WPR11LA064

NTSB accident investigation · Kennedy Lancair 320 · Hubbard, OR · November 29, 2010

Accident · FatalLimited investigationFinal report
Date
November 29, 2010, 11:30 local (19:30 UTC)
Place
Hubbard, OR
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N42BKKennedy Lancair 320
Defining event
Takeoff: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report November 22, 2011
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Portland FSDO
FAA report
20101129054899A
Case key
77887

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

The loss of control during takeoff for undetermined reasons. Contributing to the accident was the pilot's impairment from an over-the-counter sedating medication.

Findings · 2

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.

Not determinedNot determined › Not determined · Unknown/Not determinedKennedy William E C II LANCAIR 320: 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

After what appeared to be a normal takeoff roll and liftoff, the airplane flew about half way down the runway before its pitch attitude increased slightly and it began to roll to nearly 90 degrees of bank. Witnesses stated that, at that point, there was a smooth but significant reduction in engine power. The airplane then descended into the terrain with the landing gear still fully extended. A postacccident examination of the airplane revealed no evidence of a flight control system anomaly or malfunction. The pilot, who did not possess a valid Federal Aviation Administration medical certificate, had a history of progressive coronary artery disease and aviation-related post-traumatic stress disorder (PTSD). Post-mortem toxicology testing was consistent with a recent ingestion of a sedating over-the-counter antihistamine. Witness descriptions of the accident are potentially consistent with an incapacitating cardiac event, sudden psychological symptoms related to PTSD, or interference by the pilot’s dog (who was sitting in the passenger seat) with the aircraft controls. It is likely that the pilot was impaired by his recent use of the over-the-counter medication and that his response to an undetermined unexpected event was adversely affected by such impairment.

Factual narrative

On November 29, 2010, about 1130 Pacific standard time, an experimental Kennedy Lancair 320, N42BK, impacted the terrain about one-eight mile east of the runway at Lenhardt Airport, Hubbard, Oregon. The airline transport pilot, who was the sole occupant, was killed in the accident sequence, and the airplane, which was owned and operated by the pilot, sustained substantial damage. The 14 Code of Federal Regulations Part 91 flight, which was departing for an undetermined destination, was being operated in visual meteorological conditions. No flight plan had been filed. According to witnesses, the airplane's takeoff roll and liftoff appeared normal, but when it had flown about one-half way down the runway, its pitch attitude increased slightly and it began to roll slowly to the left until it had reached nearly 90 degrees of bank. At that point there was what appeared to witnesses to be a smooth but significant reduction in engine power. Then, as the airplane began turning away from the runway to the left, it descended into the terrain. During this entire sequence the retractable landing gear remained in the fully extended position. Almost immediately after the airplane impacted the terrain, a rapidly growing fire broke out, which ultimately consumed much of the airplane's structure. Witnesses stated that the winds were calm, and that the engine sounded like it was running smooth and strong, with no backfiring or coughing, even during the reduction in power. The witnesses also said that the pilot had his dog in the right seat of the airplane at the time of the takeoff. The dog, whose hair was partially burned by the fire, was later found wandering around the area where the airplane impacted the terrain. In a later discussion with the pilot's wife the FAA determined that the pilot often took his dog with him when he went flying. This was confirmed by others at the airport that had seen him take the dog with him before. According to the FAA Inspector who responded to the scene, although a full flight control continuity inspection was not possible due to the extent of impact and thermal damage, he did not find any evidence of pre-impact anomalies in the flight controls themselves. He also stated that the separations in the flight control torque tubes all appeared to be consistent with overload type failures. An autopsy provided by the Oregon State Medical Examiner determined that the mode of death was accidental, and that the cause of death was blunt force injuries. The FAA's Forensic Toxicology Research Team performed a forensic toxicology examination on specimens taken from the pilot. The results of that examination were negative for carbon monoxide and cyanide in blood taken from the heart, and negative for ethanol in the urine. The same examination showed positive results as follows: Dextromethorphan detected in the urine. Dextromethorphan detected in blood from the heart. Dextrorphan detected in the urine. Dextrorphan detected in blood from theheart. 0.125 (ug/ml, ug/g) Doxylamine detected in blood from the heart. Doxylamine detected in the urine. Pantoprazole detected in the blood. Dextromethorphan is an over-the-counter cough suppressant that may have performance and judgment effects at very high doses. Pantozole is a prescription acid-reducing medication used to treat gastroesophageal disease, and would not normally be expected to result in impairment. Doxylamine is a sedating over-the-counter antihistamine, often used as a sleep aid and commonly found in other substances, such as Dextromethorphan, and in some night-time multi-symptom cold relievers. It is one of the most sedating of antihistamines, and has a half-life of more than 10 hours. The level of Doxylamine found in the pilot's blood was consistent with ingestion of a maximal over-the-counter dose within about four hours prior to death, or a larger dose at an earlier time. The pilot’s FAA medical records noted a history of coronary artery disease with three-vessel bypass surgery performed in 1998; mild post traumatic stress disorder; insomnia that was treated with medication; and gastroesophageal reflux disease that was treated with medication. His stress echocardiograms since the 1998 bypass had been normal, with the most recent being in 2008, but the autopsy disclosed that portions of the bypass grafts contained severe atherosclerosis with thrombus formation, vessel calcification, with obvious areas of necrosis. The left anterior descending coronary artery proximal to the bypass graft was noted to have severe atherosclerosis with greater than 90% stenosis, with the distal portion beyond the graft sites being comprised of small vessels with 50-70% occlusion. A 2005 cardiology summary noted that the pilot's history of post-traumatic stress disorder (PTSD) was aviation-related, and in particular related to a low-level near crash that the pilot had experienced. His most recent Application for Airman Medical Certificate, dated September 11, 2008, was deferred for further evaluation by the aviation medical examiner, and an August 15, 2009, letter from the Manager of the FAA Aerospace Medical Certification Division noted that it had been determined that the pilot was not qualified for any class of medical certificate at that time. There was no indication in the FAA medical records that the pilot pursued FAA medical certification after that denial. Therefore, at the time of the accident, the pilot did not hold a current FAA medical certificate, due to the fact that he had failed to provided the requested records that would have allowed the FAA Medical Certification Division (AMCD) to further evaluate his medical condition.

Aircraft

Registration
N42BK
Reported as
Kennedy Lancair 320
Category
Airplane, amateur-built
Serial number
791-320-633QB
Engine
Lycoming O-320-D2J, 160 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
Kennedy William E C III
Registered owner
Kennedy William E C III
Airworthiness certificate
Special, Experimental (Special)
Departed
7S9 · Hubbard, OR
Airport
7S9 · Lenhardt Airport, runway 20, 3,200 × 45 ft, asphalt

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
68
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Seat
Left
Toxicology
Performed
Flight hours
5,500 total

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
37 °F

Docket · 2

The files NTSB released with the investigation on October 7, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 169 KB 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.