# NTSB CEN13FA066: Brian P North RAF SE5A Replica, N17SE, Watkins, CO, November 21, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 21, 2012, 13:58 local (20:58 UTC) - Place: Watkins, CO - Coordinates: 39.784168, -104.538055 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.7842&lon=-104.5381&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern downwind: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 23, 2013 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, Continental Motors, Incorporated - NTSB case key (mKey): 85645 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN13FA066 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85645/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85645 - Page: https://openairdocs.org/ntsb/CEN13FA066 ## Probable cause The pilot’s loss of airplane control and inadvertent stall while attempting to return for landing. ## 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: [Brian P North RAF SE5A REPLICA, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=05631GP), [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: [Brian P North RAF SE5A REPLICA, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05631GP), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Temp/humidity/pressure](https://openairdocs.org/ntsb-findings/03031000): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Brian P North RAF SE5A REPLICA, 1 case](https://openairdocs.org/ntsb-findings/03031000/cases.md?model=05631GP), [All aircraft, 7 cases](https://openairdocs.org/ntsb-findings/03031000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern downwind: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Brian P North RAF SE5A REPLICA, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05631GP), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot had requested to return to the airport for a full stop landing. According to a witness, the airplane appeared to be in a slow, labored climb in an abnormally high pitch attitude about 300 feet above the ground on the downwind leg in the traffic pattern. The airplane then entered a spiral descent while approaching the turn to base and impacted the ground about 0.7 miles north of the runway threshold; a postimpact fire ensued. Examination of the airplane and engine did not reveal any anomalies that would have precluded normal operation. The slow flight and high pitch followed by a spiral descent are indicative of an aerodynamic stall. ## Factual narrative HISTORY OF FLIGHT On November 21, 2012, about 1358 mountain standard time, a Brian P. North RAF SE5A replica experimental airplane, N17SE, owned by the pilot, was substantially damaged after impacting terrain near Watkins, Colorado. The certificated private pilot, the sole occupant, was fatally injured. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91, with no flight plan filed. Visual meteorological conditions prevailed. The flight departed Front Range Airport (FTG), Denver, Colorado, about 1355. While departing from Runway 26 at FTG, witnesses noticed the airplane climbing at a slow rate. On the downwind leg of the traffic pattern, witnesses noticed the airplane attempting to climb with a high pitch attitude. The pilot requested to return for a full stop landing from the air traffic control tower, due to “climb performance”. Witnesses observed the airplane enter a spiral descent while approaching the turn to base point of the pattern. The airplane impacted in a fallowed wheat field about 0.7 miles north of the Runway 26 threshold, and a post impact fire ensued. PERSONNEL INFORMATION The pilot, age 72, held a private pilot (foreign based) certificate with an airplane single-engine land rating. On May 3, 1999, the pilot was issued a Class 3 limited medical (foreign based) certificate, which required corrective lenses be worn. A review of records indicates the pilot had flown a total of 491 hours and 7 hours in the accident airplane. A friend of the pilot, who assisted with preflight actions on the day of the accident, stated that the pilot was in good health, both physically and mentally. AIRCRAFT INFORMATION The accident airplane was initially assembled by the pilot in the United Kingdom in 2008. After shipping the airplane to the United States and reassembling at FTG, an airworthiness certificate was issued by the Federal Aviation Administration (FAA) on May 17, 2012. Prior to the accident, the airplane flew four times at FTG, twice by the pilot and twice by his friend. The airplane had accumulated a total of 12 hours prior to the accident. The airplane was equipped with a 100-horsepower Continental Motors O-200A engine. The engine had accumulated 1,523 hours prior to being installed on the airplane and 12 hours after installation. METEOROLOGICAL INFORMATION The weather observing station at FTG reported the following conditions at 1350: wind 140 degrees at 5 knots, visibility 50 miles, clear skies, temperature 22 degrees Celsius, dew point minus 10 degrees Celsius, altimeter setting 29.95. Calculated density altitude for these conditions was 7,567 feet. During the four previous flights at FTG, calculated density altitude ranged from about 6,400 to 6,900 feet. The friend of the pilot, who piloted two of these four flights, stated that climb performance during these previous flights was satisfactory, with a climb rate between 400 and 450 feet per minute. WRECKAGE AND IMPACT INFORMATION The airplaneimpacted in a fallowed wheat field in a near vertical nose down spiral based on witness observations. On impact, the airplane continued to twist, coming to rest upright about 15 feet from the initial impact point, where the airplane caught fire and was destroyed. Located in the nose impact ground scar were fragmented propeller pieces. Propeller warping and tracking were not able to be examined due to impact damage. Flight control continuity was confirmed to all flight control surfaces. The engine was examined at a recovery location. The crankshaft was rotated by hand and mechanical continuity was established between the crankshaft and the camshaft; all of the rocker arms were observed to operate. A borescope inspection was performed on all the cylinders, with no signs of distress or abnormalities with any of the cylinder walls, pistons, or valves. All of the spark plugs were removed from the engine and displayed normal characteristics when compared to Champion Aviation Service Manual AV6-R. The #2 and #4 sparkplugs were oil soaked which was consistent with the orientation of the engine while at rest. It was noted that the #3 cylinder sparkplug electrodes appeared grayer in color when compared to the rest of the sparkplugs. The carburetor was disassembled and visually inspected; although thermally damaged, no abnormalities were noted. The oil filter was removed and cut open; the internal components sustained thermal damage, but exhibited no signs of metal deposits in the filter pleats. Due to the severity of thermal damage to the magnetos, the magneto internal and magneto engine timing was unable to be determined. Examination of the airframe, engine and propeller did not reveal any anomalies associated with a pre impact failure or malfunction. MEDICAL AND PATHOLOGICAL INFORMATION On November 28, 2012, an autopsy was performed on the pilot by the Adams & Broomfield Counties Coroner. The autopsy noted severe whole body burns and also identified that 3 vessels of the heart had 50% to 60% narrowing, but the heart muscle was unremarkable. The cause of death was attributed to whole body burns. The FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. Zopiclone, which is a prescription medication used in the treatment of insomnia, was detected in the urine and also at trace levels in the blood. No other drugs or ethanol were detected. ## Aircraft - Registration: [N17SE](https://openairdocs.org/deregistered/N17SE-2018-01-03), registration cancelled 2018-01-03, S/N PFA 020-13793, built 2008 (OpenAirDocs) - Reported make and model: Brian P North RAF SE5A Replica - Registry model: [Brian P North RAF SE5A REPLICA](https://openairdocs.org/model/brian-p-north-raf-se5a-replica) (registry code 05631GP) (OpenAirDocs) - Registry engine: [Continental O-200A](https://openairdocs.org/engine/continental-o-200a) (registry code 17404, 4 cycle) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: PFA 020-13793 - Airframe hours: 12 - Engines: Continental Motors O-200A 100 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Brian P. North - Registered owner: Brian P. North - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, November 1, 2011, 4 hours before - Departed: KFTG, Watkins, CO - Destination: KFTG, Watkins, CO - Airport: KFTG, Front Range Airport, Colorado, runway 26, 8,000 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: fatal; foreign, private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review August 19, 2011; seat: single; toxicology performed; flight hours: 491 total, 7 in this make and model, 1 in the last 90 days, 1 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 140° at 5 knots - Visibility: 50 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 14 °F - Altimeter: 29.95 inHg - Observed at: KFTG, 1 nm away ## 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 20121121027409A](https://openairdocs.org/incident/20121121027409A), Nov 21, 2012: Brian P North RAF SE5A REPLICA, Watkins, CO, Destroyed, 1 fatal. On October 21, 2012, at 14:58 MDT, aircraft: N17SE, model: SE5A replica (experimental aircraft), impacted the ground shortly after take-off, at the Front Range… ## Docket (6 files) The files NTSB released with the investigation on May 8, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85645. 325 KB in all. - Toxicological Report (item 1, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391521&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 2, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391522&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Witness Statement - Burt Eaton (item 3, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391523&FileExtension=.PDF&FileName=Witness%20Statement%20-%20Burt%20Eaton-Master.PDF - Witness Statement - M Buehner-Coldrey (item 4, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391525&FileExtension=.PDF&FileName=Witness%20Statement%20-%20M%20Buehner-Coldrey-Master.PDF - Witness statement - Forrest Mars (item 5, .PDF, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392142&FileExtension=.PDF&FileName=Witness%20statement%20-%20Forrest%20Mars-Master.PDF - Review of Radio Communications (item 6, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391527&FileExtension=.PDF&FileName=Review%20of%20Radio%20Communications-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.