History of Flight
On September 6, 2019, at 1312 eastern daylight time, a Vans Aircraft Inc. RV-12 airplane, registration N767FS, was destroyed when it impacted terrain in Lady Lake, Florida. The pilot was fatally injured. The flight was operated as a personal flight under Title 14 Code of Federal Regulations Part 91.
Earlier that day, three other pilots were scheduled to practice formation flying with the accident pilot. The accident pilot stated that he could not start his engine before the flight. The three pilots flew for about 45 minutes and returned to Love Field Airport (97FL) in Weirsdale, Florida, to debrief. The accident pilot joined them and said he had likely flooded his engine. The group went to his hangar to assist. After cleaning and reinserting some spark plugs, the engine started on the first attempt. A mechanic asked the pilot to perform an ignition check and a full static rpm check, which the engine passed. One observer noted that the pilot's response seemed unusually slow, raising concern because he had been in the heat for at least an hour. The mechanic then asked the pilot to turn off and restart the engine, which was normal. The pilot stated he would fly the traffic pattern once. The group left to replace the engine cowling, taking about 30 minutes. One pilot observed the airplane taxi and take off, noting that the engine "sounded good" as it departed runway 27 and began a left turn. The mechanic reported hearing an engine run-up before takeoff.
Automatic Dependent Surveillance-Broadcast (ADS-B) data from the FAA showed that the airplane departed runway 27, climbed to about 1,000 ft above ground level in an enlarged left traffic pattern. Near the end of the downwind leg, the data indicated a brief 50-ft climb followed by a rapid descent to the ground, while the flight path remained consistent with a downwind leg for runway 27.
Personnel Information
The pilot held a commercial pilot certificate with ratings for airplane single- and multi-engine land and instrument airplane. He was operating under BasicMed, with his most recent physical examination on June 1, 2017. On a 2018 aviation insurance application, he reported 10,075 total flight hours, with 90 hours in the accident airplane make and model. His logbook showed 12.2 hours in the accident airplane since his most recent flight review on November 8, 2017.
Aircraft Information
The airplane was built from a kit and issued an experimental light sport airworthiness certificate on August 10, 2010. The pilot purchased it in 2013. The most recent condition inspection was completed on July 1, 2019, with 123.8 total hours at that time.
The airplane had a forward-hinged, tip-up canopy with a locking mechanism. The handle, when turned 90°, placed a tang under a latch block on the roll bar. Witnesses stated the canopy handle latch had become bent, and the pilot had recently purchased and installed a new latch on August 1, 2019. The kit manufacturer's Pilot's Operating Handbook before takeoff checklist included "Canopy – CHECK Latched." A canopy-open warning system was developed but was not compatible with the accident airplane's electronic flight instrument system and was not installed.
Wreckage and Impact Information
The airplane impacted a grass field in a near-vertical, nose-down attitude about 1.8 nautical miles and 134° from the departure end of runway 27. All major components were present. The airplane was significantly fragmented and partially consumed by a postcrash fire. Two linear ground scars consistent with wing length radiated from the center. The debris field extended about 120 ft on a heading of about 80°, surrounded by burned grass 200 ft by 150 ft.
The engine and cockpit area were in a 2-ft impact crater. Both wings were crushed aft from the leading edge. The right flaperon was damaged, the left flaperon separated. The fuselage forward of the stabilator was severely fragmented. The stabilator, vertical stabilizer, and rudder separated. The stabilator was largely intact with damage near its center; its spar fractured midspan. The pitch trim tab remained attached, but its control rod and bracket were fractured. The rudder was damaged with the lower 4 inches of trailing edge bent right. Flight control continuity was established from stabilator and rudder to cockpit controls, but flaperon continuity could not be established due to damage. The fuel selector valve was not located. The electric fuel boost pump was sooted and thermally damaged. The nose landing gear separated. The roll bar and canopy bow were found about 12 ft apart.
The propeller hub separated, both blades separated. The engine would not rotate. Borescope inspection of cylinders showed normal coloration. Rocker arms and valve springs were intact. The gascolator was breached, empty of fuel, with debris in the filter screen; the bowl interior was sooted. Both carburetors were thermally damaged and separated, hanging by cables; bowls destroyed, floats missing. Sparkplugs appeared normal except No. 2 top had white deposits, and Nos. 1 and 3 bottom were slightly wet with oil. Intake and exhaust manifold tubing was detached. The muffler remained partially attached. The engine-driven fuel pump was removed; it rotated with binding and contained debris.
Examination of the elevator trim actuator control assembly revealed fracture surfaces on the control rod consistent with ductile overstress, with bending deformation and buckling under compression.
Examination of the metal canopy roll bar frames and latching mechanism showed the fixed portion of the canopy bow separated at the midspan attachment. The left side of the roll bar was impact twisted 180°, the right side had little deformation. The latch block remained on the left side. The canopy bow connected to the latching mechanism was fractured at the handle but not twisted. The latch handle was intact and slightly bent opposite where it latched. The pilot had purchased a latch replacement kit but only installed the handle, adding washers not in the kit. The new latch's tube was 1/4 inch longer than the original. The pre-impact functionality of the modified latching mechanism could not be established.
Additional Information
In November 2016, Van's Aircraft issued a service letter highlighting consequences of a tip-up canopy opening in flight, recommending inspection of the locking mechanism. It stated that if the canopy becomes unlatched in flight, the aircraft will most likely pitch nose down abruptly.
The NTSB has investigated similar tip-up canopy accidents, including events involving RV-12 (CEN13LA340) and RV-6 (CEN14FA306), as well as an Australian Transport Safety Bureau investigation (AO-2014-164) involving an RV-6A, which identified a safety issue regarding the in-flight opening of tip-up forward-hinged canopies leading to pitch-down tendencies.
Medical and Pathological Information
The Medical Examiner performed an autopsy on December 7, 2019, determining the pilot died from multiple blunt force injuries. FAA toxicology testing detected atorvastatin (a non-impairing cholesterol medication) in the liver and 21 mg/dL of ethanol in muscle tissue, which may be postmortem production.