NTSB Factual Report

HISTORY OF FLIGHT

0n September, 17, 1998, at 0940 hours Pacific daylight time, a Hughes Cassutt 111M2, N94HA, collided with the ground while on base leg for landing at the Stead Airport, Reno, Nevada. The airplane was participating in the Reno National Championship Air Races and being operated by its owner under the provisions of 14 CFR Part 91. The airplane completed an International Formula One (IF1) heat race and was on approach for landing at the time of the accident. The airplane sustained substantial damage in the ground collision sequence and the airline transport pilot was fatally injured. Visual meteorological conditions prevailed for the local flight and no flight plan was filed.

Witnesses stated several airplanes were sequencing for landing after the conclusion of heat 1C for IF1 airplanes. N94HA was number four in the pattern for right traffic runway 26. The first two airplanes landed successfully. The third airplane was closing on the airplane ahead and the pilot elected to do a left 360-degree turn and reenter the landing pattern. A witness stated that the third airplane had completed approximately 140 to 160 degrees of the left turn when he noticed N94HA at the beginning of its base leg for landing. Witnesses indicated N94HA started up and right, then instantly entered a nearly vertical, rolling dive. A witness near the impact site heard the engine "rev like it was going to pull up".

PERSONNEL INFORMATION

Federal Aviation Administration (FAA) records indicated the pilot was an FAA Aviation Safety Inspector, Air Carrier Operations. He held an airline transport pilot rating for airplane single and multiengine land, commercial privileges, airplane single engine sea, and private pilot privileges, glider. He had type ratings for the following airplanes: B-727, B-747, CV-240, CV-340, CV-440, DC-3, DC-4, DC-6, DC-7, DC-8, G-1159, L-49, and YS-11. He also held a certified flight instructor certificate with ratings for airplane single engine land, airplane multiengine land, instrument airplane, and basic ground. He had a Flight Engineer Certificate for jet and reciprocating airplanes. He held an airframe and powerplant mechanic certificate. His last medical application indicated a total flying time of 17,380 hours. A race pilot indicated he raced for 3 years and had approximately 30 hours in a Cassutt. On the registration form provided to the Reno Air Race Association, the pilot indicated a biennial flight review was completed on August 21, 1998.

AIRCRAFT INFORMATION

The airplane data plate indicated the airplane was a Hughes Cassutt, serial number H-1, experimental, amateur built airplane. FAA records listed the airplane as a model 111M2. Manufacture date was listed as April 12, 1972. Information supplied by the kit manufacturer recommended an approach speed of 90 mph and a touchdown speed of 70 mph. No airfoil data was available. The airplane was constructed of fabric over a metal tubular steel frame and had wooden wings. The owner's mechanic determined from the airplane's logbook that the airplane had accumulated 590.8 hours total time at the time of the last condition inspection, which was performed on July 4, 1998, at a tachometer time of 23.5. During the wreckage examination the tachometer was observed at 25.5. A prerace inspection was performed on September 13, 1998, and the airplane was found to be in an airworthy condition. IF1 representatives stated the airplane was fueled on September 14, 1998, and was not flown prior to the accident.

The engine was a 100-horsepower Teledyne Continental O-200. The owner's mechanic determined from the engine logbook that the engine had a total time of 1,639.2 hours, 6.7 hours since overhaul, and 2.2 hours since top overhaul at the time of the last condition inspection.

On August 22, 1996 the airplane was registered to the current owners.

METEOROLOGICAL INFORMATION

A weather briefing issued to race pilots on September 17, 1998 indicated occasional moderate turbulence late morning and afternoon. Forecast weather for 0900 to 1000 was for the winds to be from 180 degrees at 12 knots gusting to 20 knots. A routine aviation weather report (METAR) issued for Stead at 0945 indicated: visibility 10 statute miles; temperature, 72 degrees Fahrenheit; and winds 240 degrees at 17 knots gusting to 25 knots. The pilot of the airplane ahead of N94HA in the landing pattern stated that there were no adverse conditions encountered on his base leg. However, the winds on base to final were gusty, the ride was bumpy, and he was aware of a "sink" at the end of runway 26.

AERODROME INFORMATION

The airport/facility directory, southwest U.S., indicated Reno/Stead airport had runways 14-32 and 08-26. Runway 26 was 7,600 feet by 150 feet of grooved asphalt. It had a four-light precision approach path indicator light system and a 3-degree slope angle.

WRECKAGE AND IMPACT INFORMATION

The FAA investigator documented the wreckage. A ground scar, 20 feet in length with a maximum depth of 10 inches, was in the back yard of a private residence. A propeller blade was found in this scarred area. The airplane came to rest approximately 80 feet from the initial point of contact (IPC). The wooden spar fractured and both wings separated from the airplane. The right wing and its aileron were on top of a pile of lumber near an undamaged fence that crossed the debris path. The front, inboard section of the left wing was leaning against the fuselage. The rest of the wing had the aileron attached and was several feet away from the airplane. The airplane was resting on its right side. The vertical stabilizer, rudder, left horizontal stabilizer, and left elevator were attached and exhibited some dents and buckling. The right horizontal stabilizer and right elevator separated, and were in the debris field; the fracture surface was angular and uneven. Fabric on the right horizontal stabilizer was torn, its ribs and leading edge were bent and twisted. The landing gear separated but was in the debris field. The propeller blades fractured and separated, but the propeller hub remained attached to the engine. The engine partially separated from the airplane and was 90 degrees to the airplane, pointing in the direction of flight, when it came to rest. The investigator accounted for all flight controls at the accident site. Fuel was observed in the tank. Technical representatives for the IF1 association inspected the airplane under the supervision of the FAA investigator and indicated no structural failure was evident, all welds and glue joints were intact, and the engine was free and appeared to be operating at the time of impact. The Safety Board's investigator established control continuity from the cockpit to the control surfaces at a postaccident inspection of the wreckage. All fractures were noted to be irregular surfaces angled to the members' cross section. Some push/pull tubes and rod ends were bent.

MEDICAL AND PATHOLOGICAL INFORMATION

FAA records indicate the pilot held a second-class medical issued on April 3, 1998. Restrictions were that the pilot must wear corrective lenses and possess glasses for near and intermediate vision. Additionally, the certificate was listed as valid for 6 months following the month examined.

An examination of a certified copy of the pilot's FAA medical record was completed by the Safety Board's Medical Officer (full report attached). The pilot had a Statement of Demonstrated Ability for defective visual acuity in the left eye since 1961. Since 1991, the pilot had been using medications for the treatment of high blood pressure and high cholesterol.

An examination for a second-class medical certificate issued in April 1995 noted the use of the medications Procardia (nifedipine) and Lopid (gemfibrozil). In May 1995, the FAA Civil Aeromedical Institute (CAMI) Aeromedical Certification Branch notified the pilot they were unable to determine his eligibility for a second-class medical and requested a physician's report regarding his blood pressure and echocardiogram (EKG). In September 1995, the pilot's records indicate he underwent a cardiology evaluation. The echocardiogram was essentially normal, demonstrating left ventricular hypertrophy and a sclerotic aortic valve, but normal wall function and systolic performance. The pilot's cardiologist added aspirin and Toprol (metoprolol) to the pilot's medications, and prescribed nitroglycerin to use if necessary. In November 1995, the FAA's Great Lakes Regional Flight Surgeon denied the pilot's application and requested the return of the certificate issued in April 1995.

In January 1996, the pilot underwent balloon angioplasty of the right coronary artery, angioplasty of the major diagonal branch of the left anterior descending artery, and placement of a 4 millimeter stent in the right coronary artery.

In July 1996, the pilot applied for a Special Issuance of Medical Certificate. Under "Types of Operations" and "Duties" the pilot checked "Other," and wrote "FAA Aviation Safety Inspector, Air Carrier Operations duties plus personal flying." The category "Acrobatics" was not checked. In August 1996, Special Issuance was denied by CAMI because of the use of nitroglycerin. After the pilot notified CAMI he was not using nitroglycerin, CAMI requested additional tests in October 1996. In November 1996, a 3-day Holter monitor was performed. The test was essentially normal except for three brief supraventricular tachycardia events.

In April 1997, the pilot received an Authorization for Special Issuance of a Medical Certificate. The authorization was valid for 6 months, and required a medical evaluation including an exercise stress test every 6 months and a thallium stress test every 12 months. In November 1997, and April 1998, the FAA reissued the authorization following a Cardolite stress test with no evidence of ischemia.

The Safety Board's Medical Officer examined the report of an autopsy performed by the Washoe County Coroner's Office on September 17, 1998. Cause of death was listed in the report as "Multiple injuries due to blunt force trauma." In the description of the cardiovascular system, it stated the heart "has left ventricular hypertrophy" and the coronary arteries show "severe stenotic calcific atherosclerotic disease." Also noted were numerous areas of 75 to 99 percent stenosis of the left anterior descending artery and left main trunk. It also mentioned an area of fibrosis of the myocardium.

A Forensic Toxicology Fatal Accident Report and a Supplemental Toxicology Report from the FAA reported no carbon monoxide, cyanide, or ethanol were detected. Metoprolol was detected in blood and liver fluid samples. Nifedipine was detected in liver fluid.

In telephone conversations with the Safety Board's Medical Officer, the pilot's cardiologist and his Aviation Medical Examiner stated they were unaware he had been racing aircraft.

ADDITIONAL INFORMATION

All wreckage, except control rods from the cockpit area, was released to Plain Parts in Sacramento, California, on September 24, 1998. The control rods were returned to the owner on November 11, 1998.

NTSB Probable Cause

the pilot's failure to maintain an adequate airspeed margin while maneuvering in gusty wind conditions, which led to an inadvertent stall/spin at low altitude.