Aviation Crash Map

Hermann Bjorn LANCAIR IV N86NW

7 June 2014 · Duluth, Minnesota, United States · Fatal

Summary

On 7 June 2014 at about 16:21 local time, a Hermann Bjorn LANCAIR IV registered N86NW, operated by Alexander G. Obersteg, was involved in an accident near Duluth, Minnesota, United States. One person was on board and one died. The aircraft was substantially damaged. The NTSB has published a probable cause for this accident; it is quoted in full below.

The record

Date
at 16:21
Classification
Accident
Location
Duluth, Minnesota, United States
Nearest airport
Duluth International Airport (KDLH)
Coordinates
46.8822, -91.9189
Aircraft
Hermann Bjorn LANCAIR IV
Registration
N86NW
Category
Airplane
Year built
2005
Engines
1
Operator
Alexander G. Obersteg
Operating rule
Part 91: General Aviation
Purpose of flight
Ferry
Phase of flight
Not recorded
Route
Duluth → Goose Bay
Aircraft damage
Substantial
Weather
VMC
Light
Day
NTSB number
CEN14FA278

People

1 person died.

On board Died Serious Minor Uninjured
1 1 0 0 0

Probable cause

The pilot's failure to maintain airplane control while operating in instrument flight rules (IFR) conditions, which was due to spatial disorientation resulting from erroneous heading and bank angle information shown on the primary flight display. Contributing to the accident were the pilot's impairment due to diphenhydramine and his improper decision to operate in IFR conditions with the airplane over gross weight and at an aft center of gravity.

Quoted verbatim from the NTSB record. This site does not paraphrase or interpret it.

Read the full NTSB narrative

The pilot/owner was ferrying the airplane from the United States to Europe, and he had installed an auxiliary fuel bladder in place of the rear seat. Before takeoff, the airplane's fuel tanks were topped off, and 60 gallons of fuel were added to the auxiliary fuel bladder. The estimated weight of the airplane during takeoff was about 509 lbs over its maximum gross weight. The estimated center of gravity (CG) of the airplane was 93.2, which was near the aft limit of the CG range. The flight departed in marginal visual flight rules conditions and, soon after takeoff, climbed into instrument flight rules (IFR) conditions while passing through 1,000 ft above ground level. Air traffic control (ATC) cleared the pilot to fly a northeasterly heading and climb to 12,000 ft, but the pilot did not acknowledge the instruction, and radar track data indicated that the airplane turned right within 1 minute after departure. ATC instructed the pilot to turn back on course, and the pilot complied. The airplane continued on course for about 1.5 minutes, but then it turned right again while still in a climb. ATC instructed the pilot to turn back on course, but the pilot did not respond. The airplane continued to turn right, reached a maximum altitude of about 6,600 ft, and then entered a steep, descending right turn. ATC instructed the pilot to climb immediately, but there was no response, and the airplane continued the steep descending turn and impacted a lake about 5 minutes after departure. A comparison of the radar track data with the flight data recovered from the airplane's primary flight display (PFD) and multifunction display revealed discrepancies between the two data sources regarding airspeed, bank angle, heading, wind speed, and wind direction, indicating that erroneous information was being displayed on the PFD during the flight. Specifically, the flight data indicated periods of straight and level flight when the radar track data indicated the airplane was banking and changing heading. The erroneous information would have made it difficult for the pilot to control the airplane and navigate effectively in IFR conditions. The reason for the erroneous flight data could not be determined. The pilot's toxicology report indicated 0.146 ug/ml diphenhydramine (a sedating antihistamine) in cavity blood, which was above the therapeutic range of 0.0250 to 0.1120 ug/ml. Although diphenhydramine undergoes postmortem redistribution, the postmortem level detected suggests that the pilot likely had impairing levels of diphenhydramine in his system at the time of the accident. To maintain control of the airplane, the pilot would have needed to recognize that the PFD display was faulty and use the information from the standby attitude indicator, turn and bank indicator, and magnetic compass. However, it is likely that diphenhydramine, which impairs cognitive and psychomotor performance, diminished the pilot's ability to recognize and manage the erroneous PFD indications. The pilot's failure to acknowledge the clearance to turn to the northeast and climb to 12,000 feet only a few seconds after he initiated contact with ATC suggests that his attention was diverted for some reason about that time. The pilot verbally acknowledged and responded to a subsequent call to return to course. However, after about 1.5 minutes the airplane again deviated from course and entered a steep descending turn, most likely due to the pilot experiencing spatial disorientation as a result of the erroneous heading and bank angle information on the PFD and his ineffective use of standby flight instruments in restricted visibility conditions. The airplane's aft CG and over gross weight condition would have reduced the airplane's longitudinal stability, and this likely also contributed to the loss of control.    

Quoted verbatim from the NTSB record.

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