ERCOUPE 415

Full Narrative

HISTORY OF FLIGHTOn September 13, 2023, about 1654 eastern daylight time, an Engineering and Research Corporation Ercoupe 415-C, N2796H, was substantially damaged when it was involved in an accident near Fitzgerald Municipal Airport (FZG), Fitzgerald, Georgia. The private pilot was fatally injured and the passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight.

The passenger, who held a student pilot certificate, reported he was interested in buying the airplane, which the private pilot owned. The passenger said that the private pilot told him the day before the accident that the airplane’s annual inspection was just completed and to come to the airport the next day to go flying. The passenger reported that, after arriving on the accident date, the private pilot told him that “we” had flown the airplane earlier that day but did not indicate who was with him on that flight.

The passenger stated that, before the accident flight, the pilot did a “walk around” inspection that included a check of the wings, lights, empennage, and control surfaces. They both boarded the airplane, and the passenger occupied the right seat but was not aware the airplane was equipped with lap belts, so he did not wear any restraint. The passenger also stated that the airplane did not have a canopy and that he did not wear a headset.

After the engine was started, the pilot taxied to the approach end of the runway. The passenger stated that he questioned the pilot about the need for an engine run-up but the pilot told him it was not necessary because he had done one earlier that day. The passenger estimated that between 2 and 3 minutes elapsed between engine start and takeoff power application. He also indicated that a check of the carburetor heat after taxiing was not performed.

The airport director, who was at the airport, reported hearing an airplane start up and begin to taxi. He said he walked outside of his office onto the ramp, recognized the accident airplane and private pilot, and noted that, while the airplane was taxiing, he heard the engine was misfiring “not bad, but it was misfiring.” He stated that the private pilot had not flown in a while and that he was “surprised to see him and [the] airplane flying” since he could not remember the last time he flew it.

The passenger reported that, during the takeoff roll, the pilot told him about flight techniques for the airplane. Based on information provided by the airport director, the airplane rotated about 2,154 ft from the approach end of runway 20. The airport director said that he watched the airplane take off to the south and that, during the takeoff roll, the engine sounded normal. The airport director said that, after rotation, the airplane entered a “very shallow climb.” He estimated that it climbed about 50 to 100 feet per minute to an altitude of about 600 to 700 ft before he lost sight of it.

The passenger said that, after the airplane became airborne, it turned to the left and climbed to no more than 2,000 ft. The passenger said that the flight duration was about 3 to 5 minutes, and the only thing about the accident sequence he recalled was that the “airplane fell a little bit.” He said that the pilot told him there was a wind gust, which was his last comment, and pulled aft on the control yoke. The passenger recalled thinking that the airplane was too close to nearby treetops. The next thing he recalled was waking up on the ground unable to move his legs. When asked if he detected a change in engine sound from takeoff to the accident, he said that he did not detect any change in engine sound.

A witness who was in her home near the accident site reported hearing what she believed to be a low-flying airplane based on the engine sound. She said she then heard the engine lose power, followed by the sound of impact. Another witness, who was driving down the street where the airplane crashed, reported that he saw the airplane come from over some houses and then crash into the ditch. The witness went to the site and noticed that one occupant was under the airplane, and the other occupant was near a tree and was talking.

A review of FAA air traffic control data sources revealed no ADS-B or primary radar data associated with the accident flight. PERSONNEL INFORMATIONThe pilot’s last aviation medical examination was January 27, 2012. He reported a history of diabetes and high blood pressure and using the prescription oral diabetes medication metformin, the prescription blood pressure medications lisinopril and nifedipine, and the prescription cholesterol-controlling medication pravastatin.

The Aviation Medical Examiner (AME) documented a HbA1c of 7%. The pilot was issued a second-class medical certificate by AME-Assisted Special Issuance (AASI); he had been granted an Authorization for Special Issuance in September 2011 for high blood pressure and diabetes requiring oral medication. The most recent medical certificate was not valid for any class after January 31, 2013, and was limited by a requirement to wear corrective lenses and possess glasses for near/intermediate vision.

The pilot’s most recent Authorization for Special Issuance was granted in March 2012, for high blood pressure and diabetes requiring oral medication. The pilot completed a BasicMed Course and reported completing a BasicMed Comprehensive Medical Examination Checklist (CMEC), both most recently in July 2019.

The pilot’s daughter reported that the pilot had a history of seizures, for which he was taking the medication levetiracetam (sometimes marketed as Keppra). She stated that his last seizure had been in August or September 2023, within the 4-6 weeks before the accident. She stated that his seizures always occurred at dusk and were characterized by uncontrolled muscle spasms during which he was “present.” She stated that the pilot had undergone open-heart surgery in 2011 and had later had stents installed.

Limited medical history information in available hospital records for the pilot included history of coronary artery disease, heart attack, coronary artery bypass grafts in 2012, two cardiac stents, high blood pressure, high cholesterol, and chronic obstructive pulmonary disease. Home medications documented in the hospital records included citalopram, losartan, amlodipine, metformin, montelukast, glimepiride, ezetimibe, and clopidogrel. Additional documented home medications included baby aspirin (available without a prescription and commonly used to lower cardiovascular risk), ranolazine (a prescription medication that may be used for chronic heart-related chest pain), atorvastatin (a prescription medication commonly used to help control cholesterol and reduce cardiovascular risk), dulaglutide (a prescription injectable medication that may be used as part of diabetes treatment), esomeprazole (available without a prescription for stomach acid suppression), guaifenesin (available without a prescription for relief of chest congestion), and docusate sodium (a stool-softener available without a prescription). No seizure history or seizure medication use was documented in hospital records. AIRCRAFT INFORMATIONThe two-place, low-wing airplane was equipped with a fixed-pitch, two-bladed, McCauley metal propeller. According to the airplane’s type certificate data sheet, the engine limit for all operations was 2,575 rpm.

A review of the maintenance records revealed the airplane’s last annual inspection was performed on February 6, 2006. At the time of the accident, the airplane had accrued about 77 hours since the inspection was performed and 1,736 hours total time. The engine had accrued 1,736 hours since new, and 642 hours since last overhaul in 1977. A review of FAA aircraft registry records revealed that the airplane’s registration was not current and that the “N” number had expired.

The airplane was weighed at the last annual inspection and the weight and balance form specified the maximum weight was 1,260 lbs, the empty weight was 845 lbs, the empty weight center of gravity (c.g.) was 25.54 inches aft of datum, and the useful load was 415 lbs.

Based on this information, and considering that the pilot weighed 204 lbs (per the medical examiner) and the passenger weighed about 200 lbs (per information he provided in his interview), any usable fuel load greater than 11 lbs, or about 1.9 gallons, would exceed the airplane’s maximum gross weight.

According to fueling records, the pilot purchased 10.89 gallons of 100 low lead fuel (100LL) at FZG about 1618 on September 11, 2023, two days before the accident. The pilot’s family reported that, in anticipation of performing taxi tests, 2.5 gallons of fuel were added into each wing fuel tank the day before the accident. The total fuel quantity in each tank at the time of the accident flight’s departure could not be determined.

An airframe and powerplant mechanic at FZG reported that, the day before the accident, the pilot came into the hangar where the mechanic was working and used the spark plug cleaning and test machine. The mechanic said that the pilot cleaned the spark plugs but did not test them. The mechanic reported that the pilot did not tell him why he needed to clean the plugs.

The passenger reported that the pilot informed him that the airplane had undergone a recent annual inspection performed by an individual. That individual, an airframe and powerplant mechanic with an inspection authorization, informed an FAA inspector postaccident that he had never performed any annual inspection or work on the airplane. According to members of the pilot’s family, the individual shared a hangar with the pilot, and the individual was present and interacted with the pilot while the pilot performed an inspection of the airplane during the 2 days before the accident. The pilot did not hold an airframe and/or powerplant mechanic certificate.

A booklet labeled “Owner’s Manual” was part of the obtained records for the airplane. The booklet, which referenced the Ercoupe 415-C and other models, contained a “Before Starting Engine” checklist that included an item for fastening the seat belts and a “Starting Engine” checklist that included an item for using the engine primer, with a handwritten note next to it stating “close & lock.” It also contained a “Before Takeoff” checklist that specified engine run-up procedures that included checking the operation of the magnetos and the carburetor heat.

According to a representative from the airplane’s type certificate data sheet (TCDS) holder, no flight manual or owner’s manual was available for the model 415-C. The representative stated that, when requested, the TCDS holder would provide an owner with a copy of the flight manual for the model 415-D.

The FAA-approved “Airplane Flight Manual” for the model 415-D contained a takeoff performance chart that provided the takeoff distance to clear a 50-ft obstacle for an airplane equipped with a metal, fixed-pitch propeller; the chart assumed an airplane gross weight of 1,400 lbs, zero wind, and a paved runway. Based on the temperature and pressure altitude (used to calculate the pressure altitude) at FZG about the time of the accident flight’s departure, the calculated takeoff distance to clear a 50 ft obstacle was about 2,332 ft. The calculated distance to clear the 50 ft obstacle did not account for the slightly downsloping runway.

The pilot’s and the passenger’s cellular phones were recovered from the accident site and retained for readout by the NTSB Vehicle Recorder Division for information relevant to the accident flight. The passenger provided a passcode for his cellular phone, but the passcode did not unlock the phone. As a result, no information could be reviewed, and the NTSB returned the phone to the passenger’s attorney.

The pilot’s cellular phone was not passcode locked. No pertinent photos or other media were discovered on the device, and no electronic references were found that were related to maintenance of the airplane.

Call records showed that, at 1408 on the day of the accident, an outgoing call was made to the FZG automated weather observing system (AWOS) for a duration of about 1 minute. At 1637, another call was made to the FZG AWOS that lasted 53 seconds.

The device did not contain enough usage information to conduct a useful rest history examination for the pilot. Between September 12, 2023, and the accident date, there were six visits to Trade-a-plane.com for classified listings for various Ercoupe airplanes, including the accident airplane. The device’s web history was limited, and no other reviewed data was pertinent to the accident investigation. METEOROLOGICAL INFORMATIONBased on the temperature and dew point at FZG about the time of the accident flight’s departure, the calculated relative humidity was 52.3%. A review of the carburetor icing probability chart contained in FAA Special Airworthiness Information Bulletin CE-09-35, “Carburetor Icing Prevention,” revealed that the conditions were conducive to the formation of “serious icing at glide [idle] power.” AIRPORT INFORMATIONThe two-place, low-wing airplane was equipped with a fixed-pitch, two-bladed, McCauley metal propeller. According to the airplane’s type certificate data sheet, the engine limit for all operations was 2,575 rpm.

A review of the maintenance records revealed the airplane’s last annual inspection was performed on February 6, 2006. At the time of the accident, the airplane had accrued about 77 hours since the inspection was performed and 1,736 hours total time. The engine had accrued 1,736 hours since new, and 642 hours since last overhaul in 1977. A review of FAA aircraft registry records revealed that the airplane’s registration was not current and that the “N” number had expired.

The airplane was weighed at the last annual inspection and the weight and balance form specified the maximum weight was 1,260 lbs, the empty weight was 845 lbs, the empty weight center of gravity (c.g.) was 25.54 inches aft of datum, and the useful load was 415 lbs.

Based on this information, and considering that the pilot weighed 204 lbs (per the medical examiner) and the passenger weighed about 200 lbs (per information he provided in his interview), any usable fuel load greater than 11 lbs, or about 1.9 gallons, would exceed the airplane’s maximum gross weight.

According to fueling records, the pilot purchased 10.89 gallons of 100 low lead fuel (100LL) at FZG about 1618 on September 11, 2023, two days before the accident. The pilot’s family reported that, in anticipation of performing taxi tests, 2.5 gallons of fuel were added into each wing fuel tank the day before the accident. The total fuel quantity in each tank at the time of the accident flight’s departure could not be determined.

An airframe and powerplant mechanic at FZG reported that, the day before the accident, the pilot came into the hangar where the mechanic was working and used the spark plug cleaning and test machine. The mechanic said that the pilot cleaned the spark plugs but did not test them. The mechanic reported that the pilot did not tell him why he needed to clean the plugs.

The passenger reported that the pilot informed him that the airplane had undergone a recent annual inspection performed by an individual. That individual, an airframe and powerplant mechanic with an inspection authorization, informed an FAA inspector postaccident that he had never performed any annual inspection or work on the airplane. According to members of the pilot’s family, the individual shared a hangar with the pilot, and the individual was present and interacted with the pilot while the pilot performed an inspection of the airplane during the 2 days before the accident. The pilot did not hold an airframe and/or powerplant mechanic certificate.

A booklet labeled “Owner’s Manual” was part of the obtained records for the airplane. The booklet, which referenced the Ercoupe 415-C and other models, contained a “Before Starting Engine” checklist that included an item for fastening the seat belts and a “Starting Engine” checklist that included an item for using the engine primer, with a handwritten note next to it stating “close & lock.” It also contained a “Before Takeoff” checklist that specified engine run-up procedures that included checking the operation of the magnetos and the carburetor heat.

According to a representative from the airplane’s type certificate data sheet (TCDS) holder, no flight manual or owner’s manual was available for the model 415-C. The representative stated that, when requested, the TCDS holder would provide an owner with a copy of the flight manual for the model 415-D.

The FAA-approved “Airplane Flight Manual” for the model 415-D contained a takeoff performance chart that provided the takeoff distance to clear a 50-ft obstacle for an airplane equipped with a metal, fixed-pitch propeller; the chart assumed an airplane gross weight of 1,400 lbs, zero wind, and a paved runway. Based on the temperature and pressure altitude (used to calculate the pressure altitude) at FZG about the time of the accident flight’s departure, the calculated takeoff distance to clear a 50 ft obstacle was about 2,332 ft. The calculated distance to clear the 50 ft obstacle did not account for the slightly downsloping runway.

The pilot’s and the passenger’s cellular phones were recovered from the accident site and retained for readout by the NTSB Vehicle Recorder Division for information relevant to the accident flight. The passenger provided a passcode for his cellular phone, but the passcode did not unlock the phone. As a result, no information could be reviewed, and the NTSB returned the phone to the passenger’s attorney.

The pilot’s cellular phone was not passcode locked. No pertinent photos or other media were discovered on the device, and no electronic references were found that were related to maintenance of the airplane.

Call records showed that, at 1408 on the day of the accident, an outgoing call was made to the FZG automated weather observing system (AWOS) for a duration of about 1 minute. At 1637, another call was made to the FZG AWOS that lasted 53 seconds.

The device did not contain enough usage information to conduct a useful rest history examination for the pilot. Between September 12, 2023, and the accident date, there were six visits to Trade-a-plane.com for classified listings for various Ercoupe airplanes, including the accident airplane. The device’s web history was limited, and no other reviewed data was pertinent to the accident investigation. WRECKAGE AND IMPACT INFORMATIONThe airplane crashed in a residential area. The main wreckage was resting over a shallow ditch in front of a house. A portion of the aft empennage was located over the edge of the road. The main wreckage was located about 2.24 nautical miles and 038° from the approach end of runway 20. The airplane was oriented on a magnetic heading of 131°. There was no evidence of fire on any components. Fuel blight was noted to grass forward of the resting position of the ruptured right wing fuel tank. No fuel blight was noted to grass forward of the resting position of the left wing fuel tank.

Examination of the airplane revealed the engine was displaced, both wings exhibited extensive damage, and the aft empennage was displaced and rotated to the right. The elevator trim tab was extended tab trailing edge down (nose up). The canopy frame and glass was heavily impact damaged. The nose landing gear was displaced aft.

Examination of the cockpit revealed both seats were equipped with lap-belt restraints. Inspection of the webbing of both restraints revealed no evidence of damage. The bottom seat pan of the passenger seat was deformed downward. The primer was unlocked and extended about 1 13/16 inches. Disassembly inspection of the primer revealed the two packings, or o-rings, were in satisfactory condition with no cracks noted. One horn of the left control yoke was fractured, and both horns of the right control yoke were intact. The fuel pump was in the “on” position, the carburetor heat control was extended about 1/4 inch, and the tachometer needle was trapped about 1,600 rpm. Both side panels of the sliding canopy were observed down.

Examination of the elevator, aileron, and rudder flight control systems revealed no evidence of preimpact failure or malfunction for pitch and yaw. The aileron control cable in the cockpit exhibited overload failure and the left aileron rod end at the control surface exhibited bending overload consistent with impact damage.

Examination of the airplane’s fuel supply and vented fuel caps revealed both fuel caps were free of obstruction, and there was no blockage of any fuel supply line from either fuel tank to the engine compartment. The left fuel tank outlet finger screen was clean. The right outlet finger screen was not observed due to impact damage in that area. The right fuel tank was ruptured and the left fuel tank exhibited several punctures. No fuel was noted in either fuel tank.

The fuel shutoff valve was located past the “on” position and was free of obstructions. The airframe fuel strainer bowl was impact separated. All flexible fuel hoses were tightly secured in the engine compartment. No fuel was noted at the auxiliary fuel pump inlet and outlet fittings or at the inlet or outlet fittings of the engine-driven mechanical fuel pump. About 1/4 ounce of liquid that had a color and odor consistent with old aviation fuel was drained from the auxiliary fuel pump when the screen was removed. About 1/4 ounce of fuel was drained from the engine-driven fuel pump with no water noted in the sample. The auxiliary fuel pump operated electrically after priming with 100LL fuel. Hand actuation of the engine-driven fuel pump revealed it pumped fuel.

Examination of the engine revealed crankshaft, camshaft, and valvetrain continuity. There were no identified preimpact failures or malfunctions of the ignition, exhaust, air induction, or lubrication systems, which included operational testing of the magnetos and spark plugs. Although several areas of the ignition harness exhibited impact damage, all spark plugs produced spark when the crankshaft was rotated by hand in the direction of normal rotation. About 1/2 ounce of fuel was drained from the carburetor bowl and appeared uncontaminated. Examination of the carburetor heat revealed the cable remained attached at both ends; that is, continuity was established from the cockpit control knob to the lever at the airbox. The carburetor heat door was partially closed, and impact damage to the duct was noted.

Examination of the propeller revealed one blade exhibited a slight aft bend and full-span chordwise scratches on the cambered side of the blade. The other blade was bent aft about 45° and also exhibited full-span chordwise scratches on the cambered side of the blade. Nicks were noted on the leading edges of both blades. ADDITIONAL INFORMATIONAccording to the FAA’s “Pilot’s Handbook of Aeronautical Knowledge,” FAA-H-8-83-25C, chapter 7, “it is imperative for a pilot to recognize carburetor ice when it forms during flight to prevent a loss in power, altitude, and/or airspeed…. Once a power loss is noticed, immediate action should be taken to eliminate ice already formed in the carburetor and to prevent further ice formation. This is accomplished by applying full carburetor heat, which will further reduce power and may cause engine roughness as melted ice goes through the engine. These symptoms may last from 30 seconds to several minutes, depending on the severity of the icing.”
The handbook also stated in chapter 10 that “excessive weight reduces [an airplane’s] flight performance in almost every respect,” noting that “the most important performance deficiencies in an overloaded aircraft” include “higher takeoff speed, longer takeoff run, reduced rate and angle of climb, [and]…higher stalling speed.” MEDICAL AND PATHOLOGICAL INFORMATIONA postmortem examination of the pilot was performed by the Georgia Bureau of Investigation Medical Examiner’s Office, Macon, Georgia. The cause of death was reported to be multiple blunt force trauma and the manner of death was accidental. His weight at autopsy was 204 pounds. His autopsy identified a markedly enlarged heart with marked four-chamber dilatation. Dense fibrous adhesions limited evaluation of the coronary artery anatomy. An occluded aortocoronary venous bypass graft was observed but its insertion point could not be determined. The heart valves and aorta demonstrated atherosclerotic disease. No areas of scarring of the heart muscle were seen.

The FAA Forensic Sciences Laboratory performed toxicological testing of postmortem specimens from the pilot. Glucose (sugar) was measured at 24 mg/dL in vitreous fluid and at 366 mg/dL in urine. HbA1c was measured at 7.1% in blood. Citalopram was detected at 730 ng/mL in blood and at 1,807 ng/mL in liver tissue. N-desmethylcitalopram was detected at 127 ng/mL in blood and also was detected in liver tissue. Levetiracetam, losartan, amlodipine, and metformin were detected in blood and urine. Glimepiride and montelukast were detected in blood and liver tissue. Ezetimibe was detected in liver tissue; ezetimibe testing of blood was inconclusive. Clopidogrel was detected in urine and was not detected in blood.

Citalopram is a prescription medication commonly used to treat depression. N- desmethylcitalopram is a metabolite of citalopram. Studies of citalopram have not established that it causes significant cognitive or psychomotor impairment. However, citalopram may carry a warning that any psychoactive drug may impair judgment, thinking, or motor skills and that users should be cautioned about operating hazardous machinery, including motor vehicles, until they are reasonably certain that citalopram does not affect their ability to engage in such activities. Additionally, major depression can cause cognitive impairment, particularly of executive function. Pilots on citalopram seeking FAA medical certification are subject to case-by-case evaluation of the underlying condition and the response to treatment.

Levetiracetam is a prescription anti-seizure medication. It may cause sleepiness, fatigue, and coordination difficulties, and commonly carries warnings that users should be monitored for these signs and symptoms and advised not to drive or operate machinery until they have gained sufficient experience on the medication to gauge whether it adversely affects their ability to do so. The FAA considers levetiracetam to be a “Do Not Issue / Do Not Fly” medication. According to the medical case review for this accident, levetiracetam is unacceptable for pilot medical certification due to the underlying condition and medication side effects.

Losartan is a prescription medication commonly used to treat high blood pressure. It may also be used in the treatment of heart failure. Amlodipine is a prescription medication that can be used to treat high blood pressure and certain types of coronary artery disease. Losartan and amlodipine are not generally considered impairing.

Metformin is a prescription oral medication commonly used for blood sugar control in diabetes and prediabetes. Glimepiride is a prescription oral diabetes medication of a different class than metformin, with greater potential to cause symptomatic low blood sugar. Metformin and glimepiride are not typically impairing and may be acceptable for FAA pilot medical certification depending on a case-by-case evaluation of the individual’s diabetes and its response to treatment.

Montelukast is a prescription oral medication commonly used for the long-term control of asthma and allergic rhinitis. Montelukast is not typically impairing, although it may have adverse effects on mood in some individuals. Montelukast is on the FAA’s list of acceptable allergy medications.

Clopidogrel is a prescription antiplatelet medication that can be used to reduce cardiovascular risk in certain medical conditions, including ischemic heart disease, coronary artery stenting, recent stroke or heart attack, and peripheral arterial disease. Clopidogrel is not typically impairing. SURVIVAL ASPECTSThe lap-belt restraints of both seats exhibited no evidence of preimpact failure or malfunction and no damage to the webbing of either restraint, consistent with nonuse during the accident flight.
Title 14 CFR 91.107 specifies that the pilot in command of an aircraft must ensure before takeoff that each person on board is briefed on how to fasten and unfasten that person’s safety belt.