Salinas Airport
Aircraft Accident/Incident Report

Chualar, California 93925
Thursday, September 29, 2011 18:50 PDT

NTSB Narrative Summary Released at Completion of Accident

The owner/pilot of the experimental amateur-built aerobatic airplane was a part-time competition pilot, and he flew the airplane almost daily to practice aerobatics. His typical routine was to practice over his vineyards, located about 9 miles south of the airport where he based the airplane. On the day of the accident, the pilot took off, flew directly to his vineyard, and arrived there about 3 minutes later. He spent the next 4 minutes performing maneuvers, several of which could induce high g-loads. About 25 seconds after a steep climb and an equally steep descent and level-off, the pilot made a rapid course-reversal turn and began a loop, which terminated in ground impact. The airplane impacted in an approximate wings-level attitude, with high forward velocity and minimal vertical velocity. The debris path was aligned with the loop, and was nearly perpendicular to the vineyard trellis rows constructed of steel poles, steel wires/cables and nylon mesh. As a result, the airplane was highly fragmented. All major components of the engine and airplane, including all aerodynamic control surfaces, were accounted for at the accident site. A postaccident examination of the flight control system, airplane structure, propeller, and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The pilot’s toxicology analysis identified the low-level presence of ethanol, likely as a result of ingestion. The detected level of ethanol was unlikely, in isolation, to have significantly impaired the pilot’s performance, although there may have been some negative effect. The pilot also had a significant amount of hydrocodone in his blood, and the evidence indicated that he was a chronic user. Although hydrocodone is known to have an impairing effect on infrequent users, the effects on chronic users are less well-defined, and, therefore, the level of impairment due to the hydrocodone alone could not be determined. Similarly, the performance effects of the combination of alcohol and hydrocodone are not well defined, and although the pilot may have been impaired, the extent of his impairment could not be determined. Significant coronary artery disease and a previous infarction put the pilot at risk for an acute cardiac event, including recurrent infarction and acute arrhythmia. The toxicology revealed the presence of phendimetrazine, which, in combination with the pilot’s history of hypertension, can significantly increase blood pressure, and may have exacerbated the risk of an acute cardiac arrhythmia. The pilot had experienced g-induced loss of consciousness (g-LOC) during aerobatic maneuvers in the 3 months before the accident, but he did not report it to any medical personnel, and he did not cease aerobatic flying. Several of the maneuvers performed on the day of the accident could induce significant g-loads, and the sudden changes in cardiac work associated with g-loading and -unloading presented another risk factor for cardiac arrhythmia. Therefore, the pilot’s coronary artery disease, his previous infarction, his use of phendimetrazine, and his conduct of aerobatics all increased his risk of an acute cardiac arrhythmia. It is very likely that this pilot was medically incapacitated either by g-LOC alone, or in combination with an arrhythmia, and that this resulted in the ground impact. The investigation was unable to determine what effect the pilot’s chronic opioid use had on either his pre-flight decision-making or his performance during the flight.

NTSB Probable Cause Narrative

The pilot’s incapacitation due either to g-induced loss of consciousness alone or in combination with a cardiac arrhythmia. Contributing to the accident was the pilot’s use of several medications.

Event Information

Type of Event Accident
Event Date 9/29/2011
Event Day of the Week Thursday
Time of Event 1850
Event Time Zone Pacific Daylight Time
Event City Chualar
Event State CALIFORNIA
Event Country --
Zipcode of the event site 93925
Event Date Year 2011
Event Date Month 9
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 363509N
Event Location Longitude 1212102E
Event Location Airport Salinas
Event Location Nearest Airport ID SNS
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 9
Degrees magnetic from airport 180
Airport Elevation 85
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1853 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 360
Weather Observation Facility ID SNS
Elevation of weather observation facility 85
Distance of event from weather observation facility (units?) 9
Time Zone of the weather observation PDT
Lighting Conditions Dusk
Lowest Ceiling Height 1100
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling Overcast
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 18
Dew Point at event time (in degress fahrenheit) 14
Wind Direction (degrees magnetic) 320
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 14
Wind Velocity Indicator --
Wind Gust Indicator Not Gusting
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) 29.92
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 32888
NTSB Notification Source FAA Comm Center
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Jul 8 2014 7:56PM
User who most recently changed record huhm
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N42GP
NTSB Number WPR11FA474
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed Unknown
Flight plan Was Activated? --
Damage Substantial
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name POE G L/POE S Y
Aircraft Model 540
Aircraft Series Identifier --
Aircraft Serial Number 0015
Certified Max Gross Weight 1800
Aircraft Category Airplane
Aircraft Registration Class --
Aircraft is a homebuilt? Yes
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 1
Number of Engines 1
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Annual
Date of Last Inspection Sep 30 2010 12:00AM
Airframe hours since last inspection --
Airframe Hours --
ELT Installed Unknown
ELT Activated Unknown
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name FRANSCIONI THOMAS D and Daniel L
Aircraft Owner Street Address --
Aircraft Owner City SALINAS
Aircraft Owner State CA
Aircraft Owner Country USA
Aircraft Owner Zipcode 93901-1818
Operator is an individual? Yes
Operator Name Daniel L Franscioni
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City SALINAS
Operator State CA
Operator Country USA
Operator Zip code 93901-1818
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event No
Departure Airport Code SNS
Departure City Salinas
Departure State CA
Departure Country USA
Departure Time --
Departure Time Zone PDT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code SNS
Destination City Salinas
Destination State CA
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Jul 8 2014 7:56PM
User who most recently changed record huhm
Since inspection or accident --
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --