NYC08LA165

NTSB accident investigation · Dragon Fly GT-500 · Paris, TN · April 21, 2008

Accident · FatalLimited investigationFinal report
Date
April 21, 2008, 09:50 local (14:50 UTC)
Place
Paris, TN
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N101GPDragon Fly GT-500
Defining event
Enroute: Loss of engine power (total)
Weather
Visual (VMC) · Day
Status
Completed · report April 22, 2010
Report
Approved by Office Director
Parties
FAA/FSDO, Rotax
FAA report
20080421831339A
Case key
67858

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

A fuel system configuration that was not in accordance with the engine manufacturer's published guidance, which resulted in a complete loss of engine power due to fuel starvation.

Findings · 4

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.

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

The certificated commercial pilot was the first registered owner of the amateur-built light sport airplane, but he did not build the airplane. On the day of the accident, after two aerial application flights, he returned to his airport to replenish the application chemical for a third trip to the same agricultural field. About 30 minutes later, a witness heard the engine "sputter" during a spray run, and observed the airplane begin a climbing right turn back towards the airport. The engine stopped and restarted, and the airplane began another climb in the direction of the airport. The engine stopped a second time, and two witnesses saw the airplane descend without engine power into a wooded area. The airplane was substantially damaged, and the pilot was fatally injured. Autopsy results indicated that the pilot had diabetes, coronary artery disease, an enlarged heart, and gallstones. In addition, he was taking a medication commonly prescribed for neurological pain, and another for smoking cessation, both of which had the potential to cause distraction or impairment. It was not clear what role, if any, the medical conditions or medications played in the accident. He did not note any medications or medical conditions on his most recent application for medical certificate, but it is possible that the medications were initially prescribed since that application. At the time of the accident, the airplane and engine had accumulated approximately 89 hours since new. The pilot had previously experienced engine stoppage problems, and had conducted at least one forced landing due to an engine stoppage. Subsequent to that forced landing, and in the weeks just prior the accident, the pilot installed an electric fuel pump, which was in addition to the existing engine-driven fuel pump. Post-accident examination of the airplane indicated that the engine fuel system was not configured or equipped in accordance with the engine manufacturer's published guidance. Differences included fuel lines that were not thermally shrouded, lack of a fuel pump bypass circuit, lack of a fuel return line, and pump output pressure which exceeded the engine manufacturer's limits. The engine manufacturer's guidance contained multiple statements that such differences could result in engine problems and/or stoppage.

Factual narrative

History of flight

On April 21, 2008, about 0950 central daylight time, an experimental amateur-built Dragon Fly Aviation GT-500, N101GP, was substantially damaged when it impacted trees and terrain near Paris, Tennessee. The certificated commercial pilot was fatally injured. The local aerial application flight was being operated under the provisions of 14 Code of Federal Regulations (CFR) Part 137. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed.

According to witnesses, about 0800 on the day of the accident, the pilot departed from his private home airstrip, flew to a wheat field approximately 5 miles to the southwest, and completed one aerial chemical application flight. The pilot then returned to his airstrip. About 0845, a witness saw the pilot depart from the airstrip the second time, and awaited the pilot’s return. About 0915 the pilot returned for refueling and chemical replenishment. According to the witness, the pilot was concerned about the engine oil pressure, and stated that it was approximately "20 pounds less than it should be." The pilot and the witness checked the oil quantity, and confirmed it was "full." The pilot began loading the chemical, and the witness left the airstrip.

About 0930 the airplane returned to the wheat field and resumed the aerial application. According to another witness located west of the wheat field, about 0950, the airplane was flying south, when the engine "sputtered" approximately mid-way through a spray run. The chemical spray stopped, and the airplane began a climbing right turn to the north. The engine stopped when the airplane was approximately 800 feet above the field on a northerly heading. The engine restarted, and the airplane began to climb, still on its northerly heading. When the airplane was at approximately 900 feet, the engine "sputtered" and stopped a second time. The airplane descended while it continued on the northerly heading, which took it over a wooded area.

Another witness located north of the wheat field also heard the engine stop, restart, and stop a second time. She and the previous witness both saw the airplane disappear from view when it was in an engine-out glide over the wooded area, and heard the sounds of impact shortly thereafter.

First responders to the accident indicated that the pilot occupied the front seat, and that he was not wearing a helmet. His five-point restraint harness was buckled, but the shoulder straps were found behind/under his arms and shoulders.

Personnel information

The accident pilot held commercial pilot, flight instructor, and 14 CFR Part 137 (Private) operating certificates, and he had accumulated approximately 9,000 total hours of flight experience. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued in December 2006.

Aircraft information

FAA records indicate that the airplane serial number was 397. The airplane was equipped with a Rotax 912 ULS non-certificated engine, and the engine serial number was 5644471. FAA documents indicate that the airplane was first registered to the accident pilot in December 2005, and that the initial airworthiness certificate, also in the accident pilot's name, was issued in February 2006. As of the date of the accident, the airplane and engine had accumulated a total time in service of about 89 hours.

Meteorological information

The 0955 weather observation at an airport located approximately 47 miles northeast of the accident location reported winds from 100 degrees at 5 knots, 7 miles visibility, clear skies, temperature 18 degrees C, dew point 11 degrees C, and altimeter setting of 30.08 inches of mercury.

Wreckage and impact information

According to information provided by the FAA and local law enforcement personnel, the accident site was located in a wooded area approximately 1 mile north of the subject wheat field. The accident site was located between the wheat field and the accident pilot's home airstrip.

There was no significant horizontal dimension to the wreckage path; the wreckage was tightly contained, and the surrounding trees exhibited minimal damage. The trees were spaced approximately 20 to 30 feet from one another, and were approximately 30 feet tall. The pilot was seated in the front seat, and the chemical hopper was located where the rear seat was normally located. All airplane components were found at the site. The fuselage was oriented on its left side, approximately 20 degrees nose down. The forward portion of the fuselage was partially fractured and crushed. The wings and tailboom exhibited significant impact damage. The fuel system was not compromised, and there were no fuel leaks. FAA and recovery personnel estimated that approximately 2 gallons remained in each fuel tank. The engine and propeller did not exhibit any impact damage. The flap handle had four positions, and was in the aft-most position, corresponding to the full flap deflection of 30 degrees. The flaps were also in the full-down position. The Hobbs meter installed in the airplane indicated a time of 88.6 hours. Residual chemical remained in the hopper. There were no indications of pre- or post-impact fire.

Medical and pathological information

The Henry County Medical Examiner, Tennessee Department of Health and Environment, conducted an autopsy on the pilot. The cause of death was cited as "multiple blunt force injuries." The medical examiner’s report noted that the pilot had a "history of diabetes and a cardiac history of unknown etiology, an enlarged heart, severe coronary artery disease, and gallstones." Toxicological testing of the pilot's tissue samples was conducted by the FAA Civil Aero Medical Institute, and gabapentin, varenicline and atenolol were detected.

The pilot’s most recent application for 2nd class Airman Medical Certificate, dated 12/27/2006, noted “No” to “Do You Currently Use Any Medication,” and to all conditions under “Medical History,” including specifically “Heart or Vascular Problems,” “Diabetes,” “Neurological disorders,” and “Mental disorders of any sort; depression, anxiety, etc.” “Total Pilot Time” was noted as “Approx. 9000” hours “To Date” and 45 hours in the “Past 6 Months.”

Additional information

Registration and Airworthiness Documentation

According to one FAA Form 8050-2, "Aircraft Bill of Sale," the initial sale was from Quicksilver Manufacturing to Dragon Fly Aviation. The form had the pre-printed word "Aircraft" struck out, and the word "Kit" typed in front of "Aircraft." The sale date on the form was listed as February 28, 2005, and the "In testimony whereof" date was listed in as July 7, 2005. The form also bore a stamped notation in the "For FAA Use Only Block" of "Dec 13 2005."

According to another FAA Form 8050-2, "Aircraft Bill of Sale," the airplane was sold from Dragon Fly Aviation to the accident pilot. The pre-printed word "Aircraft" was not struck out or overwritten on this form. Both the sale date and the "In testimony whereof" date on the form were listed as July 8, 2005. The form also bore a stamped notation in the "For FAA Use Only Block" that stated "Conveyance Recorded 2005 Dec 13."

According to an Affidavit of Ownership (FAA Form 8050-88), the builder and owner of the airplane were both cited as "Dragon Fly Aviation," and the box accompanying the statement "More than 50% of the above-described aircraft was built from a kit (prefabricated parts) and I am the owner" was selected. The form was notarized on July 14, 2005. The form also bore a stamped notation "Conveyance Recorded 2005 Dec 13."

Wing Washout Adjustments

Wing washout is a deliberate twist in both wing panels which provides the outboard wing sections with a lower angle of incidence than the root sections. Wing washout primarily affects airplane stall characteristics by enabl

Aircraft

Registration
N101GP
Reported as
Dragon Fly GT-500
Category
Airplane, amateur-built
Serial number
397
Airframe hours
89
Engine
Rotax 912, reciprocating
Damage
Substantial damage
Flight
Aerial application · Part 137
Operator
Joel D. Pennington
Registered owner
Joel Pennington
Airworthiness certificate
Special, Experimental (Special)
Departed
NONE · Paris, TN
Destination
Paris, TN

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
67
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Medical
Class 2, With waivers/limitations
Seat
Single
Toxicology
Performed
Flight hours
9,088 total · 88 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
100° at 5 knots
Visibility
7 statute miles
Lowest ceiling
None
Temperature
64 °F, dew point 52 °F
Altimeter
30.07 inHg
Observed at
HOP, 47 nm away

Docket · 16

The files NTSB released with the investigation on October 8, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.0 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.