WPR23LA112

NTSB accident investigation · Star Lite SL1 · Corning, CA · February 16, 2023

Accident · FatalClass 3 · LimitedFinal report
Date
February 15, 2023, 17:30 local (Feb 16, 2023, 01:30 UTC)
Place
Corning, CA · orchard
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
UNREGStar Lite SL1
Defining event
Maneuvering-aerobatics: Part(s) separation from AC
Weather
Visual (VMC) · Dusk
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
Case key
106771

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 student pilot’s loss of airplane control during an intentional aerobatic maneuver, which resulted in an inflight separation of the left wing and subsequent impact with the terrain.

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Student/instructed pilotAll aircraft: 9,295 casesProbable cause
Info processing/decision: decision making/judgmentPersonnel issues › Action/decision · Student/instructed pilotAll aircraft: 3,098 cases
Wing structureAircraft › Aircraft structures · Capability exceededAll aircraft: 48 casesProbable cause
Health/Fitness: use of medication/drugsPersonnel issues › Physical · Student/instructed pilotAll aircraft: 73 cases

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

Witnesses stated that the pilot initiated a barrel roll and was pulling out of the bottom of the roll when the left wing separated from the airplane’s fuselage. The airplane subsequently collided with the ground. All major structural components of the airplane were located within the wreckage path, with the left wing about 60 yards from the main wreckage. The owner disposed of the airplane wreckage before an examination could be conducted. The pilot held a student pilot certificate and reported 120 total hours of flight experience on the application for that certificate; however, no pilot logbooks were located and the pilot’s flight experience and training history could not be determined. According to the pilot’s wife, the pilot had recently been diagnosed with bipolar disorder and was being treated for attention deficit hyperactivity disorder (ADHD). Reviewed records contained no further details regarding the student pilot’s health conditions or any associated symptoms. Although the owner’s disposal of the wreckage prevented further examination of the wing’s failure, based on witness statements the pilot likely intentionally attempted an aerobatic maneuver, lost control, and was not able to recover due to the low altitude. Postmortem toxicology testing was positive for methamphetamine and bupropion; both drugs were disqualifying for FAA pilot medical certification. The use of bupropion and amphetamine without the addition of a mood stabilizing medication in persons with bipolar disorders may increase the risk of mania or manic behavior. Even in individuals without bipolar disorder, amphetamine use can adversely affect cognition, perception of risk, and judgment/decision-making. The pilot exhibited increased risk-taking behavior by attempting to perform aerobatics with inadequate experience (as a student), in a non-aerobatic airplane, leading to a catastrophic structural failure. The pilot’s likely mental health condition and substance use placed him at an increased risk of impaired judgment; however, the diagnoses of the pilot’s mental health condition(s) could not be verified, and the pilot’s baseline risk tolerance is unknown. Thus, whether the pilot’s mental health condition(s) or use of bupropion and amphetamine contributed to the accident cannot be determined.

Factual narrative

On February 15, 2023, about 1730 Pacific standard time, an unregistered Star Lite SL-1 airplane was destroyed when it was involved in an accident near Corning, California. The student pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The owner of the airplane stated that on the day of the accident he and the accident pilot were taking turns flying the airplane in the traffic pattern at Corning Municipal Airport (0O4). The owner performed five or six takeoffs and landings, and then switched with the accident pilot. The accident pilot flew once around the traffic pattern and landed without incident. On the second flight, the pilot took off from runway 35 and performed what the owner described as an “aerobatic” or barrel roll. He stated that the pilot appeared to pull out of the roll too slowly, while in a nose-down attitude, and that the pilot attempted an aggressive recovery. As the airplane‘s speed increased , the left wing separated, and the airplane impacted terrain. Another witness to the accident provided a statement consistent with that of the airplane owner. The airplane impacted the ground about 0.5 miles southwest of the airport. The airplane came to rest in an orchard with debris scattered throughout an approximate 90-yard radius. The left wing was located about 60 yards northwest of the main wreckage. The owner discarded the wreckage before an examination could be performed. The airplane owner stated that he had purchased the airplane three to four months before the accident. He was under the impression it was in the ultralight category, and he did not provide maintenance records. The owner stated that the airplane was not aerobatic capable. The pilot held a student pilot/third class medical certificate, issued in September 2021. At the time of the medical examination, the pilot reported 120 total hours of flight experience, with 45 hours in the previous six months. The pilot reported no medications. No pilot records were located and the pilot’s total flight experience at the time of the accident was not determined. An autopsy of the pilot was performed by Bennet Omalu Pathology, at the request of the County of Tehama Sheriff-Coroner’s Department. According to the autopsy report, the cause of death was acceleration-deceleration polytrauma. The FAA Forensic Sciences Laboratory performed toxicology testing of postmortem specimens from the pilot. Amphetamine was detected in cavity blood at 149 ng/mL and in liver tissue at 144 ng/g. Bupropion was detected in cavity blood at 40 ng/mL and in liver tissue at 38 ng/g. Hydroxybupropion was detected in cavity blood at 122 ng/mL and in liver tissue at 1345 ng/g. According to the pilot’s wife, the pilot had recently been diagnosed with bipolar disorder and was being treated for attention-deficit/hyperactivity disorder. Reviewed records contained no further details regarding the pilot’s health conditions or any associatedsymptoms. Amphetamine is a prescription Federal Schedule II controlled substance. Amphetamine may be prescribed for attention-deficit/hyperactivity disorder, narcolepsy, and obesity. Amphetamine usually carries a warning that the drug may impair the ability to operate a vehicle, and care should be taken until the effects of the drug are assessed after initiation of use. Amphetamine also generally carries a warning that use in individuals diagnosed with bipolar disorder without an additional medication to stabilize mood can precipitate mania. Amphetamine can be used recreationally by users seeking euphoric effects and to increase alertness and relieve fatigue. Abuse of amphetamine may lead to psychosis, paranoia, auditory and visual hallucinations. In addition to being available as a drug itself, amphetamine is a metabolite of methamphetamine, another drug in the same class. The FAA considers amphetamine or methamphetamine use disqualifying for pilot medical certification. Bupropion is a prescription medication that acts on the central nervous system (CNS) and can be used to treat depression and to help people quit smoking. Bupropion is sometimes used as part of the treatment of ADHD or of depression in bipolar disorder. Hydroxybupropion is a metabolite of bupropion. Bupropion’s mechanism of action and side-effect profile differs from other antidepressants; it does not typically cause sedation but may cause insomnia; to avoid adverse events including an increased risk of seizures, strict dosing guidelines are recommended. One small study of healthy subjects found no significant impact of sustained-release bupropion on psychomotor performance, including on tests intended to simulate flying performance. In patients with major depression, bupropion may improve associated neurocognitive deficits. Research on motor vehicle crash risk indicates that depression, antidepressants, or the combination of depression and antidepressants may present a safety hazard, but the independent contributions of antidepressants to that hazard generally are not well-defined. Typically, bupropion carries a warning that any drug that acts on the CNS may impair users' ability to perform tasks requiring judgment or motor and cognitive skills, and that bupropion users should not drive or operate hazardous machinery until they are reasonably certain that the drug does not adversely affect their performance. Bupropion also generally carries a warning that use in individuals with bipolar disorder without an additional medication to stabilize mood, can precipitate mania. At the time of this accident and the final FAA medical case review for this accident, bupropion use was unacceptable for pilots.

Aircraft

Registration
UNREG
Reported as
Star Lite SL1
Category
Airplane, amateur-built
Serial number
UNK
Engine
Rotax 447, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
None
Destination
Same as departure
Airport
0O4 · Corning Muni
Equipment
Unknown

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
35
Injuries
Fatal
Certificate
Student
Medical
Class 3, Without waivers/limitations
Last flight review
September 4, 2021
Seat
Center
Toxicology
Performed
Flight hours
120 total · 0 in this make and model · 45 in the last 90 days

Weather

Conditions
Visual (VMC) · Dusk
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
54 °F, dew point 14 °F
Altimeter
30.24 inHg
Observed at
KRBL, 13 nm away
METAR
METAR KRBL 160154Z AUTO 00000KT 10SM CLR 12/M10 A3024 RMK AO2 SLP242 T01171100=

Docket · 5

The files NTSB released with the investigation on February 20, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.0 MB in all.