# NTSB CEN13LA244: Dean Leslie N Highlander, N58LD, Bryan, OH, April 27, 2013 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: April 27, 2013, 08:30 local (12:30 UTC) - Place: Bryan, OH - Coordinates: 41.508335, -84.563613 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.5083&lon=-84.5636&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report February 10, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 86753 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN13LA244 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/86753/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=86753 - Page: https://openairdocs.org/ntsb/CEN13LA244 ## Probable cause The pilot's failure to maintain sufficient airspeed during a go-around, which resulted in an aerodynamic stall and subsequent impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Dean Leslie N HIGHLANDER, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05629FY), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Dean Leslie N HIGHLANDER, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05629FY), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Communication (personnel): lack of communication](https://openairdocs.org/ntsb-findings/02063510): Personnel issues › Task performance · Pilot; cases with it: [Dean Leslie N HIGHLANDER, 1 case](https://openairdocs.org/ntsb-findings/02063510/cases.md?model=05629FY), [All aircraft, 84 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR go-around: Air traffic event](https://openairdocs.org/ntsb-events/100); cases with it: [Dean Leslie N HIGHLANDER, 1 case](https://openairdocs.org/ntsb-events/100/sequence.md?model=05629FY), [All aircraft, 115 cases](https://openairdocs.org/ntsb-events/100/sequence.md) - [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Dean Leslie N HIGHLANDER, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05629FY), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Approach-VFR go-around: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Dean Leslie N HIGHLANDER, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05629FY), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis A passenger onboard the accident airplane reported that it was approaching the runway to the east when the pilot noticed another airplane landing in the opposite direction on the same runway. The passenger stated that the pilot was using the radio and called in. The pilot made a hard left turn and advanced the throttle to full forward to avoid the other airplane. He added right aileron, but the airplane did not respond and continued turning left until it impacted terrain. It is likely that because of the slow airspeed, the aileron control input was not effective and the airplane entered an aerodynamic stall. A postaccident examination of the airframe and engine did not reveal any mechanical malfunctions or failures that would have precluded normal operation. According to the pilot of the other airplane, during the landing flare, he noticed the accident airplane landing in the opposite direction, so he aborted the landing and climbed straight ahead. The pilot of the other airplane stated that he was monitoring frequency 122.8 MHz. Postaccident examination of the accident airplane revealed that the radio was set to 122.5 MHz as the active position and 122.8 MHz in the standby position; therefore, the pilot of the other airplane would not have heard his radio communications. At the time of the accident, the Bryan Aero Park did not have a common traffic advisory frequency (CTAF) for pilots to communicate on while operating at the air park. As a result of the investigation, Bryan Aero Park management has adopted 122.8 as the CTAF for pilots to communicate on while operating at the field. Although evidence indicates that the pilot had severe coronary artery disease, high cholesterol, and hypertension, no evidence was found indicating that the pilot's cardiac issues contributed to the accident. Also, the investigation was unable to determine whether or not the pilot's diabetes or his use of sertraline contributed to the accident. ## Factual narrative Electronic Devices The MGL Avionics Stratomaster Enigma, which is an electronic flight information system, was examined by the NTSB Vehicle Recorders Laboratory, Washington, DC. When power was applied to the device, two information pages were available: a flight log viewer and a radio file frequency selection. The flight log displayed information for the last logged flight. The MGL Avionics Com Radio from the Highlander was examined by the NTSB lab and when power was applied to the device the following frequencies were displayed: 122.85 in the active position and 122.8 in the standby position. The airplane was a Dean Highlander experimental amateur-built, 2 seat, high-wing, tail wheel airplane, serial number JA189-09-09, and manufactured in 2010. It was powered by a 120 horsepower Jabiru 3300 reciprocating engine and driven by a Sensenich R64ZN propeller. A review of the maintenance records revealed on April 2, 2012 the pilot performed a conditional inspection in accordance with 14 Code of Federal Regulation Part 43 Appendix D. On April 15, 2013, he performed an oil change and had an oil sample tested by Lab One Aviation, which returned with "normal" results. On June 29, 2011, the pilot installed the Sensenich propeller. The Bryan Aero Park is a privately owned and operated air park which is located about 2 miles north of Bryan, Ohio. The air park features one turf runway which is situation on an east-west heading between two crop fields. The air park has a wind sock and no lighting. Prior to the accident, there was not a specific common traffic advisory frequency (CTAF) for pilots to communicate on while operating at the air park. Since then, the air park has adopted 122.8 as its CTAF. On April 27, 2013, about 0830 eastern daylight time, a Dean Highlander experimental amateur-built airplane, N58LD, impacted terrain after executing a go-around at Bryan Aero Park, Bryan, Ohio. The commercial pilot was fatally injured and the passenger sustained serious injuries. The airplane sustained substantial damage to the wings and fuselage. The airplane was registered to an operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions prevailed for the flight which operated without a flight plan. The flight originated from Ann Arbor Municipal Airport (KARB), Ann Arbor, Michigan about 0715. The passenger onboard the Highlander airplane reported that they were approaching the runway to the east when the pilot noticed another airplane, a Taylorcraft, on the runway. The pilot then commented to the passenger about it landing in the opposite direction. At the time, the airplane was at a low altitude so the pilot turned the airplane to the left and advanced the throttle. The passenger observed the Taylorcraft take off and make a right turn which conflicted with the flight path of the Highlander. The pilot of the Highlander executed a hard left turn with about 45 degrees ofbank and advanced the throttle to full forward. The Highlander started to get slow so the pilot applied full right aileron and nothing happened. The airplane was very slow at this point and continued to turn left until it impacted terrain. In a statement provided by the pilot of the Taylorcraft, he reported that he was monitoring the radio frequency 122.8, the wind was light, and He elected to land to the west. During the landing flare, he noticed the Highlander landing in the opposite direction. He aborted his landing, executed a go-around, and continued to fly on the runway heading. He was climbing out near the west end of the runway when he noticed the Highlander come up from underneath him, passed by his right window in a left hand turn, and continued into the ground. An autopsy was performed on the pilot by the Lucas County Coroner's Office, Toledo, Ohio, on April 29, 2013. The pilot's cause of death was listed as multiple blunt trauma and the manner of death was an accident. The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Fatal Accident Report. Toxicology testing was negative for alcohol but identified fexofenadine (Allegra) and its primary metabolite, azacyclonol, in liver as well as atorvastatin (another cholesterol lowering agent). The medications administered during post-accident medical care were also identified. Salicylate (aspirin) was identified in urine. Sertraline (Zoloft) and its primary metabolite, desmethylsertraline, were found in muscle and liver. Sertraline was also identified in blood at 0.122 ug/mL. During the investigation, a medication card for the pilot was found at the accident site and listed the following medications for the pilot: lisinopril (used to treat hypertension), metformin (marketed under the trade name Glucophage, used to treat diabetes), Byetta (exenatide, an injectable medication used to treat diabetes), sertraline, a serotonin specific re-uptake inhibitor used to treat depression, Zocor (simvastatin, a cholesterol lowering agent) and Allegra (fexofenadine, a non-sedating antihistamine). The closest weather reporting station was located at Defiance Memorial Airport, Defiance, Ohio which was 12 miles southeast of the accident site. At 0753 the wind was clam, visibility 10 miles, clear skies, temperature 5 degrees Celsius (C), dew point 2 degrees C, and atmospheric pressure 30.34 inches of mercury. At 0853 the wind was from 090 at 3 knots, visibility 10 miles, clear skies, temperature 10 degrees C, dew point 3 degrees C, and atmospheric pressure 30.33 inches of mercury. The pilot of the Taylorcraft reported that the wind was calm during the time of the accident. The pilot, age 62, held a commercial pilot certificate with ratings for airplane single engine land and instrument airplane issued on July 28, 1976. He was issued a second class medical certificate on February 24, 1989 with no restrictions. A review of the pilot's most recent logbook revealed that he received hiscommercial pilot certificate on July 28, 1976 and received his instrument airplane rating on December 24, 1975. He completed his most recent flight review on October 5, 2011. The pilot had accumulated a 2,248 hours of total flight time; 896 of which were in the accident airplane type. He accumulated about 44 hours in the accident airplane in the previous 30 days. The airplane came to rest upright on a north westerly heading. The wings were partially separated at the fuselage attachment points. The underside of the fuselage was crushed upward. The main landing gear separated from the fuselage and the propeller blades separated at the propeller hub. The Federal Aviation Administration (FAA) inspectors conducted an examination of the. Flight control continuity was confirmed to all control surfaces. The airframe and engine revealed no evidence of malfunctions or failures that would have precluded operation. ## Aircraft - Registration: [N58LD](https://openairdocs.org/deregistered/N58LD-2017-10-31), registration cancelled 2017-10-31, S/N JA189-09-09, built 2010 (OpenAirDocs) - Reported make and model: DEAN LESLIE N HIGHLANDER - Registry model: [Dean Leslie N HIGHLANDER](https://openairdocs.org/model/dean-leslie-n-highlander) (registry code 05629FY) (OpenAirDocs) - Registry engine: [Jabiru 3300](https://openairdocs.org/engine/jabiru-3300) (registry code 34802, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: JA189-09-09 - Year built: 2010 - Airframe hours: 532 - Engines: JABIRU 3300 120 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Leslie Dean - Registered owner: Leslie Dean - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, April 2, 2012 - Departed: ARB, ANN ARBOR, MI - Destination: ---, Bryan, OH - Airport: ---, Bryan Aero Park - Equipment: Data recorder ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 2,248 total, 896 in this make and model, 44 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 50 °F, dew point 37 °F - Altimeter: 30.32 inHg - Observed at: KDFI, 12 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 20130427011229A](https://openairdocs.org/incident/20130427011229A), Apr 27, 2013: Dean Leslie N HIGHLANDER, Bryan, OH, Destroyed, 1 fatal. N58LD was attempting to land eastbound, into the morning sun, on Bryan Aero Park?s grass strip. Another aircraft was landing westbound but was not seen by… ## Docket (11 files) The files NTSB released with the investigation on December 4, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=86753. 21.8 MB in all. - Toxicological Report (item 1, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397146&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Weather Reports (item 2, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397147&FileExtension=.PDF&FileName=Weather%20Reports-Master.PDF - Witness Statements (FAA) (item 3, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40401572&FileExtension=.PDF&FileName=Witness%20Statements%20(FAA)-Redacted.PDF - Evidence Control Form (item 4, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397148&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Redacted.PDF - Record of Conversation - Airport Manager (item 5, .PDF, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397149&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Airport%20Manager-Redacted.PDF - Medical Factual (item 6, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400457&FileExtension=.PDF&FileName=Medical%20Factual-Master.PDF - Photograph 1: Airplane in field (item 7, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397151&FileExtension=.PDF&FileName=Photograph%201%3A%20Airplane%20in%20field-Master.PDF - Photograph 2: MGL Avionics Stratomaster Enigma (item 8, .PDF, 7.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397154&FileExtension=.PDF&FileName=Photograph%202%3A%20MGL%20Avionics%20Stratomaster%20Enigma-Master.PDF - Photograph 3: MGL Avionics Stratomaster Enigma (item 9, .PDF, 7.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397155&FileExtension=.PDF&FileName=Photograph%203%3A%20MGL%20Avionics%20Stratomaster%20Enigma-Master.PDF - Photograph 4: Com Radio (item 10, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397156&FileExtension=.PDF&FileName=Photograph%204%3A%20Com%20Radio-Master.PDF - Photograph 5: Google Earth Overlay - Flight Path (item 11, .PDF, 507 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40397158&FileExtension=.PDF&FileName=Photograph%205%3A%20Google%20Earth%20Overlay%20-%20Flight%20Path-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.