VANS RV14

Full Narrative

HISTORY OF FLIGHTOn August 12, 2023, about 0848 central daylight time, a Vans RV-14A airplane, N6161, was substantially damaged when it was involved in an accident near Virden, Illinois. The pilot was fatally injured. The flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight.
Automatic Dependent Surveillance–Broadcast (ADS-B) data provided by the Federal Aviation Administration (FAA) captured the accident flight. The airplane departed the Litchfield Municipal Airport (3LF), Litchfield, Illinois, from runway 27 at 0838. The airplane flew to the north toward Virden and at 0847, the airplane pitched down rapidly and rolled roll until the airplane was inverted. The airplane made an estimated heading change of 125° toward the southwest.
There were no witnesses for the initial inflight upset. When witnesses near the city of Virden first observed the airplane, it was already inverted and flying southwest. Some witnesses reported the engine made unusual noises. One witness observed the airplane inverted before it banked left and rolled upright. Another witness about ½ mile from the accident site saw the airplane upright at low altitude traveling from east to west. PERSONNEL INFORMATIONThe pilot was the builder of the airplane. According to the hours recorded in the Garmin G3X system, the pilot had logged about 79 hours in the airplane and had also completed his most recent flight review in the airplane.
Garmin Autopilot Knowledge
Flight information extracted from the Garmin G3X showed that the pilot first flew the airplane on November 2, 2022. The pilot began using the autopilot system on the third recorded flight, November 11, 2022. Of the 40 flights, data showed the pilot used the autopilot most of the time during 28 flights. Most of the flights that contained autopilot usage, at minimum, involved using a heading selection mode and an altitude selection mode. Some of the flights contained recorded data showing the pilot used advanced autopilot features, including, but not limited to using different types of vertical navigation modes. Furthermore, on the flights that did contain data related to simple autopilot use, such as altitude hold modes, the data was consistent with pilot proficiency using the system.
Aerobatics
Of the sampled flights prior to the accident, there was only 1 maneuver that was greater than 40° of bank. The bank angles on all other flights rarely exceeded 30° bank. The airplane’s pitch never exceeded +/- 10° prior to the accident flight. There was no recorded evidence of the pilot performing any aerobatic maneuver. AIRCRAFT INFORMATIONThe airplane was a kit-built assembly completed by the pilot. He documented his build progress through the Experimental Aircraft Association Builder’s Log website. The airplane was issued an airworthiness certificate on October 11, 2022. AIRPORT INFORMATIONThe airplane was a kit-built assembly completed by the pilot. He documented his build progress through the Experimental Aircraft Association Builder’s Log website. The airplane was issued an airworthiness certificate on October 11, 2022. WRECKAGE AND IMPACT INFORMATIONThe airplane collided with trees and terrain about 0.8 miles southwest of the center of Virden. The first impact signatures were broken tree limbs about 20 ft above the ground. The main impact point was located just beneath the trees. Impact signatures were consistent with an impact angle around 45° nose low. The airplane remained relatively intact with both wings, the engine, fuselage, and empennage accounted for at the accident site.
Flight control continuity was established from the rudder pedals to the rudder control surface. Elevator control continuity was continuous from the control surface through to the cockpit controls; however, the tube was bent in an area just aft of the cockpit seats consistent with airframe impact damage, which limited elevator travel. The push-pull tubes to the ailerons remained relatively intact. The left aileron torque tube pushrod was fractured at the wing interchange, and the aileron was found torn from the left wing. The right aileron torque tube pushrod was fractured at the aileron attach point. The right aileron was found torn from the right wing.
Examination of the engine did not reveal any malfunctions or failures that would preclude normal operation.
Canopy

Figure 1. Canopy Assembly (Van’s Aircraft Manual)
The airplane was equipped with a tip-up style canopy. Examination of the airplane’s canopy found that it was impact damaged and fractured in multiple locations. The roll bar was separated from the primary structure. The canopy hinge plates remained attached to the forward canopy frame. The canopy release pins were inserted into the canopy hinge plate. The canopy release handle remained attached to the jettison system and the release pins were engaged in a non-jettison position. The canopy release handle remained attached to the jettison system.
The canopy hinge plate hinge was buckled laterally beneath the forward top skin. The right canopy guide pin had scoring around its circumference. The left canopy guide pin had minor scuffing consistent with normal wear. The Van’s-provided knob was mounted to the canopy latch handle, which was found in the closed position. The canopy latch was distorted forward consistent with impact forces. No preimpact anomalies of the assembly and installation of the canopy latch and handle were observed.
The canopy latch pushrod was found fractured. Both the left and right latch bellcranks were deformed and jammed. The torque tube was fractured and the latches were found partially disengaged. The canopy latch micro switch remained attached to the frame. The canopy frame was buckled outward on both sides. The canopy acrylic had shattered during impact and fragments were found scattered around the accident site.
Per Van’s build instructions, only one cockpit canopy micro switch is installed on the left side of the canopy frame. After micro switch installation, the builder sets the micro switch’s position in an assembled bracket so that left canopy pin begins to depress the micro switch’s plunger when the pin is fully seated and the canopy is closed. On the accident airplane, the builder had set the micro switch in the full aft position. In the full aft position, the switch would signal the canopy as closed when additional canopy pin travel would be needed for the canopy to be fully closed. A check of the micro switch’s functionality showed that the switch operated within tolerances.
Both the left and right canopy pin blocks were examined. The back of the left pin block was covered in earthen debris. Once cleaned it revealed a score mark near the 5 o’clock position with about a one-inch-long gouge trailing below it. Additionally, a vertical gouge mark started about mid-block and ran downward toward the 6 o’clock position. The bottom of the pin block had divots consistent with the canopy having rested previously on the latch pin (see figure 2).
The back of the right pin block had a score mark near the 7 o’clock position, with about a one-inch-long gouge trailing below it. The bottom of the pin block had divots consistent with the canopy having rested previously on the latch pin (see figure 2).

Figure 2. Canopy pin blocks (right photo from Van’s Aircraft)
Foreign Object
While conducting a follow-up examination of the wreckage, when cutting away lower fuselage skin to examine flight controls, a AA-size battery fell out of an area that was enclosed by the under-fuselage skin, fuselage ribs, and seat ramp cover. That area contained the mid-elevator push rod and idler assembly. There was a semi-circular dent on one side of the battery; on the other side of the dent was a gouge about the diameter of a rivet. ADDITIONAL INFORMATIONRay Allen T3-12A Trim Servo
The trim servo was found installed consistent with the instructions. The trim motor appeared to be functional and moved freely.
Garmin G3X Configuration Module
The G3X contained data which was extracted by Garmin. Information showed that the autopilot pitch engagement limits were set to +/- 75° roll and +/- 50° pitch. The feature to allow the G3X system to control the pitch trim motor control was disabled, which meant that automatic pitch trim control via the Garmin GSA 28 module was inhibited. This complied with Garmin Service Bulletin 22122 Rev B, since the installed software version was not the updated version. The pilot would have had to make appropriate pitch trim adjustments using an electric switch. “Miscompare Monitoring” was enabled, and data recorded no miscompare flags for the accident flight. Electronic Stability Protection (ESP) was enabled and the system’s limits were set for at 45° roll, 10° pitch, and minimum airspeed at 100 knots (kts). The torque limit for both pitch and roll servos were set to 45% of the maximum value.
G3X Flight Data
Data extracted from the G3X system found 100 records, 40 of which were flights. The data entries were consistent with the pilot/builder having configured the canopy warning mechanism prior to flight 25. On flights 28, 39, and the accident flight (40), a canopy open warning was recorded while the airplane was airborne.
For the accident flight, data showed that during the airplane’s taxi for takeoff, the canopy warning message stops reporting, consistent with the pilot at least partially closing the canopy for the annunciator to extinguish.
Shortly after departure, the pilot turned on the autopilot and engaged the roll and pitch modes to climb to 3,500 ft mean sea level (msl). As the airplane leveled off at 3,500 ft, the autopilot transitioned to altitude mode and the pilot selected GPS for the lateral mode and the airplane accelerated to 160 kts indicated airspeed (KIAS). The pilot changed the vertical mode from altitude hold to pitch mode and changed the altitude select to 4,500 ft. The airplane was about 3,420 ft and the flight director pitch command showed a nose down command; however, the airplane’s pitch was between level and slight nose up and the autopilot pitch torque was recorded as 42% nose down. Shortly after, the pilot changed the vertical mode to a vertical speed command of +800 ft/min to 4,500 ft, which was changed several seconds later to +300 ft/min to 4,200 ft.
During this time, the autopilot/trim down annunciator (AP/TRIM DOWN) would have been displayed on the pilot’s flight display, indicating that the autopilot was engaged, and requesting the pilot add nose-down trim to help the autopilot follow the commanded flight path. A few seconds later, the pilot changed the vertical mode to altitude hold at 4,030 ft. About this time, a series of intermittent but frequent canopy open warnings were recorded, which would continue until just before the inflight upset. The airplane’s computed airspeed was 153 KIAS and AP/TRIM DOWN would have been on the flight display. Autopilot pitch torque varied between 15% to 42% nose down. The airplane’s pitch at this time would increase to about 3 degrees nose up, while the flight director pitch command remained slightly nose down to maintain the altitude hold. The airplane climbed to 4,450 ft before descending to 4,100 ft msl.
The intermittent but frequent canopy open warning persisted. The inflight upset or negative pitch event began about 0847:00 when the airplane went from 1.02 G to 0.35 G in 1 second. At this time, autopilot pitch torque transitioned from 25% nose down to 16% nose down (nose down force had lessened) and the airplane began to pitch nose down. In the next second, autopilot pitch torque changed to a positive value for the first time as the airplane’s pitch went to 10° nose down. From 0847:00 through 0847:07 the pitch and roll servo torque values indicated that the autopilot servos worked to return the airplane to level flight, but the attitude continued toward negative pitch and excessive roll. At 0847:08 the airplane exceeded the autopilot engagement limits, and the data shows that the servos disconnected.
Performance Study and Memorandum
A performance study was performed for the accident flight using a combination of data retrieved from the Garmin G3X and ADS-B data.
At 0838, the airplane departed from 3LF, climbed and made a right turn toward the north-northwest. The initial right turn was flown with a roll of 14° right wing down, which was the largest roll input of the flight until the inflight upset. The autopilot was engaged at 0840:36, just after the initial right turn was completed. At 0842, the airplane was above 3,500 ft msl and on a heading of approximately 345°. After the initial climb, pitch varied between 3.4° nose up and -2.2° nose down.
At 0846:30, as the airplane approached the town of Virden, it climbed from 4,100 ft to 4,200 ft and slowed from 168 KAIS to 160 KIAS within 30 seconds. At 08:47:00, the autopilot, which had been in “AP/TRIM DOWN” setting moved through “AP” to “AP/TRIM UP”, then to “Manual disengage/ESP Roll/ESP Pitch”, and then to “ESP Roll/ESP Pitch”, where it remained for four seconds before recording “Fail” for the rest of the recording.
Simultaneous with the release from “AP/TRIM DOWN” to “AP”, the airplane began a right roll and pitched down rapidly. By 0847:06 the airplane was 35° right wing down and 34° nose down. The airplane had descended 470 ft, but the heading remained straight until 0847:07 when the airplane heading moved towards the west followed by the track angle. At 0847:16, the airplane had descended to 1,400 ft msl and was inverted near wings level. The airplane stayed inverted until the end of data at 0847:30, 460 ft from the final wreckage location.
Data from 29 previous flights showed that the pilot had only flown one maneuver that exceeded 45° of bank. In general, the pilot rarely exceeded 30° of bank. None of the flights had a nose down pitch greater than 10° or a nose up pitch greater than 10° after takeoff. There was no evidence in the recorded data of the pilot performing any aerobatic maneuvers.
A performance memorandum, developed subsequent to the performance study, documents how further examination of the flight data found evidence of a disturbance in the airflow over the airplane’s static pressure port as the inflight upset occurred. Data showed that just prior to the inflight upset, the airplane’s static system recorded values lower in pressure altitude than from the Global Navigation Satellite System (GNSS) altitude, along with a similar deviation of airspeed from groundspeed. A representative from Van’s Aircraft conducted a series of flight-test pushover maneuvers in an exemplar RV-14 in order to determine if these sensed altitude and airspeed deviations could have been the result of the dynamics of the accident airplane’s inflight upset and final dive. While one of the pushover maneuvers had a descent profile similar to that on the accident flight, none of the pushover maneuvers replicated pressure disturbances similar to those observed in the accident data. The performance memorandum states that the recorded data from the accident flight and test flight presented in this memorandum indicate that a significant pressure disturbance at N6161’s static pressure port was present at the beginning of the airplane’s final dive, and that a similar disturbance is not observed in any of the test flight pushover maneuvers. The pressure disturbance observed on the accident flight could possibly have been produced by the canopy opening in flight. The team could not identify a potential different cause of the pressure disturbance that would not also have been observed during the test flight pushovers.
Canopy Open Inflight Reports
In 2019, Van’s Aircraft released Service Letter 16-11-04 which stated that “[f]ield reports indicated that if the canopy does become unlatched in flight, the aircraft will most likely pitch nose down abruptly.” A pilot who reported a previous RV-14 canopy open in-flight event was contacted for possible data stored within a Dynon HDX. The data had been overwritten so no data could be retrieved from the event. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy was performed by a forensic pathologist in Springfield, Illinois, at the request of the Maucopin County Coroner’s Office. In the opinion of the pathologist who performed the pilot’s autopsy, the pilot’s cause of death was multiple blunt force injuries. Structural evaluation of the brain was limited by the severity of injuries and the heart was absent. Within these limitations, the autopsy did not identify significant natural disease.
The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem specimens from the pilot. Ethanol was detected in blood at 0.01 g/dL and in urine at 0.018 g/dL. Ethanol was not detected in vitreous fluid. Lorazepam was detected in urine at 82 ng/mL, and lorazepam testing in blood was inconclusive. O-desmethylvenalfaxine (also called desvenlafaxine) was detected in urine at 10,880 ng/mL and in blood at 522 ng/mL. Quetiapine was detected in urine at 48 ng/mL and in blood at 44 ng/mL. Norquetiapine was detected in blood and urine. The specimen was unsuitable for carboxyhemoglobin testing.
Ethanol is a type of alcohol. It is the intoxicating alcohol in beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. Alcohol consumption is not the only possible source of ethanol in postmortem specimens. Ethanol sometimes can be produced by microbes in a person’s body tissues and fluids after death. Postmortem ethanol production is made more likely by severe trauma.
Lorazepam is a prescription medication used to treat anxiety and depression. Lorazepam can cause sedation as well as amnesia, memory impairment, disorientation, disinhibition, and a feeling of euphoria. The FAA considers lorazepam to be a "do not fly" medication.7 According to the FAA medical case review for this accident, lorazepam is conditionally acceptable for FAA medical certification if use is short-term and a five-day waiting period is observed from last dose to piloting an aircraft.
Desvenlafaxine is a prescription medication commonly used to treat major depression. Desvenlafaxine also is an active metabolite of venlafaxine, another prescription medication commonly used to treat major depression (venlafaxine was not detected in this case). Desvenlafaxine may cause drowsiness and dizziness and typically carries a warning that users should not drive or operate heavy machinery until they know how the medication affects them. According to the FAA medical case review for this accident, venlafaxine was considered unacceptable for pilot medical certification. In April 2024, the FAA added venlafaxine to the list of antidepressants that may be considered for FAA medical certification via Special Issuance on a case-by-case basis, depending on an assessment of the underlying condition and response to treatment.
Quetiapine is a prescription antipsychotic medication. It may be used to treat schizophrenia, acute episodes of mania and depression in bipolar disorder, and as part of a multi-drug maintenance treatment for a major depressive disorder and bipolar disorder. Quetiapine may also be prescribed for treatment of insomnia without underlying psychiatric illness. Quetiapine may also be misused or abused, often in combination with other recreational substances. Quetiapine commonly causes drowsiness, especially in the initial days after starting a treatment regimen; however, users may develop tolerance to this effect over time. Quetiapine typically carries a warning that it has the potential to impair judgment, thinking, and motor skills, and that users should be cautioned about performing activities requiring mental alertness, such as operating a motor vehicle or hazardous machinery, until they are reasonably certain that the drug does not affect them adversely. The FAA considers quetiapine to be a “Do Not Issue/Do Not Fly” medication.
According to FAA medical records, the 62-year-old male pilot’s last aviation medical examination was August 19, 2019. At that time, he reported using prednisolone eye drops and ketorolac eye drops. Prednisolone eye drops are prescription steroid medication commonly used to reduce inflammation and swelling associated with allergies or eye surgery. Ketorolac eye drops are prescription nonsteroidal anti-inflammatory medication commonly used to treat inflammation and pain after eye surgery. The pilot reported having undergone bilateral cataract surgeries (July 2019) and treatment for a retinal detachment (April 2019).
The Aviation Medical Examiner deferred the medical certification decision to the FAA due to his recent surgeries. In March 2020, the FAA granted the pilot an Authorization for Special Issuance of medical certification for retinal detachment and a right visual field defect. The pilot was issued a third-class medical certificate limited by a requirement to have available glasses for near vision, and not valid after August 31, 2020. He completed a BasicMed Course, most recently in September 2022, and had reported completing a Comprehensive Medical Examination Checklist (CMEC), most recently in August 2020.