Pilot Debrief

Heisler Lancair Legacy near Parowan, UT — 2008-10-18

Final reportWPR09LA016
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Date
2008-10-18
Location
Parowan, UT, USA
Airport
1L9
Aircraft
Heisler Lancair Legacy
Registration
N151HT
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot failed to secure the canopy prior to takeoff, resulting in his inability to control the aircraft during the takeoff. Contributing to the accident was the pilot’s impairment from prescription medications and possible obstructive sleep apnea.

Contributing factors

Contributing to the accident was the pilot’s impairment from prescription medications and possible obstructive sleep apnea.

NTSB narrative

During departure, witnesses in the area reported that the airplane appeared unusually low and then entered a left turn. As the airplane entered the turn, items from the cockpit fell from the airplane. The airplane continued in the left turn until it impacted the ground. Examination of the wreckage revealed no evidence of preimpact mechanical malfunction. The airplane, by design, does not have a cockpit indication for the security of the canopy. Structural documentation of the canopy latching mechanism did not reveal any damage to the latching mechanism, which is indicative of it not being latched when the airplane impacted the ground. Based on post-mortem toxicology results, the pilot had likely recently used two different prescription painkillers that commonly result in impairment, and that may increase risk of seizure, particularly when used together. Based on his height and weight, poorly controlled blood pressure in spite of the use of at least two different medications to lower it, and the presence on autopsy of right-sided heart enlargement, he likely had obstructive sleep apnea, a condition associated with fatigue and cognitive impairment. His response to a real or perceived emergency may have been impaired by the medications themselves, by a seizure induced by the medications, or by the effects of possible obstructive sleep apnea. The pilot did have a single blocked small coronary artery, but the condition had been present and evaluated just over two years prior to the accident, with evidence of good blood flow in spite of the blockage. It is unlikely that the blockage was related to the accident. The pilot had not indicated high blood pressure, use of medications to treat high blood pressure, or use of prescription painkillers on his most recent application for airman medical certificate just over 16 months prior to the accident.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have aborted takeoff after initial climb issues were observed.

NTSB coding

Evidence available

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

Docket documents24

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