# NTSB ANC22LA012: Flight Design Ctls, N992SA, Hana, HI, January 15, 2022 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: January 15, 2022, 09:55 local (19:55 UTC) - Place: Hana, HI - Coordinates: 20.79556, -156.02172 - Nearby events: https://openairdocs.org/map.md?lat=20.7956&lon=-156.0217&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Alaska Regional Office - Parties: FAA, Rotax Aircraft Engines - NTSB case key (mKey): 104533 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC22LA012 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104533/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104533 - Page: https://openairdocs.org/ntsb/ANC22LA012 ## Probable cause The pilot’s exceedance of the airplane’s critical angle of attack during the initial climb, which resulted in an aerodynamic stall and subsequent impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Flight Design CTLS, 4 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=060005B), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Flight Design CTLS, 22 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=060005B), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Flight Design CTLS, 4 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=060005B), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Flight Design CTLS, 4 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=060005B), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis The pilot and pilot-rated passenger completed several takeoffs and landings before departing to their destination. The pilot reported that, during the accident takeoff, the airplane “had no power to climb” and was “sinking.” The airplane descended into trees and impacted terrain in a near-vertical attitude just past the departure end of the runway. The pilot-rated passenger stated that the pilot pitched the airplane “higher than he needed” and “held the high pitch attitude” until the airplane descended into the trees, and pilot-rated witnesses reported that the airplane exhibited an “unusually high” nose-up pitch attitude during the takeoff. Postaccident examination of the engine and engine monitoring system data revealed no evidence of mechanical malfunctions or anomalies that would have precluded normal operation of the engine. Given the passenger and witness statements regarding the airplane’s nose-high pitch attitude, it is likely that the pilot exceeded the airplane’s critical angle of attack during the initial climb after takeoff, resulting in an aerodynamic stall and subsequent impact with terrain. ## Factual narrative On January 15, 2022, about 0955 Hawaii-Aleutian standard time, a Flight Design CTLS light sport airplane, N992SA, sustained substantial damage when it was involved in an accident near Hana, Hawaii. The pilot sustained serious injuries, and the pilot-rated passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that he and the passenger conducted several touch-and-go landings before departing to their destination. During the accident takeoff, the airplane performed normally until about 75 ft above ground level, when the pilot noted that the airplane had “no power to climb” and was “sinking.” The airplane descended into trees and impacted the ground in a near vertical attitude just past the departure end of the runway, resulting in substantial damage to the fuselage and wings. Two pilot-rated witnesses reported that they heard no unusual sounds. The witnesses noticed that the airplane had an “unusually high” nose-up attitude during takeoff. The pilot-rated passenger reported that the pilot pitched the airplane “higher than he needed” and “held the high pitch attitude” until the airplane descended into the trees. A Dynon EMS-D120 engine monitoring system was removed from the airplane and sent for data download at the NTSB Recorders Laboratory. The flight data indicated that, about 40 seconds before impact, the engine RPM increased from idle to maximum RPM and maintained maximum engine RPM to the end of recording. A postaccident examination of the engine was conducted by an accident investigator from the engine manufacturer with oversight provided by an inspector from the Federal Aviation Administration. The examination revealed all spark plugs appeared normal with no anomalies, carburetor main jet was clear of obstruction and floats were within weight limitation. The fuel shut off was operational, and no obstructions observed in the fuel lines. All engine rocker arms, valves, valve springs were intact and operated normally. No anomalies seen with the exhaust system. Gearbox was in good condition and the propeller shaft rotated smoothly. Continuity was established with the crankshaft when the engine was rotated. Thumb compression was observed in all cylinders. ## Aircraft - Registration: [N992SA](https://openairdocs.org/aircraft/N992SA), registered now, S/N 08-02-06 (OpenAirDocs) - Reported make and model: FLIGHT DESIGN GMBH CTLS - Registry model: [Flight Design CTLS](https://openairdocs.org/model/flight-design-ctls) (registry code 060005B) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 08-02-06 - Year built: 2008 - Airframe hours: 825 - Engines: ROTAX 912ULS SERIES 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental light sport (Special) - Last inspection: 100 hour, April 23, 2022, 35.9 hours before - Departed: HNM, Hana, HI - Destination: OOG, Kahului, HI - Airport: HNM, Hana Airport, runway 26, 3,606 × 100 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: serious; sport pilot; airplane ratings: single-engine land; last flight review March 13, 2014; seat: left; restraint: 4-point; flight hours: 500 total, 27 in this make and model, 416 as pilot in command - Pilot-rated passenger; injuries: minor; flight instructor; seat: right ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Temperature: 79 °F, dew point 63 °F - Altimeter: 30.04 inHg - Observed at: PHOG, 24 nm away - METAR: PHOG 151954Z 00000KT 10SM FEW050 26/17 A3004 RMK AO2 SLP176 T02610172 ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20220115000669A](https://openairdocs.org/incident/20220115000669A), Jan 15, 2022: Flight Design Gmbh CTLS, Hana, HI, Substantial damage. On Saturday, 1/15/2022, aircraft tail number N992SA, Flight Design Gmbh light sport airplane crashed into the jungle while on climb out after taking off runway… ## Docket (7 files) The files NTSB released with the investigation on August 23, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104533. 12.1 MB in all. - Cockpit displays - specialist's factual report (item 1, PDF, 7 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14068438&FileExtension=pdf&FileName=ANC22LA012%20Cockpit%20Displays%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to cockpit displays - specialist's factual report (item 2, CSV, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14068810&FileExtension=csv&FileName=ANC22LA012%20Attachment%201%20to%20Cockpit%20Displays%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 3, PDF, 9 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14201433&FileExtension=pdf&FileName=ntsb%206120%20ANC22La012%20redacted-Rel.pdf - Flight data recorder (item 4, PDF, 5 pages, 5.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14021995&FileExtension=pdf&FileName=ANC22LA012%20Data%20from%20Dnyon-Rel.pdf - Witness statements (item 5, PDF, 13 pages, 657 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14021985&FileExtension=pdf&FileName=ANC22LA012%20witness%20interviews_Redacted-Rel.pdf - Investigative photographs (item 6, PDF, 3 pages, 815 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14022015&FileExtension=pdf&FileName=Photo%20Array%20ANC22LA012-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 7, PDF, 4 pages, 480 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15161595&FileExtension=pdf&FileName=ANC22LA012%20Wreckage%20Release%20Form%202_Redacted-Rel.pdf From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.