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NTSB Releases Factual Report on Halladay Accident

by Matt Thurber

 - April 16, 2020, 9:10 AM

The National Transportation Safety Board (NTSB) yesterday released a factual report on the crash of former Major League Baseball pitcher Roy Halladay’s Icon A5 light sport amphibious airplane on Nov. 7, 2017, in which Halladay died. Although not breaking news, as autopsy results were released in January 2018, the NTSB factual report identifies a number of drugs found in Halladay’s specimens during toxicology testing. The report also documents the high angle of attack (AoA) maneuvers at low altitude that Halladay flew in the A5 just before the accident.

Halladay bought the A5 about four weeks before the accident, according to the NTSB, and had logged 14.5 hours in that airplane. The NTSB was able to confirm from recovered GPS data that the airplane had been flown under the Sunshine Skyway Bridge, near St. Petersburg, Florida, and Halladay documented the maneuver in his logbook. The vertical clearance of the bridge is 180 feet.

According to the factual report, the FAA’s Forensic Sciences Laboratory found the following drugs in Halladay’s specimens: Zolpidem (Ambien), a sleep aid; Amphetamine (2.2 μg/ml in cardiac blood; “generally, levels above 0.2 μg/ml indicate amphetamine misuse to maximize the drug's psychoactive effects”); Morphine; Fluoxetine (an antidepressant) and its metabolite norfluoxetine; Baclofen, a muscle relaxant; and Hydromorphone, an opioid pain medication.

The report noted: “Review of the available personal medical records for the pilot indicated a history of substance abuse requiring inpatient rehabilitation twice between 2013 and early 2015 and diagnoses of chronic back pain, insomnia, and depression, which were treated with various prescribed medications. The pilot's personal medical records for 2016 and 2017 were not available.”

NTSB investigators were able to analyze data from the A5’s onboard digital-to-analog converter (DAC) data memory unit and Rotax engine control unit. According to the report, “The recorded data indicated that, at 1201:19, the pilot began a rapid climbing ’S' turn from a GPS altitude of 0 to 134 feet and then descended to 36 feet; the airplane reached a maximum load factor of 1.94 g and a maximum AOA of 7.53 degrees. At 1202:29, the pilot performed a second maneuver, a climbing right 360-degree turn from a GPS altitude of 19 to 136 feet; the airplane reached a maximum load factor of 1.93 g and a maximum AOA of 15.73 degrees, which is within the red band on the AOA indicator.

"At 1203:34, the pilot initiated a final maneuver: a climbing right turn from a GPS altitude of 210 feet and an indicated airspeed of 81 knots. The airplane's load factor increased rapidly to 1.91 g and then varied between 1 and about 2 g as the AOA increased steadily to 15 degrees, which is at the top of yellow band on the AOA indicator. About three seconds after initiating the climb, the engine throttle lever was retarded from 99 percent to 27 percent, resulting in a corresponding decrease in engine speed from about 5,393 to 2,261 rpm.

"The lowest recorded indicated airspeed during the maneuver, 54 knots, occurred as the airplane reached a GPS altitude of 358 feet, the apex of the maneuver, with a low energy state. The computed bank angle exceeded 50 degrees and the computed pitch angle exceeded 30 degrees before the airplane descended toward the water.”

Witness reports included two commercial fishermen, one saying he saw the A5 fly over his vessel below 300 feet. Another said he saw the A5 flying “really close” to houses, then he watched it descend, climb steeply, then descend steeply in a decreasing pitch attitude, finally reporting that “the airplane impacted the water in a 45 degree nose-down, wings-level attitude.”

Halladay died of blunt trauma, with drowning contributory, according to the report. The NTSB found that “no pre-accident anomalies were noted with the airframe or engine that would have precluded normal operation.” There was also no evidence of impact damage that could have been due to a bird strike.

The report concluded with a description of Icon Aircraft’s “Low Altitude Flying Guidelines,” which were sent to all A5 clients and owners on Oct. 23, 2017. The final sentence of the report stated: “The guidelines also warned pilots ‘Do not show off.’”