# NTSB MIA02LA153: Reviere Vans RV6A, N747ES, Tampa, FL, August 18, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: August 18, 2002, 09:36 local (13:36 UTC) - Place: Tampa, FL - Coordinates: 27.915555, -82.449165 - Nearby events: https://openairdocs.org/map.md?lat=27.9156&lon=-82.4492&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 30, 2003 - Report: Approved by Office Director - Parties: Lycoming, FAA - NTSB case key (mKey): 55510 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA02LA153 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/55510/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=55510 - Page: https://openairdocs.org/ntsb/MIA02LA153 ## Probable cause the failure of the pilot to maintain airspeed, which resulted in an inadvertent stall/spin, while maneuvering, and subsequent impact with a concrete wall. A factor in this accident was the impairment of the pilot in command due to the use of prescription drugs. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - airspeed(vs) - not maintained, pilot in command (cause) - impairment(drugs), pilot in command (contributing factor) - stall/spin - inadvertent, pilot in command (cause) - physical impairment(other organic problem), pilot in command - In flight collision with object, descent - uncontrolled - object - wall/barricade ## Analysis Witnesses watched the flight depart, and about one mile from the airport, the flight turned 180-degrees, and headed downwind back to the airport. It appeared to the witnesses that the flight would be landing; however, the airplane stayed about 25 to 50 feet above the runway, they heard power being applied, and the airplane started a steep climb. Initially, the aircraft started to go into a left turn, but then turned right, over the water. The flight was then observed going into a steep spiral descent and crashed. Examination of the airplane did not disclose evidence of mechanical malfunction. Amitriptyline, a sedating antidepressant and nortriptyline, a metabolite of amitriptyline, were detected in the blood of the pilot-in-command at levels consistent with the regular use of the medication. Paroxetine, another prescription antidepressant, was detected in the blood at almost 10 times the level expected with regular use. The pilot was noted to have a history of migraine headaches. A migraine headache may have adversely affected his ability to fly the aircraft. The possibility that the pilot was intentionally engaging in a risky or self-destructive act cannot be conclusively excluded. ## Factual narrative On August 18, 2002, about 0936 eastern daylight time, a homebuilt Reviere Vans RV6A, N747ES, registered to, and operated by an individual, impacted with a concrete wall of a dry dock at the Port of Tampa, Tampa, Florida. Visual meteorological conditions prevailed at the time, and no flight plan was filed. The local personal flight was conducted under 14 CFR Part 91. The airplane was destroyed. The private-rated pilot in command and commercial-rated second pilot were fatally injured. There were no injuries to anyone on the ground. The flight had originated from the Peter O'Knight Airport, Tampa, Florida, at 0925. According to witnesses at the airport, the flight departed on runway 17, and about 1 mile from the airport, the flight turned 180 degrees, and headed downwind back to the airport in line with runway 35. The witnesses thought the flight appeared to be landing; however, the airplane stayed about 25 to 50 feet above the runway, they heard power being applied, the airplane started a steep climb. Initially, the aircraft started to go into a left turn, but then turned right, over the water. The flight was then observed going into a steep spiral descent and crashing. There was no smoke observed coming from the airplane prior to the crash. According to the FAA inspector's statement, the pilot topped off both of N747ES's fuel tanks with 33.3 gallons of 1OO low lead (LL) fuel, the morning of August 18, 2002, at Plant City, Florida. The weight of the aircraft during the accident flight sequence could not be positively determined. The available aircraft records showed the gross weight as 1,850 pounds. The last known weight of the pilot was 280 pounds and his passenger was 200 pounds. The estimated gross weight of the airplane at takeoff was 1,824 pounds, without any consideration of any baggage that may have been on board. The engine was examined under the supervision of the FAA, on August 22, 2002, and revealed that the engine with the aircraft firewall assembly had separated from the airframe. The engine had sustained impact and postimpact fire damage. Impact damage was noted to be more severe on the front right and bottom sections. The engine did not display any external indications of mechanical failure or malfunction. The oil sump was crushed. The propeller had separated from the engine, the propeller hub remained attached to the engine crankshaft flange, the crankshaft was fractured aft of the flange. One propeller blade was torn in two places. About two inches of tip material was not located or recovered. About ten inches of span material was torn at both sides and exhibited torsional twisting. The inboard section of blade, was bent aft about twenty-four inches. The opposite blade was bent aft slightly and exhibited signs of rotation, leading edge damage and chord wise scoring. The propeller governor had separated and displayed fire damage. The control mechanism was destroyed. The fractured surfaces of the crankshaft displayed signs of torsional overload. Impact damage to the front right number 1 cylinder assembly was noted; the cylinder head, rocker box and push rods were displaced. Multiple cracks along the front right quadrant of the engine crankcase were observed, including areas between the number 1 and 3 cylinders. Crankshaft rotation was not obtainable due to the extent of damage. Accessory components were impact separated and fire damaged. Each component was individually examined, no discrepancies were noted. Disassembly examination of the engine was accomplished which revealed no discrepancies. Internal engine continuity was established. All internal components of the power section, including crankshaft, camshaft, gears and valve train remained connected. An autopsy was performed on both pilots, at the Hillsborough County Medical Examiner's Office, Tampa, Florida, on August 19, 2002. According to the autopsy report the cause of death was "...Multiple...Blunt Impacts to head and torso." No significant pre-existing disease was noted on the autopsy. Toxicological tests were conducted on the second pilot at the Federal Aviation Administration, Research Laboratory, Oklahoma City, Oklahoma, and revealed that, "No ethanol or drugs were detected. " Toxicological tests were conducted on the pilot-in-command (PIC) at the Federal Aviation Administration, Research Laboratory, Oklahoma City, Oklahoma, and revealed, "No ethanol was detected. The following drugs were detected: NORTRIPTYLINE present in Urine 0.117 (ug/ml, ug/g); NORTRIPTYLINE detected in Blood; PAROXETINE present in Urine 0.579 (ug/mL, ug/g); PAROXETINE detected in Blood; Amitriptyline present in Urine 0.052 (ug/ml, ug/g); Amitriptyline detected in Blood. Amitriptyline is a prescription antidepressant also known by the trade name Elavil. Paroxetine is a prescription antidepressant often known by the trade name Paxil. The pilot did not indicate the use of medications or a history of migraine headaches on his last application for Airman Medical Certificate; however, in a phone conversation with the NTSB investigator-in-charge, on October 30, 2003, the pilot's brother revealed that the pilot had been treated for migraine headaches, and had been on medication to treat the headaches for a number of years. The FAA's 1999 Guide for Aviation Medical Examiners notes (page 70) "...the use of a psychotropic drug is considered disqualifying. This includes all sedatives, tranquilizers, antipsychotic drugs, antidepressant drugs, analeptics, anxiolytics, and hallucinogens." The Guide also indicates (page 63) that a history or the presence of migraine headaches precludes the issuance of a medical certificate. ## Aircraft - Registration: [N747ES](https://openairdocs.org/deregistered/N747ES-2003-01-14), registration cancelled 2003-01-14, S/N 25321, built 2001 (OpenAirDocs) - Reported make and model: Reviere Vans RV6A - Registry model: [Reviere Scott A VANS RV6A](https://openairdocs.org/model/reviere-scott-a-vans-rv6a) (registry code 056120O) (OpenAirDocs) - Registry engine: [Lycoming O-360 series](https://openairdocs.org/engine/lycoming-o-360-series) (registry code 41575, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 25321 - Airframe hours: 102.5 - Engines: Lycoming O-360-A1D 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Scott A. Reviere - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, July 11, 2002 - Departed: TPF, Tampa, FL - Airport: TPF, Peter O'Knight, runway 17, 2,688 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 39; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 127 total, 32 in this make and model, 25 in the last 90 days - Other flight crew; age 59; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: unknown, unknown; seat: right; toxicology performed; flight hours: 4,200 total ## Weather - Conditions: Visual (VMC), Day - Wind: 0° at 0 knots - Visibility: 6 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 73 °F - Altimeter: 30.12 inHg - Observed at: TPA, 10 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 20020818025229A](https://openairdocs.org/incident/20020818025229A), Aug 18, 2002: Amtr RV6A, Tampa, FL, Destroyed, 2 fatal. (.19) On August 18, 2002, about 0936 eastern daylight time, a homebuilt reviere vans RV6A, N747ES, operated and registered to an individual, impacted with a… ## Docket (11 files) The files NTSB released with the investigation on November 7, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=55510. 2.6 MB in all. - Supplement E (item 1, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199604&FileExtension=.PDF&FileName=Supplement%20E-Master.PDF - Witness Statements (item 2, .PDF, 363 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40448620&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Report from Federal Agencies (item 3, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40448621&FileExtension=.PDF&FileName=Report%20from%20Federal%20Agencies-Master.PDF - Reports from Parties to the Investigation (item 4, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199607&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation-Redacted.PDF - Other Pertinent Forms and Reports (Record of phone call) (item 5, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40448622&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20(Record%20of%20phone%20call)-Master.PDF - Other Pertinent Forms and Reports (Fuel Slip). (item 6, .PDF, 374 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199609&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%20(Fuel%20Slip).-Master.PDF - Toxicological Report (item 7, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40448623&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 381 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40448625&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40448624&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photo 1. General view of the wreckage. Photo taken and provided by the FAA. No negative. (item 10, .PDF, 578 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199613&FileExtension=.PDF&FileName=Photo%201.%20%20General%20view%20of%20the%20wreckage.%20%20Photo%20taken%20and%20provided%20by%20the%20FAA.%20%20No%20negative.-Master.PDF - Photo 2. Propeller. Photo taken and provided by the FAA. No negative. (item 11, .PDF, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40199614&FileExtension=.PDF&FileName=Photo%202.%20%20Propeller.%20%20Photo%20taken%20and%20provided%20by%20the%20FAA.%20%20No%20negative.-Master.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.