# NTSB WPR11LA064: Kennedy Lancair 320, N42BK, Hubbard, OR, November 29, 2010 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: November 29, 2010, 11:30 local (19:30 UTC) - Place: Hubbard, OR - Coordinates: 45.180278, -122.743614 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.1803&lon=-122.7436&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report November 22, 2011 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Portland FSDO - NTSB case key (mKey): 77887 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR11LA064 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/77887/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=77887 - Page: https://openairdocs.org/ntsb/WPR11LA064 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Kennedy William E C II LANCAIR 320, 1 case](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=056159O), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Impairment/incapacitation: oTC medication](https://openairdocs.org/ntsb-findings/02012030): Personnel issues › Physical · Pilot (probable cause); cases with it: [Kennedy William E C II LANCAIR 320, 1 case](https://openairdocs.org/ntsb-findings/02012030/cases.md?model=056159O), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02012030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Kennedy William E C II LANCAIR 320, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=056159O), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Kennedy William E C II LANCAIR 320, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=056159O), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N42BK-2018-01-19), registration cancelled 2018-01-19, S/N 791-320-633QB, built 2004 (OpenAirDocs) - Reported make and model: KENNEDY LANCAIR 320 - Registry model: [Kennedy William E C II LANCAIR 320](https://openairdocs.org/model/kennedy-william-e-c-ii-lancair-320) (registry code 056159O) (OpenAirDocs) - Registry engine: [Lycoming O-320-D2J](https://openairdocs.org/engine/lycoming-o-320-d2j) (registry code 41595, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 791-320-633QB - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; 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 ## 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 20101129054899A](https://openairdocs.org/incident/20101129054899A), Nov 29, 2010: Kennedy Wil LANCAIR 320, Hubard, OR, Destroyed, 1 fatal. On 11/29/2010, at approximately 1200 (noon) PST, N42BK, this homebuilt model Lancair 320 crashed and burned at lenhardt airpark (7S9), a private airport near… ## Docket (2 files) The files NTSB released with the investigation on October 7, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=77887. 169 KB in all. - Record of Conversation - FAA Inspector (item 1, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353803&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF - Toxicological Report (item 2, .PDF, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40353783&FileExtension=.PDF&FileName=Toxicological%20Report-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.