Pilot Debrief

Vans RV 4 near Middleburg, FL — 2019-10-31

Final reportERA20FA025
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Date
2019-10-31
Location
Middleburg, FL, USA
Aircraft
Vans RV 4
Registration
N425JW
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

Impact with power lines for reasons that could not be determined based on available evidence.

NTSB narrative

According to a family member, the pilot intended to conduct a brief local flight. A witness at the departure airport reported that he heard an airplane take off. He did not identify the airplane; however, about 10 minutes later the airport experienced a complete electrical power outage. The airplane was located in a clearing in a heavily wooded area. The wreckage and accident site were consistent with the airplane impacting powerlines before impacting terrain. Most of the airplane was destroyed by postcrash fire. The engine was examined, and no anomalies were noted. The pilot had recent diagnoses of several cardiovascular conditions that would increase his risk for an acute cardiovascular event, including severe mitral valve regurgitation, ventricular enlargement, and heart failure; however, there were no autopsy findings or radio communication to determine if the pilot experienced a cardiac event. Post-mortem toxicology detected the impairing medication gabapentin in liver tissue and urine, but it could not be determined if the concentration was at therapeutic or impairing levels; therefore, whether the pilot’s medical conditions or his use of medication contributed to the accident could not be determined. Given the lack of available evidence, the reason for the airplane’s impact with power lines could not be determined.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have reconsidered flight after taking gabapentin.

NTSB coding

Evidence available

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

Docket documents8

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