# NTSB WPR20LA201: Avia Stroitel AC-5M, N263R, Bend, OR, June 30, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: June 30, 2020, 13:24 local (20:24 UTC) - Place: Bend, OR - Coordinates: 44.1025, -121.197776 - Nearby events: https://openairdocs.org/map.md?lat=44.1025&lon=-121.1978&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: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 101516 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR20LA201 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101516/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101516 - Page: https://openairdocs.org/ntsb/WPR20LA201 ## Probable cause A loss of control just after takeoff for reasons that could not be determined based on the available information. ## 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 · Unknown/Not determined (probable cause); cases with it: [Avia Stroitel AC-5M, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=05610QZ), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Avia Stroitel AC-5M, 1 case](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=05610QZ), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/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: [Avia Stroitel AC-5M, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=05610QZ), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Unknown: Unknown or undetermined](https://openairdocs.org/ntsb-events/000); cases with it: [Avia Stroitel AC-5M, 1 case](https://openairdocs.org/ntsb-events/000/sequence.md?model=05610QZ), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) ## Analysis The pilot was departing in the self-launching motorglider when the accident occurred. A witness stated that, once airborne, the glider began to climb rapidly. The glider then banked to the right and entered a “dive” to ground contact. Another witness stated that, shortly after takeoff, the glider “went directly vertical” then banked to the right before diving toward the ground. The glider came to rest on airport property near the departure end of the runway and was almost entirely consumed by postimpact fire, except for the left wing. The glider was not examined, and the wreckage was disposed of before examination could take place. The pilot’s experience in the accident glider was not determined. Autopsy revealed an implanted pacemaker/defibrillator that was not interrogated by the medical examiner. Although the condition of having an abnormal heart rhythm placed the pilot at increased risk of a sudden cardiac event, operational evidence does not suggest that such an event occurred, and it is unlikely that the pilot’s cardiovascular disease was a factor in this accident. Toxicology detected therapeutic levels of the antidepressant duloxetine in the pilot’s blood and the presence of the antidepressant amitriptyline and its active metabolite nortriptyline in the pilot’s liver tissue. Nortriptyline was also detected in cardiac blood, likely at therapeutic levels. Side effects of these medications include drowsiness and dizziness, especially when first starting the medications. The reason, duration of time he used the medication, and whether he had side effects from the medications are unknown; therefore, whether the effects of the pilot’s use of duloxetine and amitriptyline were a factor in this accident could not be determined. The glider’s rapid climb after takeoff and subsequent vertical descent are consistent with an inflight loss of control; however, because the glider was not examined after the accident, whether a mechanical malfunction or anomaly contributed to the loss of control could not be determined based on the available information. ## Factual narrative According to FAA records, the glider was originally issued an FAA airworthiness certificate in the Experimental – Exhibition category on October 28, 2002. The glider was then exported to Canada and re-imported to the United States upon purchase by the pilot in February 2018. An FAA airworthiness certificate application completed by the accident pilot around the time of purchase indicated a total airframe time of 26.3 hours. The glider’s total time at the time of the accident could not be determined. On June 30, 2020, at 1324 Pacific daylight time, an Aviastroitel AC-5M motorglider, N263R, was destroyed when it was involved in an accident near Bend, Oregon. The pilot was fatally injured. The glider was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The pilot was departing in the self-launching motorglider when the accident occurred. A video of the glider’s takeoff roll revealed that the glider’s right wing remained low for much of the takeoff roll. The video did not capture the initial climb or the accident. A witness stated that, once airborne, the glider began to climb rapidly. The glider then banked to the right and entered a “dive” to ground contact. Another witness stated that, shortly after takeoff, the glider “went directly vertical” then banked to the right before diving toward the ground. A postcrash fire ensued and the glider was destroyed. An autopsy of the pilot was completed by the Oregon State Medical Examiner’s office, Clackamas, Oregon. According to the autopsy, the pilot’s cause of death was generalized blunt force trauma and the manner of death was accident. The pilot had an implanted pacemaker/defibrillator that was not interrogated. No other significant natural disease was identified. Toxicology testing by the FAA Forensic Sciences Laboratory detected the antidepressant duloxetine in the pilot’s cavity blood at 45 nanograms per milliliter (ng/mL) and in his liver tissue. The antidepressant amitriptyline and its metabolite nortriptyline were detected in his liver tissue; nortriptyline was also detected in his cavity blood at 699 ng/mL. The non-impairing medications atorvastatin, tamsulosin, and metoprolol were detected in his cavity blood and liver tissue. The pilot held a private pilot certificate with ratings for airplane single-engine land and glider. His most recent Federal Aviation Administration (FAA) medical certificate was issued in April 2004, at which time he reported 1,500 total hours of flight experience. The pilot completed the requirements for operation under BasicMed in February 2020. His recent flight experience and his experience in the accident glider make and model was not determined. Information from local law enforcement indicated that the glider came to rest on airport property near the departure end of the runway. The glider was almost entirely consumed by postimpact fire, except for the left wing. The glider was not examined and was disposed of before examination couldtake place; therefore, whether any mechanical malfunctions or anomalies contributed to the accident could not be determined. ## Aircraft - Registration: [N263R](https://openairdocs.org/deregistered/N263R-2021-06-05), registration cancelled 2021-06-05, S/N 028, built 2002 (OpenAirDocs) - Reported make and model: AVIA STROITEL AC-5M - Registry model: [Avia Stroitel AC-5M](https://openairdocs.org/model/avia-stroitel-ac-5m) (registry code 05610QZ) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Glider - Serial number: 028 - Year built: 2002 - Engines: Compact Radial Engines MZ 35 27 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Departed: BDN, Bend, OR - Destination: BDN, Bend, OR - Airport: BDN, Bend Muni, runway 34, 5,200 × 75 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: fatal; private; airplane ratings: single-engine land; medical: basicmed; seat: single; toxicology performed; flight hours: 1,500 total, 0 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 12 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 39 °F - Altimeter: 30.00 inHg - Observed at: KBDN ## Docket (6 files) The files NTSB released with the investigation on December 8, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101516. 12.7 MB in all. - Medical factual (item 1, PDF, 4 pages, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14625596&FileExtension=pdf&FileName=WPR20LA201_Bend_OR_Medical_Factual_FINAL_102522-Rel.pdf - Memorandum for record a�� NTSB (item 2, PDF, 1 page, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14620008&FileExtension=pdf&FileName=Memorandum%20of%20Record%20WPR20LA201-Rel.pdf - Reports from state agencies - bend pd report (item 3, PDF, 7 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14609683&FileExtension=pdf&FileName=Bend%20PD%20Report_Redacted-Rel.pdf - Video file glider on takeoff bend pd (item 4, MOV, 6.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14610395&FileExtension=MOV&FileName=IMG_6783-Rel.MOV - Toxicological report (item 5, PDF, 2 pages, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14609808&FileExtension=pdf&FileName=Tox_Redacted-Rel.pdf - Photos (item 6, PDF, 3 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14619460&FileExtension=pdf&FileName=photos%20Bend%20PD-Rel.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.