oriented on a magnetic heading of 023°. Flight control continuity was established to all primary flight control surfaces. The nose of the airplane wascrushed aft to the cockpit, and the engine and avionics instruments were destroyed by impact. The wings remained attached to the fuselage and exhibited impact damage, including accordion-style crush damage along the leading edges. The empennage was bent over the fuselage but remained partially attached. The engine’s crankshaft could not be rotated due to impact damage, and cylinder compression could not be confirmed. The spark plugs were removed for examination, and the electrodes exhibited normal wear and were dark in color when compared to a Champion Check-a-Plug chart, with no evidence of fouling. The left magneto produced spark on all leads, but the right magneto did not produce any spark due to impact damage to the impulse coupling. The oil screen was removed and was free of debris. The carburetor bowl was clean, and the float moved freely. The right side of the engine case, between the cylinders, was impact-fractured with a crack measuring about 6 inches. Fuel was found inside the lines from the fuel pump to the carburetor. The fuel strainer was opened, and the screen was clean and unobstructed. The lever-action pumps functioned normally when operated by hand. The examination of the airframe and engine did not reveal evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. ## Aircraft - Registration: [N1478E](https://openairdocs.org/deregistered/N1478E-2024-05-11), registration cancelled 2024-05-11, S/N 7AC-5041, built 1946 (OpenAirDocs) - Reported make and model: AERONCA 7AC - Registry model: [Aeronca 7AC](https://openairdocs.org/model/aeronca-7ac) (registry code 2110102) (OpenAirDocs) - Registry engine: [Continental A&C65 series](https://openairdocs.org/engine/continental-a-c65-series) (registry code 17003, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 7AC-5041 - Year built: 1946 - Engines: Continental A-65-8F 65 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Destination: Same as departure - Airport: JAU, Colonel Tommy C Stiner Airfield - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 800 total, 2 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 72 °F - Altimeter: 30.16 inHg - Observed at: JAU - METAR: KJAU 291655Z AUTO 00000KT 10SM SCT029 29/22 A3016 RMK A01 ## 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 20220829015559A](https://openairdocs.org/incident/20220829015559A), Aug 29, 2022: Aeronca 7AC, Jacksboro, TN, Destroyed, 1 fatal. The pilot taxied to the hold short line performed his flight control checks then proceeded to back taxi on 23 for departure turned in to the wind for run up.… ## Other investigations on N1478E (1) 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. - [NTSB NYC07CA115](https://openairdocs.org/ntsb/NYC07CA115), May 4, 2007: Aeronca 7AC (N1478E), Lagrangeville, NY, substantial damage. Probable cause: The pilot's failure to identify a partially buried rock in the landing surface of an unimproved grass runway, which resulted in an inadvertent collision during the landing roll. ## Docket (7 files) The files NTSB released with the investigation on September 26, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105818. 3.3 MB in all. - Witness mor (item 1, PDF, 1 page, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17600132&FileExtension=pdf&FileName=MOR%20Cooper%20statement%20FA391-Rel.pdf - Witness video (item 2, MP4, 806 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17600810&FileExtension=mp4&FileName=Jimmy%20Cole%20Plane%20Crash%20Video-Rel.mp4 - NTSB examination summary (item 3, PDF, 6 pages, 383 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17600142&FileExtension=pdf&FileName=NTSB%20Examination%20Summary%20FA391-Rel.pdf - Investigative photographs (item 4, PDF, 3 pages, 645 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17600653&FileExtension=pdf&FileName=Investigative%20Photos%20FA391-Rel.pdf - Medical factual memorandum for record (item 5, PDF, 4 pages, 180 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17473435&FileExtension=pdf&FileName=ERA22FA391_Jacksboro%20TN%20shortformmedicalfactualreport%20-Rel.pdf - Toxicological report (item 6, PDF, 1 page, 740 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17603570&FileExtension=pdf&FileName=Tox%20report%20FA391_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 1 page, 462 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17599534&FileExtension=pdf&FileName=N1478E%20Wreckage%20%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.