CEN12FA611 · Fairley Gooch LANCAIR IV

The airline transport pilot was landing the airplane after a local test flight that involved calibrating the fuel system. According to several witnesses, they heard an increase in engine rpm consistent with the pilot adding power to perform a go-around. Several witnesses reported hearing a subsequent loss of engine power. The nose of the airplane rose and then dropped. The airplane was substantially damaged when it impacted terrain beyond the departure end of the runway. The damage to the airplane and the resultant ground scars were consistent with the airplane being in a stalled condition at the time of the accident. An examination of the airframe and engine revealed no anomalies that would have precluded normal operation. An examination of the fuel system revealed that the fuel selector was stiff and difficult to rotate. Further examination revealed that the O-rings on the fuel selector valve’s internal spindle were swollen past the plane of the shaft of the spindle, preventing easy rotation. The pilot was aware of the fuel selector valve anomaly; however, a service bulletin addressing the problem with the fuel selector O-rings had not yet been complied with. The fuel blighting evidence at the accident site and the quantity of fuel found in the right fuel tank suggest that the right wing contained fuel at the time of impact. Based on the circumstances of the accident, it is most likely that the engine lost power due to fuel starvation during the go-around with the fuel selector valve positioned to the left tank, and the pilot became distracted when he tried to switch fuel tanks and lost control of the airplane.

Toxicological testing revealed the presence of antidepressant and cardiac medications in the pilot’s system. The blood level of the antidepressant medication was higher than usual therapeutic levels, indicating a high dose and prolonged use. The antidepressant medication in the pilot’s system comes with the warning that it may impair mental and/or physical abilities required for the performance of potentially hazardous tasks. In addition, depression is associated with significant cognitive degradation.

A review of the pilot’s medical records revealed an extensive history of psychiatric and cardiac issues and subsequent difficulties obtaining a medical certificate for flight. Before the pilot’s most recent medical certification exam, he provided the Federal Aviation Administration (FAA) medical examiner with documentation indicating that he was no longer taking antidepressants. Required standardized neuropsychological testing placed the pilot at average, below average, or mildly impaired when compared with other (somewhat younger) pilots. Based on the levels of antidepressant medication in the pilot’s system, the pilot likely knowingly misreported his medication use to the FAA when he applied for his medical certificate. The pilot’s underlying depression, personality disorder, cognitive issues, and medication use likely contributed to his unwillingness to address the airplane’s fuel selector valve problem. In addition, these conditions would have adversely affected the pilot’s ability to maintain control of the airplane in an emergency.

Verbatim NTSB analysis and probable cause from the NTSB dataset