ERA23FA045

NTSB accident investigation · Bearhawk Patrol · Hanover Township, PA · October 29, 2022

Accident · FatalClass 3 · FieldFinal report
Date
October 29, 2022, 14:52 local (18:52 UTC)
Place
Hanover Township, PA · Doran Farm
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N964RSBearhawk Patrol
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Mechanic/Kit Builder, FAA/FSDO, Lycoming Engines, Bearhawk
FAA report
20221029020309A
Case key
106223

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 pilot’s decision to unlatch his seatbelt during flight, which allowed him to exit the airplane and impact the tail, resulting in a loss of control and impact with terrain.

Findings · 5

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: pitch controlAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleSnyder Ronald L BEARHAWK PATROL: 1 caseAll aircraft: 526 casesProbable cause
Empennage structureAircraft › Aircraft structures · Damaged/degradedSnyder Ronald L BEARHAWK PATROL: 1 caseAll aircraft: 14 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedSnyder Ronald L BEARHAWK PATROL: 1 caseAll aircraft: 2,247 casesProbable cause

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

Before the flight, the pilot told a friend that the airplane had a rigging issue that seemed to cause the airplane to “kick” laterally during turns. His friend performed a 10-minute flight and reported that he noticed the odd yawing moment while performing turns. The pilot responded that he would address the issue at a later time. After fueling the airplane, the pilot and pilot-rated passenger fastened their seatbelts and departed the airport. Flight track information indicated that, several minutes after departure, the airplane leveled off. Soon thereafter, witnesses reported that the airplane “rolled” then “bucked” as its nose “dipped down initially,” then pitched up “quickly.” Several witnesses reported seeing the pilot out of the airplane at this time, and one reported seeing the pilot impact then “spiral” off the airplane’s tail. Witnesses then observed the pilot and airplane descend to the ground. Ground scars and wreckage patterns indicated that the airplane impacted terrain in a near-vertical, nose-down attitude. All major airplane components were located at the accident site; however, paint chips, the airworthiness certificate, and portions of the cockpit ceiling or side window Plexiglas were the first items along the 1,900-ft-long debris path leading to the main wreckage (along the airplane’s flightpath), followed by a portion of a tail rib at 900 ft, and the pilot at 530 ft from the main wreckage. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Postaccident examination of the airframe revealed evidence consistent with the witness statements that the pilot impacted the empennage during flight. Toxicology testing for the pilot detected the high cholesterol medication atorvastatin and the high blood pressure medication terazosin. There was no evidence of any acute issue on autopsy, and the pilot had been actively flying the airplane and was then observed outside of the airplane. Thus, the pilot’s cardiovascular conditions were not a factor in this accident. Toxicology testing detected the antidepressant citalopram in the pilot’s heart blood and urine. While it is unknown how long the pilot was on this medication or the severity of his depression, witnesses reported that the pilot was functioning well, and looking forward to participating in a holiday airport event. Thus, effects from the pilot’s use of citalopram or the psychiatric condition for which he was taking the medication were not factors in this accident. That the pilot was observed to have buckled his seatbelt and shoulder harness before flight, and that his seatbelt and shoulder harnesses were found intact, unlatched, and undamaged, suggests that he intentionally unbuckled his seatbelt during the short flight. Given his concern about the yaw during turns, he may have been attempting to observe the problem with the tail. It is possible that either the pilot fell out ofthe airplane while attempting to observe the tail section, or that the pilot displaced a flight control while attempting to observe the tail, which then caused an abrupt pitching moment that ejected him from the airplane. Although the reason for the pilot’s exit from the airplane during flight could not be determined, his impact with the tail section of the airplane during flight resulted in substantial damage to the tail section and a subsequent loss of control during flight from which the pilot-rated passenger would not have been able to recover.

Factual narrative

The airplane was composed of a fabric-covered steel tubular fuselage and tail, and an aluminum strut-braced wing. On October 29, 2022, about 1452 eastern daylight time, an experimental amateur-built Bearhawk Patrol airplane, N964RS, was substantially damaged when it was involved in an accident near Hanover Township, Pennsylvania. The pilot and pilot-rated passenger were fatally injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Witnesses reported that the pilot and pilot-rated passenger departed Farmers Pride Airport (9N7), Lebanon County, Pennsylvania, earlier in the day. They reported that the pilot was functioning well, happy, and looking forward to participating in a holiday airport event. The pilot and his pilot-rated passenger flew to the Hazleton Regional Airport (HZL), Hazleton, Pennsylvania, then on to the Wilkes-Barre Wyoming Valley Airport (WBW), Wilkes-Barre, Pennsylvania. At WBW, the pilot told a friend that the airplane had a rigging issue that seemed to cause the airplane to “kick” laterally during turns. He suggested that his friend fly the airplane to see what he thought. The friend performed a 10-minute flight and reported that he noticed the odd yawing moment in the turns. The pilot responded that he would address the issue “this winter.” After lunch and fueling the airplane, the pilot and pilot-rated passenger intended to return to 9N7. Witnesses reported that the pilot sat in the front seat and fastened his seatbelt and shoulder harness while in their presence. Automatic dependent surveillance - broadcast (ADS-B) data revealed that the airplane departed runway 25 at WBW about 1448. After departure, the airplane turned slightly left, flew in a southwesterly direction, and climbed to an altitude of 1,700 ft mean sea level (msl). The recorded data indicated a 35-second level-off, followed by a descent to about 1,500 ft msl where the airplane’s altitude varied slightly over about two minutes. In the final seconds of the flight, data indicated a 400-ft descent in fewer than 2 seconds. At this same time, witnesses reported that the airplane “rolled” then “bucked” as its nose “dipped down initially,” then pitched up “quickly.” Several witnesses reported seeing the pilot out of the airplane at this time. One heard the pilot impact the airplane’s tail, and another observed the pilot impact, then “spiral” off, the airplane’s tail. The witnesses then observed the pilot and airplane descend to the ground. According to the autopsy report prepared for the Luzerne County Coroner’s Office, Hanover Township, Pennsylvania, the pilot’s cause of death was multiple traumatic injuries, and the manner of death was accident. Toxicology testing performed by the Federal Aviation Administration (FAA) Forensic Sciences Laboratory detected the antidepressant citalopram in the pilot’s heart blood and in his urine. Citalopram’s metabolite, n-desmethylcitalopram, was detected in his heartblood and in his urine. The high cholesterol medication atorvastatin and the high blood pressure medication terazosin were detected in the pilot’s heart blood and urine; these two medications are generally considered non-impairing. Citalopram was a prescription antidepressant medication marketed under the trade name Celexa. N-desmethylcitalopram is the active metabolite of citalopram. Both carry the warning that their use may impair mental of physical ability for performing hazardous tasks. The FAA will consider a special issuance of a medical certificate for depression after 6 months of treatment if the applicant is clinically stable and using only one approved treatment medication; however, the pilot had not applied for a special issuance. Citalopram is one of the FAA-approved antidepressant medications. According to the autopsy report, the cause of death of the pilot-rated passenger was multiple traumatic injuries, and the manner of death was accident. Toxicology testing was negative for ethanol in the pilot-rated passenger’s vitreous fluid and tested-for-drugs in his liver tissue. The airplane impacted a grass field about 5.2 nautical miles southwest of WBW. A linear ground scar, consistent with the length of the left wing, extended from the center of the wreckage with the scar oriented toward a magnetic heading of 338°, and the wings came to rest oriented on a magnetic heading of 319°. All major airplane components were located on site; however, paint chips, the airworthiness certificate, and portions of the cockpit ceiling or side window Plexiglas were the first items along the 1,900-ft-long debris path leading to the main wreckage, followed by a portion of a tail rib at 900 ft and the pilot at 530 ft from the main wreckage (see figure 1.) Figure 1 - Flight path (yellow line) with annotated position, time, altitude, ground speed, and path heading. The locations of recovered debris are also plotted. Both wings were accordion-crushed aft and remained attached to the fuselage, which came to rest adjacent to the right wing. The airframe structure aft of the cockpit was intact to the tail area, where the forward attachments of both the vertical and horizontal stabilizers were fractured. The tail section was largely destroyed, except for the left horizontal stabilizer, to which its elevator and elevator trim tab remained attached. The engine was partially attached to the engine mounts and embedded in an impact crater. The propeller hub remained attached to the crankshaft flange, and both propeller blades were impact separated from the propeller. A ground scar consistent with a propeller blade strike was found near the impact crater, where one blade was located. The other propeller blade was recovered about 100 ft from the main wreckage. Both blades showed light rotational chordwise scratches from dirt, and minimal damage to the blade leading edges. There was no evidence of fire on any portion of the airplane. There was evidence of fuel blight inthe field and a witness reported smelling fuel. The engine was hoisted from the remaining engine mount, and the rocker box covers removed to facilitate examination. The crankshaft rotated when the propeller was rotated by hand, and continuity of the crankshaft to the camshaft was confirmed. Thumb compression was established on cylinder Nos. 1, 2, and 4, and on cylinder No. 3 after the impact-damaged exhaust valve pushrod was removed. Borescope inspection of all cylinders revealed no anomalies. The carburetor, with throttle and mixture control cables attached, was impact separated from the bottom of the sump housing and located next to the engine at the accident site. Liquid consistent with fuel was noted inside the carburetor bowl and in the fuel pump. Both magnetos displayed impact damage to the mounting flanges. The left magneto was not capable of producing spark due to the capacitor being impact separated from the unit. The unit was opened for further examination and the points opened and closed as expected when the shaft was rotated. The right magneto produced spark at all four leads when rotated with a drill. The oil filter element appeared clean. Examination of the engine revealed no pre-impact anomalies that would have prevented normal operation. Examination of the airframe revealed that the wing spars remained attached to the fuselage structure and both wing fuel tanks were breached. All flight control cables and tubes were connected at their associated cockpit controls. Aileron continuity was established from the cockpit control stick to the aileron control surfaces. Left rudder continuity was established from the cockpit rudder pedals to the rudder control horn; however, right rudder continuity could only be established from the cockpit rudder pedals to the cable end loop, which was not attached to the clevis at the rudder control horn. The clevis was opened and hanging from the control horn, and the clevis pin was located nearby. Examination of the elevator trim cables revealed that both cables were continuous from their attachment points at the cockpit trim control lever, through broom-strawed fractures consistent with tensile overload above the rear pilot seat, to each control surface; however, the right elevator trim tab had separated from the elevator at the two hinged attachment points. A detailed examination of the tail tube structure by the NTSB Materials Laboratory revealed that all fractures to the tail section displayed features that were consistent with overstress. A tube that formed the trailing edge of the vertical stabilizer fractured with aft bending overstress, and the carry-through tube for mounting the aft edge of the horizontal stabilizer to the fuselage fractured in downward bending overstress, both consistent with impact with the pilot during flight. The pilot seats remained attached to their rails, and the seatbelts remained attached to their mounts. The rear pilot’s seat was equipped with the lap belt, which wascut to assist in the recovery of the pilot-rated passenger. The forward pilot’s seat was equipped with a lap belt and shoulder harnesses, which were intact, unlatched, and undamaged.

Aircraft

Registration
N964RS
Reported as
Bearhawk Patrol
Category
Airplane, amateur-built
Serial number
P318
Built
2020
Engine
Lycoming O-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Departed
WBW · Wilkes-Barre, PA
Destination
9N7 · Lebanon County, PA
Equipment
ADS-B

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
Age
76
Injuries
Fatal
Certificates
Airline transport, Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
BasicMed
Seat
Front
Restraint
None
Toxicology
Performed
Flight hours
21,000 total
Role
Pilot-rated passenger
Age
59
Injuries
Fatal
Certificates
Sport Pilot, Student
Airplane ratings
Single-engine land
Medical
Sport pilot
Seat
Rear
Restraint
4-point
Toxicology
Performed

Weather

Conditions
Visual (VMC) · Day
Wind
290° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 30 °F
Altimeter
30.41 inHg
Observed at
AVP, 11 nm away
METAR
KAVP 291854Z 29004KT 10SM CLR 16/M01 A3041 RMK AO2 SLP298 T01611011

Docket · 12

The files NTSB released with the investigation on April 10, 2024, 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.