# NTSB WPR13FA022: Behne Glasair III, N655DB, Byron, CA, October 23, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 23, 2012, 14:03 local (21:03 UTC) - Place: Byron, CA - Coordinates: 37.89722, -121.643608 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.8972&lon=-121.6436&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 8, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 85421 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR13FA022 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85421/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85421 - Page: https://openairdocs.org/ntsb/WPR13FA022 ## Probable cause The pilot's failure to maintain control of the airplane while maneuvering, which resulted in a stall and subsequent spin. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Behne David S GLASAIR III, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=05610OI), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Behne David S GLASAIR III, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05610OI), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Impairment/incapacitation: illicit drug](https://openairdocs.org/ntsb-findings/02012020): Personnel issues › Physical · Owner/builder; cases with it: [Behne David S GLASAIR III, 1 case](https://openairdocs.org/ntsb-findings/02012020/cases.md?model=05610OI), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/02012020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Behne David S GLASAIR III, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05610OI), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Behne David S GLASAIR III, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05610OI), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Behne David S GLASAIR III, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05610OI), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The two pilots, one of whom owned the airplane, departed for a personal flight. The airplane was equipped with dual flight controls; however, it could not be determined which pilot was manipulating the controls at the time of the accident. Witnesses located adjacent to the accident site reported that they heard a loud noise and then saw the airplane slow down and begin to spin left in a slight nose-low attitude. The witnesses further reported that the airplane continued to spin until it impacted terrain. Postaccident examination of the engine and airframe revealed no evidence of any preexisting mechanical anomalies that would have precluded normal operation. Wreckage and impact signatures were consistent with a flat-spin, slightly nose-low impact with terrain. Postmortem toxicology tests for the left seat pilot/owner were positive for doxylamine (an antihistamine used in over-the-counter sleep aids and cough medicines) and methamphetamine (a central nervous system stimulant). Because the amount of doxylamine in his system at the time of the crash was below the therapeutic limit, its direct effects on the left-seat pilot's performance at the time of the crash could not be determined. Although methamphetamine was present in the left-seat pilot's blood, the amount was below the calibration limit of the toxicology tests. However, both methamphetamine and its metabolite (amphetamine) were present in his urine. Regardless, no direct correlation exists between the concentration of drug in the blood and the user's symptoms. Although it is unlikely that the left-seat pilot was actively euphoric at the time of the flight, he was likely in the late phase of symptoms or in the withdrawal phase(during which concentrations of the drug may be undetectable), which would have been impairing. However, as noted, it could not be determined which pilot was manipulating the controls at the time of the accident; therefore, the impact of the left-seat pilot's drug impairment on the flight could also not be determined. ## Factual narrative An Advanced Flight Instrument panel was located within the recovered wreckage and subsequently sent to the NTSB Recorders Laboratory for data recovery. The recovered data for the accident flight included various parameters such as airspeed, cylinder head temperature, exhaust gas temperature, heading, manifold pressure, pitch, roll, and engine rpm. No GPS location data was recorded. The data depicted that following takeoff, the airplane ascended to an altitude of about 1,410 feet mean sea level (msl) over the timeframe of about 3 minutes, 30 seconds before descending to an altitude of 210 feet msl throughout the following 60 seconds of recorded data. The last 50 seconds of recorded data depicted an increase of altitude from 210 feet msl to 2,290 feet msl, and a decrease in airspeed from 228 knots to 154 knots. The last two recorded data points showed heading change from 168 degrees to 187 degrees. The vertical acceleration varied from 1.4 g's to 4g's at the last recorded data point over the last 50 seconds of recorded data. Throughout the entire accident flight, the engine parameters exhibited normal operational indications. For further information, see the recovered data files and data plots in the public docket for this accident. The two-seat, low-wing, retractable-gear experimental amateur-built airplane, serial number (S/N) 3051, was completed in 2008. It was powered by a Lycoming IO-540-K1B5 engine, serial number L-20707-48A, rated at 300 horse power. The airplane was also equipped with a Hartzell model HC-C2YR-1BF adjustable pitch propeller. The airplane maintenance records were not obtained during the investigation. On October 23, 2012, about 1403 Pacific daylight time, an experimental amateur- built Behne Glasair III, N655DB, was destroyed when it impacted terrain while maneuvering near Byron, California. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The private pilot who occupied the left seat, and the private pilot who occupied the right seat were fatally injured. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The local flight originated from the Funny Farm Airport (4CA2), Brentwood, California, about 1357. Witnesses located adjacent to the accident reported that they observed the accident airplane flying at an altitude of about 1,000 feet above ground level when it suddenly nosed over and began to spin to the left in a slight nose low attitude. The witnesses further reported that the airplane continued to spin until it impacted terrain where post-crash fire ensued. Pilot #1 (left seat pilot/airplane owner) The Contra Costa County Coroner conducted an autopsy on the pilot on October 25, 2012. The medical examiner determined that the cause of death was "…Multiple blunt force injuries." The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot/owner.According to CAMI's report, carbon monoxide, cyanide, volatiles, and drugs were tested, and had positive results for 0.073 (ug/ml, ug/g) amphetamine in urine, amphetamine not detected in Blood (Cavity), 0.033 (ug/ml, ug/g) doxylamine detected in blood (Cavity), doxylamine detected in Urine, 0.172 (ug/ml, ug/g) methamphetamine detected in Urine, and methamphetamine detected in Blood (Cavity) The FAA blue ribbon medical file, autopsy results, toxicology report, and the investigator's report were reviewed by the Chief Medical Officer for the National Transportation Safety Board. No personal medical records were discovered; according to the investigator, the family did not believe that the pilot was taking any medications. The pilot's FAA blue ribbon medical file indicated that he was first certified in 1972. In 1997, his medical certification was surrendered when the FAA became aware that his driver's license had been suspended twice; once in 1994 and again in 1997. Both times the incidents were alcohol related but later reduced to convictions for reckless driving. The pilot argued that he had not misled the FAA in 1996 when he responded in the negative to question v. "yes or no? History of (1) any convictions(s) involving driving while intoxicated by, while impaired by, or while under the influence of alcohol or a drug; or (2) history of any convictions(s) or administrative action(s) involving an offense(s) which resulted in the suspension, cancellation, or revocation of driving privileges or which resulted in attendance at an educational or a rehabilitation program." The pilot argued that neither episode resulted in a conviction and pointed out that while his California license had been suspended, he retained his Nevada license to drive. In 1998 he underwent an addiction evaluation and was issued a second-class medical certificate. In 2007, the pilot reported another alcohol related suspension, and his medical certificate was revoked. On this occasion, he was convicted of driving under the influence and underwent the FAA's required psychological testing and psychiatric evaluation. In 2010 he was granted a regular third-class medical certificate. The cause of death was multiple blunt force injuries. The toxicology testing identified methamphetamine in blood (amount below the calibration level of the machine) and 0.172ug/ of methamphetamine in urine; 0.073ug/ml of amphetamine was found in urine but none in the blood. In addition, 0.033ug/ml of doxylamine was detected in blood; doxylamine was also detected in urine. Methamphetamine and amphetamine are central nervous system stimulants and schedule II controlled substances used in prescription medications that treat narcolepsy, attention deficit disorder, and for weight control. Methamphetamine has high abuse potential due to its early euphoric effects; amphetamine is one of its metabolites. Following methamphetamine use, a greater proportion of the drug is excreted unchanged in urine than isexcreted as amphetamine. Symptoms following use occur in phases: "Early phase – Psychological: Euphoria, excitation, exhilaration, rapid flight of ideas, increased libido, rapid speech, motor restlessness, hallucinations, delusions, psychosis, insomnia, reduced fatigue or drowsiness, increased alertness, heightened sense of well-being, stereotypes behavior, feelings of increased physical strength, and poor impulse control. Physiological: Increased heart rate, increased blood pressure, increased respiration rate, elevated temperature, palpitations, irregular heartbeat, dry mouth, abdominal cramps, appetite suppressed, twitching, pallor, dilated pupils, horizontal gaze nystagmus at high doses, faster reaction time, increased strength, and more efficient glucose utilization. Late phase – Psychological: Dysphoria, residual stimulation, restlessness, agitation, nervousness, paranoia, violence, aggression, lack of coordination, pseudo-hallucinations, delusions, psychosis, and drug craving. Physiological: Fatigue, sleepiness with sudden starts, itching/picking/scratching, normal heart rate, and normal to small pupils which are reactive to light." The time to onset of symptoms and to their end depends on the method of use; oral ingestion is slower and has lower peak blood levels but longer period of action than snorting, smoking, or injecting the drug. Withdrawal in chronic users or after a binge is associated with depression, fatigue, and strong cravings. Long term use can result in insomnia that may persist through at least month(s) long periods without the drug. Doxylamine is a first generation antihistamine used in over-the-counter sleep aids and cough medicines. It carries a Food and Drug Administration (FDA) warning: "Warnings - may impair mental and/or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating heavy machinery)." The therapeutic dose range is 0.0500 to 0.1500ug/ml. Family of the pilot reported that they were unaware if the pilot was taking any current prescription medication. Pilot #2 (right seat pilot) The Contra Costa County Coroner conducted an autopsy on the pilot on October 25, 2012. The medical examiner determined that the cause of death was "…Multiple blunt force injuries." The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report, carbon monoxide, cyanide, volatiles, and drugs were tested, and had negative results. A review of recorded data from the Livermore Municipal Airport automated weather observation station, located about 15 miles southwest of the accident site, revealed at 1353 conditions were wind from 220 degrees at 5 knots, visibility 10 statute miles, scattered cloud layer at 7,000 feet, temperature 16 degrees Celsius, dew point 6 degrees Celsius, and an altimeter setting of 30.02 inches of mercury. It was not determined which one of the two pilots, a private pilot and owner of theairplane seated in the left seat or the private pilot seated in the right seat, was manipulating the flight controls when the accident occurred. Pilot #1 (left seat pilot/airplane owner) The pilot/owner, age 57, held a private pilot certificate with an airplane single-engine land, airplane multi-engine land, and instrument airplane rating. A third-class airman medical certificate was issued to the pilot on April 10, 2012, with no limitations stated. The pilot reported on his most recent medical certificate application he had accumulated 3,457 total flight hours. The pilot's personal logbook was not obtained during the investigation. Pilot #2 (right seat pilot) The pilot, age 56, held a private pilot certificate with an airplane single-engine land and instrument airplane rating. A third-class airman medical certificate was issued to the pilot on September 9, 2010, with the limitation that stated "…must have glasses available for near vision." The pilot-rated passenger reported on his most recent medical certificate application he had accumulated 900 total flight hours. The pilot's personal logbook was not obtained during the investigation. Examination of the recovered wreckage revealed that the airframe, wings, and empennage were mostly consumed by fire. Flight control continuity was established throughout the airframe from the cockpit controls to all primary flight control surface attach points. Numerous separations observed throughout the torque tubes were consistent with post impact fire damage. The recovered Lycoming IO-540-K1B5 engine was separated from the airframe and intact. The accessory case was mostly consumed by fire, exposing the aft accessory gears. Molten metal was observed throughout the aft accessory gear area. The top spark plugs and rocker box covers were removed. The crankshaft was partially rotated by hand using the propeller assembly. Mechanical continuity was established throughout the engine and valve train. The exhaust system was compressed upwards into the engine and flattened. The induction system was impact and fire damaged. The magnetos were mostly consumed by fire; however, the magneto drive gears were intact. The top spark plugs exhibited normal operational signatures. The throttle body/fuel control was partially separated from the engine. All linkages and control arms were intact, however, would not move freely by hand. The fuel screen was full of molten metal debris. The throttle body fuel control diaphragm was consumed by fire. The fuel flow divider was intact and exhibited fire damage. All six fuel lines from the divider to the cylinders were intact and fire damaged. The propeller governor was partially separated from its mount and was mostly intact. The propeller governor oil screen was free of debris. The propeller hub remained attached to the crankshaft propeller flange. One of the two propeller blades remained attached to the propeller hub and exhibited aft bending about mid span with trailing edge gougingnear the blade tip. The remaining propeller blade was separated from the propeller hub and exhibited "S" bending and leading edge polishing. Postaccident examination of the recovered airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Examination of the accident site by a Federal Aviation Administration (FAA) inspector revealed that the airplane came to rest within an open field about 3 miles south of 4CA2. All major structural components of the airplane were present at the accident site. The inboard portion of both wings and center section of the fuselage were mostly consumed by a postimpact fire. Wreckage debris remained within about 40 feet of the main wreckage. The inspector reported that there was no debris path. The inspector reported that the left aileron was partially separated from its mounts and the left flap remained attached via its mounts and exhibited fire damage. The right aileron and flap remained attached via their respective mounts and exhibited fire damage. The rudder was partially separated from the vertical stabilizer, and the left and right elevators remained attached via their respective mounts and exhibited fire damage. The empennage of the airplane from slightly forward of the dorsal fin was displaced to the left when looking aft to forward. The engine was partially embedded within soft dirt. ## Aircraft - Registration: [N655DB](https://openairdocs.org/deregistered/N655DB-2018-02-15), registration cancelled 2018-02-15, S/N 3051, built 2008 (OpenAirDocs) - Reported make and model: BEHNE GLASAIR III - Registry model: [Behne David S GLASAIR III](https://openairdocs.org/model/behne-david-s-glasair-iii) (registry code 05610OI) (OpenAirDocs) - Registry engine: [Lycoming IO-540-K1B5](https://openairdocs.org/engine/lycoming-io-540-k1b5) (registry code 41665, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 3051 - Engines: LYCOMING IO-540-K1B5 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Dsb Inc - Registered owner: Dsb Inc - Airworthiness certificate: Special, Experimental (Special) - Departed: 4CA2, Brentwood, CA - Destination: 4CA2, Brentwood, CA - Airport: 4CA2, Funny Farm Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3; seat: left; toxicology performed; flight hours: 3,457 total - Pilot; age 56; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: right; toxicology performed; flight hours: 900 total ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 43 °F - Altimeter: 30.02 inHg - Observed at: LVK, 15 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 20121023024599A](https://openairdocs.org/incident/20121023024599A), Oct 23, 2012: Behne David S GLASAIR III, Brentwood, CA, Destroyed, 2 fatal. An experimental amateur built Glasair III was destroyed by impacted with plowed field. The private pilot owner and his private pilot rated passenger were… ## Docket (12 files) The files NTSB released with the investigation on April 15, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85421. 9.7 MB in all. - Medical Factual (item 1, .PDF, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391740&FileExtension=.PDF&FileName=Medical%20Factual-Master.PDF - Cockpit Display Specialist's Factual Report (item 2, .PDF, 771 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411184&FileExtension=.PDF&FileName=Cockpit%20Display%20Specialist%27s%20Factual%20Report-Master.PDF - Cockpit Display - Attachment 1 - Tabular Data (CSV) (item 3, .CSV, 21 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411185&FileExtension=.csv&FileName=Cockpit%20Display%20-%20Attachment%201%20-%20Tabular%20Data%20(CSV)-Master.csv - Witness Report (item 4, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411186&FileExtension=.PDF&FileName=Witness%20Report-Redacted.PDF - NTSB Summary of Recovered Wreckage Examination (item 5, .PDF, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411187&FileExtension=.PDF&FileName=NTSB%20Summary%20of%20Recovered%20Wreckage%20Examination-Master.PDF - Local Law Enforcement Report (item 6, .PDF, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411188&FileExtension=.PDF&FileName=Local%20Law%20Enforcement%20Report-Redacted.PDF - Evidence Tracking Form (item 7, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411189&FileExtension=.PDF&FileName=Evidence%20Tracking%20Form-Redacted.PDF - Toxicological Report - Left Seat Pilot (item 8, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411190&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Left%20Seat%20Pilot-Master.PDF - Toxicological Report - Right Seat Pilot (item 9, .PDF, 114 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411191&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Right%20Seat%20Pilot-Master.PDF - Photo 1. View of Main Wreckage (Courtesy of FAA) (item 10, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411192&FileExtension=.PDF&FileName=Photo%201.%20View%20of%20Main%20Wreckage%20(Courtesy%20of%20FAA)-Master.PDF - Photo 2. View of Recovered Wreckage (item 11, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411193&FileExtension=.PDF&FileName=Photo%202.%20View%20of%20Recovered%20Wreckage-Master.PDF - Photo 3. View of Recovered Engine (item 12, .PDF, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40411194&FileExtension=.PDF&FileName=Photo%203.%20View%20of%20Recovered%20Engine-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.