N2796H

Substantial
Fatal

ERCOUPE 415S/N: 3421

Accident Details

Date
Wednesday, September 13, 2023
NTSB Number
ERA23FA370
Location
Fitzgerald, GA
Event ID
20230913193060
Coordinates
31.719532, -83.244536
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
1
Serious Injuries
1
Minor Injuries
0
Uninjured
0
Total Aboard
2

Probable Cause and Findings

The pilot’s failure to perform pre-takeoff engine runup and carburetor heat check procedures, which resulted in rotation with inadequate climb performance, and his subsequent failure to maintain adequate airspeed and exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall or mush shortly after takeoff. Contributing to the accident was the partial loss of engine power due to the formation of carburetor ice.

Aircraft Information

Registration
N2796H
Make
ERCOUPE
Serial Number
3421
Engine Type
Reciprocating
Year Built
1946
Model / ICAO
415ERCO
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
MCA AIRCRAFT SALES INC
Address
109 PECAN BLVD
Status
Deregistered
City
FITZGERALD
State / Zip Code
GA 31750-8449
Country
United States

Analysis

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 Man...

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# ERA23FA370