Pilot Debrief

AMERICAN AA-1 near Bay Minette, AL — 2022-03-11

Final reportERA22FA153
Sign in to save
Date
2022-03-11
Location
Bay Minette, AL, USA
Airport
1R8
Aircraft
AMERICAN AA-1
Registration
N5774L
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Preflight

Probable cause

The pilot’s loss of control during taxi, which resulted in a taxiway overrun and subsequent impact with terrain. Contributing to the incident were the low visibility conditions that existed at the airport around the time of the incident.

Contributing factors

Contributing to the incident were the low visibility conditions that existed at the airport around the time of the incident.

NTSB narrative

The pilot purchased the airplane about 6 months before the incident; however, he did not have a current Federal Aviation Administration (FAA) medical certificate and had not previously flown the airplane. A family member reported that the pilot often went to the airport at night to run the airplane’s engine and taxi around the airport property. In the early morning hours on the night of the incident, the airport was unattended and the weather conditions were conducive to low visibility in mist. Later that day, the airplane was found inverted in the grass off the end of a taxiway and down an embankment. The pilot was fatally injured. Examination of the incident site revealed that the airplane likely traveled off the end of the taxiway and went about 130 ft down an embankment before it came to rest inverted, sustaining substantial damage to the airframe in the process. Tire (skid) marks consistent with the left and right main landing gear tires braking were observed leading up to the edge of the taxiway at the top of the embankment. The postincident examination of the airplane also revealed that it was not configured for takeoff. Even the pitot tube cover had remained installed on the pitot tube. During the examination, no evidence of any preimpact failures or malfunctions of the airplane or engine were discovered that would have precluded normal operation. The pilot had moderate to severe atherosclerosis of two coronary arteries. While this condition placed him at an increased risk for a sudden cardiac event, the autopsy findings indicated that the pilot initially likely had initially survived the impact. Thus, the pilot’s cardiovascular disease was not a contributing cause to the incident. Toxicology testing revealed that the pilot had used cannabis. THC and 11-OH-THC were detected in his blood at low concentrations. While the pilot was found to have cannabis in his system, it could not be determined if the concentration would have been impairing and influenced his ability to control the airplane on the taxiway. The late-night taxiing of his airplane was typical behavior for the pilot. All evidence indicated that there was no intent for flight as the airplane was not configured for, or in a position to conduct a takeoff. It is likely that, with the pitot cover still on the pitot tube, which would have prevented use of the airspeed indicator, the pilot did not realize how fast he was taxiing. He also may not have realized in the darkness and reduced visibility due to mist that he was quickly approaching the end of the taxiway. This was supported by the presence of the skid marks leading up to the edge of the taxiway and the top of the embankment. Based on this information, it is likely that the pilot lost control of the airplane while taxiing and overran the taxiway edge, after which the airplane traveled down the embankment and came to rest inverted.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should have ensured the pitot tube cover was removed before flight.

NTSB coding

Evidence available

  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

Related mishaps