# NTSB MIA02LA022: Robert N. Gilmore Rans S-10, N96AU, Oneonta, AL, November 18, 2001 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: November 18, 2001, 15:37 local (21:37 UTC) - Place: Oneonta, AL - Coordinates: 33.972221, -86.379447 - Nearby events: https://openairdocs.org/map.md?lat=33.9722&lon=-86.3794&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 3, 2002 - Report: Approved by Office Director - Parties: FAA FSDO - NTSB case key (mKey): 53791 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA02LA022 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/53791/pdf - Page: https://openairdocs.org/ntsb/MIA02LA022 ## Probable cause The failure of the pilot to maintain airspeed following loss of engine power resulting in the airplane stalling and entering a spin from which it crashed. Factors in the accident was improper repair of the front cylinder intake manifold seal by the pilot after a prior accident which resulted in seizure of the front piston in the cylinder and failure of the engine and the pilots use of Alprazolam, a drug which has adverse effects on pilot performance. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, takeoff - initial climb - induction air control,intake manifold - cracked - maintenance,replacement - not performed, pilot in command (contributing factor) - engine assembly,piston - seized - Loss of control - in flight, emergency landing after takeoff - impairment(drugs), pilot in command (contributing factor) - airspeed(vs) - not maintained, pilot in command (cause) - stall/spin - inadvertent, pilot in command - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis A witness stated that as the airplane climbed through about 250 feet after takeoff, when the airplane was about 2/3 of the way down runway 23, the propeller stopped rotating. The pilot initiated a slow turn to the left and dropped the nose. The airplane then fell sharply to the left and spiraled to the left one and a half turns and went out of sight behind trees. Postcrash examination of the airplane showed the airplane crashed about 100-150 yards northwest of runway 23, about 2/3 of the way down the runway. The airplane came to rest on a 050 degree heading, in a 45 degree nose down attitude. The engine was seized and the propeller had no rotational damage. The tachometer read 196.8 hours. Postcrash examination of the engine showed the front cylinder walls showed evidence of galling, as did the compression ring, which remained compressed in the piston groove after removal. The damage was most severe on the exhaust side. An intake manifold seal for this cylinder was found cracked and the internal metal ring of this seal rusted. The second seal had no damage. The rear cylinder was removed and had no damage. Postmortem toxicology testing was negative for carbon monoxide, cyanide, and ethanol. The tests were positive for .005 ug/ml Alprazolam in blood, .225 ug/ml Alprazolam in urine, .343 ug/ml Alpha-Hydroxyalprazolam in urine, 54.821 ug/ml Acetaminophen in urine, and Triamterene in blood and urine. Triamterene is a prescription diuretic, is approved by the FAA for use by pilots, and was reported to be prescribed by the pilot on his last medical exam application, dated 09-17-2001. Alprazolam is a prescription tranquilizer, is not approved by the FAA for use by pilots, and was not reported by the pilot as a prescription on his 09-17-2001 medical application. The level found in the pilot's blood and urine was consistent with a very low dose. The drug has measurable adverse effects on performance. Acetaminophen is an over the counter pain reliever, and is approved for use by pilots by the FAA. A picture was found by an FAA Inspector in aircraft documents that show the airplane was involved in a previous accident. No record of this accident was found in the NTSB Accident Database. ## Factual narrative On November 18, 2001, about 1537 central standard time, a Robert N. Gilmore, Rans S-10, amateur built airplane, N96AU, registered to an individual, crashed following loss of engine power shortly after takeoff from Robbins Field, Oneonta, Alabama, while on a 14 CFR Part 91 personal flight. Visual meteorological conditions prevailed at the time and no flight plan was filed. The airplane was destroyed and the private-rated pilot received fatal injuries. The flight was originating at the time of the accident. A witness stated that as the airplane climbed through about 250 feet after takeoff, when the airplane was about 2/3 of the way down runway 23, the propeller stopped rotating. The pilot initiated a slow turn to the left and dropped the nose. The airplane then fell sharply to the left and spiraled to the left one and a half turns and went out of sight behind trees. (See attached police department report.) Examination of the airplane at the crash site was performed by an FAA inspector. The airplane crashed about 100-150 yards northwest of runway 23, about 2/3 of the way down the runway. The airplane came to rest on a 050 degree heading, in a 45-degree nose down attitude. The engine was seized and the propeller had no rotational damage. The tachometer read 196.8 hours. (See attached record of telephone conversation.) Postcrash examination of the engine was performed by an FAA inspector and two mechanics who are knowledgeable of the engine model. The front cylinder walls showed evidence of galling, as did the compression ring, which remained compressed in the piston groove after removal. The damage was most severe on the exhaust side. An intake manifold seal for this cylinder was found cracked and the internal metal ring of this seal rusted. The second seal had no damage. The rear cylinder was removed and had no damage. A photograph showing the airplane after having been involved in another accident was found by the FAA Inspector in documents that were with the engine during examination. No record of this accident was found in the NTSB Accident Database. (See attached FAA inspector statement.) Postmortem examination of the pilot was performed by Joseph H. Embry, M.D., Regional Medical Examiner, Birmingham, Alabama. The cause of death was attributed to multiple blunt force injuries. No findings that could be considered causal to the accident were reported. Postmortem toxicology testing on specimens obtained from the pilot was performed by Dennis V. Canfield, PhD, Manager, FAA Toxicology Laboratory, Oklahoma City, Oklahoma. The tests were negative for carbon monoxide, cyanide, and ethanol. The tests were positive for .005 ug/ml Alprazolam in blood, .225 ug/ml Alprazolam in urine, .343 ug/ml Alpha-Hydroxyalprazolam in urine, 54.821 ug/ml Acetaminophen in urine, and Triamterene in blood and urine. Triamterene is a prescription diuretic, is approved by the FAA for use by pilots, and was reported to be prescribed by the pilot on his last medical exam application, dated 09-17-2001. Alprazolam is a prescription tranquilizer, is not approved by the FAA for use by pilots, and was not reported by the pilot as a prescription on his 09-17-2001 medical application. The level found in the pilot's blood and urine was consistent with a very low dose. The drug has measurable adverse effects on performance. Acetaminophen is an over the counter pain reliever, and is approved for use by pilots by the FAA. (See attached toxicology report and FAA medical records for the pilot) The pilot held a FAA private pilot certificate with airplane single engine land, airplane single engine sea, and instrument airplane ratings, last issued on 02-14-1997, when the airplane single engine sea rating was added. The pilot was the builder of N96AU, and held a FAA repairman certificate for the airplane. The pilot held a third class medical certificate, issued on 09-17-2001, with limitations that the holder wear correcting lenses while exercising the privileges of the certificate. A current pilot logbook for the pilot was not located after the accident. The pilot reported on his medical application on 09-17-2001, that he had accumulated 1,350 total flight hours and that he had flown 100 flight hours in the preceding 6 months. N96AU had accumulated 76 total flight hours since being built by the pilot in 1994. The airplane was a Robert N. Gilmore, Rans S-10, amateur built airplane, which was built by the pilot in 1994. An experimental airworthiness certificate was issued for the airplane by the FAA, on 08-27-1994. Aircraft logbook records showed the airplane was last inspected on October 19, 2000. FAA regulations require that experimental airplanes receive an inspection by a FAA licensed mechanic or repairman, each 12 calendar months. ## Aircraft - Registration: [N96AU](https://openairdocs.org/deregistered/N96AU-2013-10-31), registration cancelled 2013-10-31, S/N 096, built 1994 (OpenAirDocs) - Reported make and model: Robert N. Gilmore Rans S-10 - Registry model: [Gilmore Robert N RANS S-10](https://openairdocs.org/model/gilmore-robert-n-rans-s-10) (registry code 05618KX) (OpenAirDocs) - Registry engine: [Bombardier ROTAX (ALL)](https://openairdocs.org/engine/bombardier-rotax-all) (registry code 09050, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 096 - Airframe hours: 76 - Engines: Rotax 582 65 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Robert N. Gilmore - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, October 19, 2000, 5 hours before - Departed: 20A, Oneonta, AL - Airport: 20A, Robbins Field, runway 23, 4,210 × 80 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: fatal; private; airplane ratings: single-engine land, single-engine sea; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,350 total ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 45 °F - Altimeter: 30.23 inHg - Observed at: GAD, 20 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 20011118031439A](https://openairdocs.org/incident/20011118031439A), Nov 18, 2001: Amtr RANSS10, Oneonta, AL, Destroyed, 1 fatal. (-23) Aircraft was departing runway 23 at Robbins field. Aircraft was found about 3/4 of the way down and approximately 100 yards to the right side of runway… 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.