Pilot Debrief

BRYANT C CROSBY BC ULTRA PUP near Bardstown, KY — 2017-10-05

Final reportERA18FA005
Sign in to save
Date
2017-10-05
Location
Bardstown, KY, USA
Airport
BRY
Aircraft
BRYANT C CROSBY BC ULTRA PUP
Registration
N484HC
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Go-around

Probable cause

The pilot's improper decision to initiate a flight in an airplane he had never flown and with no currency in any airplane nor a medical certificate, which resulted in his loss of airplane control. Contributing to the accident was the pilot's psychiatric disease, which likely affected his decision-making and judgment.

Contributing factors

Contributing to the accident was the pilot's psychiatric disease, which likely affected his decision-making and judgment.

NTSB narrative

A pilot-rated witness saw the airplane in the traffic pattern conducting what seemed to be a normal approach to landing. The witness stated that, during the landing flare, the pilot appeared to be "over controlling the plane" and that he subsequently performed a go-around without touching down. The airplane remained in the traffic pattern for the second approach. The witness then saw the airplane about two-thirds of the way down the runway, and it was not climbing at the same rate as it had during the previous two departures. As the airplane passed the departure end of the runway, the right wing dropped, and the airplane descended straight down below a stand of trees and then reappeared with the nose slightly up and pointing generally to the left of the runway centerline. It then disappeared behind the trees again and crashed. The witness reported that the engine sounded normal during the entire flight. This evidence indicates that the pilot lost airplane control and that the airplane likely entered an aerodynamic stall during the attempted go-around. Examination of the wreckage revealed no evidence of any preaccident mechanical malfunctions or anomalies that would have precluded normal operation. The pilot purchased the airplane about 5 months before the accident, and the accident flight was his first flight in the airplane. He had not recorded a flight review in about 25 years. About 3 years before the accident, the pilot applied for a Federal Aviation Administration medical certificate, which was denied for multiple physical and mental health reasons, and the pilot did not appeal the denial. Thus, the pilot was ineligible to fly any aircraft. According to personal medical records, the pilot had obsessive compulsive disorder, depression/anxiety (not further specified), paroxysmal atrial fibrillation/supraventricular tachycardia, and chronic obstructive pulmonary disease. He had also had a hernia and had undergone back surgery. Although individually controlled, the pilot's numerous physical health issues in the year preceding the accident likely exacerbated his underlying psychiatric illnesses. Postaccident toxicology testing identified sertraline, which is used to treat depression, and its metabolite desmethylsertraline in blood and liver; however, this medication does not generally affect judgment or decision-making, thus it is unlikely that the effects from the pilot's medications contributed to the accident. However, it is likely that his depression and anxiety affected his judgment and contributed to his improper decision to initiate the flight in an airplane he had never flown, especially given he had not flown for several years and was not eligible to fly any aircraft; this poor decision-making ultimately led to the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot's lack of recent experience and medical issues should have prevented the flight.

NTSB coding

Evidence available

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

Docket documents11

Related mishaps