# NTSB CEN11FA443: Koen Lancair Laser IV-P, N11001, Port O'Connor, TX, July 3, 2011 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 3, 2011, 10:25 local (15:25 UTC) - Place: Port O'Connor, TX - Coordinates: 28.45861, -96.291946 - Nearby events: https://openairdocs.org/map.md?lat=28.4586&lon=-96.2919&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report November 7, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Flight Standards District Office - NTSB case key (mKey): 80967 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11FA443 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/80967/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=80967 - Page: https://openairdocs.org/ntsb/CEN11FA443 ## Probable cause The pilot’s loss of airplane control for reasons that could not be determined from the available information. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Koen Lyle D LASER/LANCAIR IVP, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=05626UY), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Koen Lyle D LASER/LANCAIR IVP, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05626UY), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Abrupt maneuver](https://openairdocs.org/ntsb-events/270); cases with it: [Koen Lyle D LASER/LANCAIR IVP, 1 case](https://openairdocs.org/ntsb-events/270/sequence.md?model=05626UY), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Koen Lyle D LASER/LANCAIR IVP, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05626UY), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Koen Lyle D LASER/LANCAIR IVP, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05626UY), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis A witness saw the airplane take off and make a slow climbing left 180-degree turn to about 3,000 feet above ground level (agl). The airplane then made a sharp 180-degree left turn as if it was returning to the airport. The wings were leveled, and the airplane made a snap roll, entered a dive, spun once, and impacted the water. Another witness saw the airplane pass overhead about 500 to 600 feet agl. He heard the engine make a series of pops, and the airplane then rolled 360 degrees, leveled off, then abruptly rolled left and dove vertically into the water. Postaccident examination of the airframe revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The engine was disassembled and examined, and no anomalies were found that would have precluded it from developing power. ## Factual narrative HISTORY OF FLIGHT On July 3, 2011, about 1025 central daylight time, a Koen Lancair Laser IV-P, N11001, impacted water shortly after taking off from Pierce Field (72TA), Port O'Connor, Texas. The airline transport pilot (ATP) and the private pilot-rated passenger on board the airplane were fatally injured. The airplane was substantially damaged. The airplane was registered to and operated by the ATP pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Visual meteorological conditions (VMC) prevailed at the time of the accident, and no flight plan had been filed. The cross-country flight had just originated and was en route to Austin-Bergstrom International Airport (AUS), Austin, Texas. According to one witness, the airplane took off and made a slow climbing left 180-degree turn to approximately 3,000 feet. As it crossed Matagorda Bay, it made a sharp 180-degree left turn. The witness thought the airplane was returning to the airport. The wings were leveled, and then the airplane made what the witness described as a snap roll and dove straight down and impacted the water. The witness said he thought he saw the airplane spin once before impact. Another witness said he saw the airplane pass overhead about 500 to 600 feet. The engine made a series of pops, like a string of fire crackers. The airplane continued in a straight line over the bay and seemed to be climbing. The airplane then rolled 360 degrees, leveled off, then abruptly rolled left and dove vertically into the bay. PERSONNEL (CREW) INFORMATION The 68-year-old pilot held an ATP certificate with an airplane multi-engine land rating; commercial privileges with an airplane single-engine land rating; and private pilot privileges with airplane single-engine sea and glider ratings. He also held a flight instructor certificate with airplane single-engine land, multi-engine land , and instrument ratings. His third class airman medical certificate, dated March 30, 2011, required him to wear corrective lenses. On his application for medical certification, he estimated he had accrued 3,000 hours total flight time. The 42-year-old pilot-passenger held a private pilot certificate with an airplane single-engine land rating. He also held a mechanic’s certificate with airframe and powerplant ratings. His third class airman medical certificate, dated May 1, 2009, contained no restrictions or limitations. On his application for medical certification, he estimated he had accrued 200 hours total flight time. AIRCRAFT INFORMATION N11001 (serial number 153), a Lancair Laser IV-P, was built by the ATP pilot. Construction began in December 1992 and was completed in December 1994. The first flight occurred on December 28, 1994, and the airplane received its Certificate of Airworthiness in the Experimental Category on January 23, 1995. The airplane was powered by a Continental TSIO-520-B2B engine (serial number 637582A958), rated at 550 horsepower, driving a Hartzell3-blade, all-metal, constant-speed propeller (model number HC-H3YF-1). According to the maintenance records, the last conditional inspection was performed on July 18, 2010, at an airframe time of 1,160 hours. The last documented engine inspection was on January 6, 2001, at an engine time of 330 hours. The propeller was overhauled on June 18, 2010. METEOROLOGICAL INFORMATION The following weather observations were made at 0953 and 1053, respectively, at the Aransas County Airport (KRKP), Rockport, Texas, located about 50 miles southwest of the accident site: 0953: Wind, 290 degrees at 5 knots; visibility, 8 statute miles; sky condition, few clouds at 1,100 feet, scattered clouds at 1,800 feet; temperature, 29 degrees C.; dew point, 25 degrees C.; altimeter, 30.01 inches of Mercury. 1053: Wind, 330 degrees at 6 knots; visibility, 10 statute miles; sky condition, 2,100 feet scattered, ceiling 2,700 feet broken; temperature, 30 degrees C.; dew point, 24 degrees C.; altimeter, 30.02 inches of Mercury. WRECKAGE AND IMPACT INFORMATION The Texas Department of Public Safety recovered the wreckage from Matagorda Bay on July 4. It was in 12-1/2 feet of water. The wings were taken to, and stored at, the United States Coast Guard Station in Port O’Connor. The remainder of the wreckage was taken to Sonny’s Portable Buildings in Port Lavaca, Texas. The wings were later taken to Port Lavaca where, on July 21, they were examined along with the rest of the wreckage. Both wings had separated from the fuselage. Pushrods and bellcranks for the flaps and ailerons were in place and secured. The flap handle was in the stowed position on the floor. The main and nose landing gears were retracted. The fuel selector was slightly past the left tank position. Both seatbelts were attached. The shoulder harnesses were not attached. MEDICAL AND PATHOLOGICAL INFORMATION The passenger was recovered with the airplane wreckage on July 4. The pilot was recovered 1 mile northeast of the accident site on July 8. Autopsies were performed on both occupants by the Galveston County Medical Examiner’s Office. The Federal Aviation Administration’s (FAA) Civil Aerospace Medical Institute (CAMI) performed a toxicology screen on the pilot-passenger. According to CAMI’s report, no carbon monoxide, cyanide, ethanol, or drugs were detected. TESTS AND RESEARCH The engine was disassembled and examined at Teledyne Continental Motors in Mobile, Alabama, on April 9-13, 2012. No anomalies were found that would have precluded the engine from developing power. ## Aircraft - Registration: [N11001](https://openairdocs.org/deregistered/N11001-2015-05-15), registration cancelled 2015-05-15, S/N 153, built 1994 (OpenAirDocs) - Reported make and model: Koen Lancair Laser IV-P - Registry model: [Koen Lyle D LASER/LANCAIR IVP](https://openairdocs.org/model/koen-lyle-d-laser-lancair-ivp) (registry code 05626UY) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 153 - Airframe hours: 1160 - Engines: Continental IO-550- reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Lyle D. Koen - Registered owner: Lyle D. Koen - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, July 18, 2010 - Departed: 72TA, Port O'Connor, TX - Destination: AUS, Austin, TX - Airport: 72TA, Pierce Field ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; airline transport, commercial, private, flight instructor; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; toxicology performed; flight hours: 3,000 total - Pilot; age 42; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, unknown; toxicology performed; flight hours: 200 total ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 5 knots - Visibility: 8 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 70 °F - Altimeter: 30.01 inHg - Observed at: RKP ## 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 20110703013699A](https://openairdocs.org/incident/20110703013699A), Jul 3, 2011: Koen Lyle D LASER/LANCAIR IVP, Matagorda Bay, TX, Destroyed, 2 fatal. An experimental amateur built Lancair IV-4 aircraft took off from Pierce Field (72TA) a privately owned airfield in port o'connor, Texas. Aircraft departed to… ## Docket (19 files) The files NTSB released with the investigation on August 14, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=80967. 11.5 MB in all. - Memorandum of Telephone Conversation with NTSB Air Safety Investigator Craig Hatch (item 1, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40373198&FileExtension=.PDF&FileName=Memorandum%20of%20Telephone%20Conversation%20with%20NTSB%20Air%20Safety%20Investigator%20Craig%20Hatch-Master.PDF - NVM 17 - Specialist's Factual Report (item 2, .PDF, 642 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364884&FileExtension=.PDF&FileName=NVM%2017%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Memorandum of Telephone Conversation with Mark Daniel (item 3, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357635&FileExtension=.PDF&FileName=Memorandum%20of%20Telephone%20Conversation%20with%20Mark%20Daniel-Master.PDF - Witness Statement (item 4, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40357636&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Pierce Field (72TA), Port O'Connor, Texas (item 5, .PDF, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363132&FileExtension=.PDF&FileName=Pierce%20Field%20(72TA),%20Port%20O%27Connor,%20Texas-Master.PDF - Pierce Field and its proximity to Port O'Connor (item 6, .PDF, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363133&FileExtension=.PDF&FileName=Pierce%20Field%20and%20its%20proximity%20to%20Port%20O%27Connor-Master.PDF - Weather Reports and Records (item 7, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363130&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Toxicology Report, David Eddington (item 8, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40373329&FileExtension=.PDF&FileName=Toxicology%20Report,%20David%20Eddington-Redacted.PDF - Certification of Party Representative (item 9, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40373330&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representative-Redacted.PDF - NTSB Form 6120.15, Release of Aircraft Wreckage (item 10, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374234&FileExtension=.PDF&FileName=NTSB%20Form%206120.15,%20Release%20of%20Aircraft%20Wreckage-Redacted.PDF - Photo 1 - Texas Department of Public Safety personnel locate the submerged wreckage. (item 11, .PDF, 801 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358105&FileExtension=.PDF&FileName=Photo%201%20-%20Texas%20Department%20of%20Public%20Safety%20personnel%20locate%20the%20submerged%20wreckage.-Master.PDF - Photo 2 - Recovering the cabin area. (item 12, .PDF, 554 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358106&FileExtension=.PDF&FileName=Photo%202%20-%20Recovering%20the%20cabin%20area.-Master.PDF - Photo 3 - Recovery of the engine and propeller. (item 13, .PDF, 441 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358107&FileExtension=.PDF&FileName=Photo%203%20-%20Recovery%20of%20the%20engine%20and%20propeller.-Master.PDF - Photo 4 - Main landing gear. (item 14, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358108&FileExtension=.PDF&FileName=Photo%204%20-%20Main%20landing%20gear.-Master.PDF - Photo 5 - Nose landing gear. (item 15, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358109&FileExtension=.PDF&FileName=Photo%205%20-%20Nose%20landing%20gear.-Master.PDF - Photo 6 - Fuel selector. (item 16, .PDF, 893 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358110&FileExtension=.PDF&FileName=Photo%206%20-%20Fuel%20selector.-Master.PDF - Photo 7 - Seat belts and shoulder harnesses. (item 17, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358111&FileExtension=.PDF&FileName=Photo%207%20-%20Seat%20belts%20and%20shoulder%20harnesses.-Master.PDF - Photo 8 - The engine. (item 18, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358112&FileExtension=.PDF&FileName=Photo%208%20-%20The%20engine.-Master.PDF - Photo 9 - The propeller. (item 19, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40358113&FileExtension=.PDF&FileName=Photo%209%20-%20The%20propeller.-Master.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.