CEN15FA187

NTSB accident investigation · Aircraft Mfg & Dvlpmt CH601XL · Pleasanton, KS · March 31, 2015

Accident · FatalField investigationFinal report
Date
March 31, 2015, 15:40 local (20:40 UTC)
Place
Pleasanton, KS
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N623HSAircraft Mfg & Dvlpmt CH601XL
Defining event
Initial climb: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Day
Status
Completed · report May 23, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
Continental Motors, FAA Flight Standards District Office
FAA report
20150331004649A
Case key
90972

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's excessively high angle-of-attack on rotation that prevented the airplane from climbing sufficiently to avoid the approaching trees.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Incorrect use/operationAircraft Mfg & Dvlpmt CH601XL SLSA: 1 caseAll aircraft: 990 casesProbable cause
Performance/control parameters: climb rateAircraft › Aircraft oper/perf/capability · Incorrect use/operationAircraft Mfg & Dvlpmt CH601XL SLSA: 1 caseAll aircraft: 265 casesProbable cause
Wind: crosswindEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentAircraft Mfg & Dvlpmt CH601XL SLSA: 1 caseAll aircraft: 1,008 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The sport pilot was conducting a personal flight with a pilot-rated passenger onboard. Witnesses stated that they saw the airplane lift off the runway in a nose-high attitude; they were unsure if the tail contacted the runway. They said the airplane appeared to be "behind the power curve" and "flying in ground effect." The airplane drifted left of the extended runway centerline and collided with the tops of trees at the end of the runway, fell to the ground inverted, and caught fire. Examination of the engine and propeller indicated the engine was operating at high power at the time of impact. The pilot's autopsy report showed severe coronary artery disease that posed a very significant hazard. However, the cause of death was attributed to thermal injuries. The circumstances of the accident were consistent with the pilot over-rotating the airplane on takeoff, resulting in an excessively high angle-of-attack with insufficient power available to climb and clear the trees on departure. It is unlikely the pilot could have seen or avoided the trees as the airplane approached the end of the runway.

Factual narrative

HISTORY OF FLIGHT On March 31, 2015, about 1540 central daylight time, a CH601XL N623HS, a light single-engine, 2-place low wing monoplane, manufactured by the Aircraft Manufacturing and Development Company, Mexico, Missouri, collided with trees on takeoff and crashed at a private airstrip in Pleasanton, Kansas. The pilot and pilot-rated passenger were fatally injured. The airplane was destroyed by impact forces and a post-impact fire. The airplane was registered to Light Sport Ventures LLC, Wilmington, Delaware, and operated by the pilot of Stilwell, Kansas, under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan had been filed. The flight was originating at the time of the accident and was destined for the Johnson County Executive Airport (KOJC), Olathe, Kansas, where it was based. There were two witnesses to the accident: the airport owner-manager (a retired airline pilot and flight instructor), and an airplane mechanic. Both witnesses stated they observed the airplane lift off runway 34 in a nose-high attitude. They were unsure if the tail section contacted the runway. They said the airplane appeared to be "behind the power curve" and "flying in ground effect." They said there was a slight right crosswind from about 020 degrees and less than 5 to 7 knots. The airplane drifted left of the extended runway centerline and collided with the tops of trees at the end of the runway. The airplane fell to the ground inverted and caught fire. The witnesses said because of the high angle of attack, they did not believe the pilot saw the approaching trees. PERSONNEL (CREW) INFORMATION The owner-pilot, age 67, was seated in the left seat. He held a sport pilot certificate. He also held a private pilot certificate with a glider rating. In lieu of a Federal Aviation Administration (FAA) airman medical certificate, the pilot was operating under his Kansas driver's license. A portion of the pilot's logbook was recovered from the wreckage. After cleaning and drying the pages, it could not be determined when the recorded flights took place. However, according to his application for airplane insurance with USAIG (United States Aircraft Insurance Group), dated October 21, 2014, the pilot estimated his total flight time to be 529 hours, of which 327 hours were logged in the CH601XL, and 25 hours were logged in the previous 12 months. The pilot-rated passenger, age 57, was seated in the right seat. He held a commercial pilot certificate with airplane single-engine, multiengine, and instrument ratings. His last FAA second class airman medical certificate, dated April 6, 2005, contained the restriction: "Must have available glasses for near vision." When the pilot was issued this medical certificate, he estimated his total flight to be 1,800 hours. AIRCRAFT INFORMATION N623HS (serial number 601-026S), a model CH 601XL Zodiac, was manufacturedin 2006 by the Aircraft Manufacturing and Development (now called the Zenith Aircraft Company) in Mexico, Missouri. According to the company's website, the CH 601 was a light, all-metal, 2-place low-wing monoplane, introduced in 1984. Although manufactured as a complete aircraft, most of the airplanes have been built from kits by amateur enthusiasts. The CH 601XL was introduced in 2001 and was classified as a light sport aircraft (LSA). It had a larger wing area and airfoil, flaps, and larger wing tanks and baggage area. It also featured an all flying rudder, hingeless ailerons, bubble canopy, and a 44-inch wide cabin. Its assembly incorporated blind rivets. N623HS was powered by a Continental O-200-A engine (serial number 256198), rated at 100 horsepower, driving a wood, 2-blade, fixed-pitch propeller. A portion of the maintenance logbook was recovered at the wreckage. After cleaning and drying, it was determined that the last annual inspection was performed on April 9, 2014, at an airframe time of 306 hours. METEOROLOGICAL INFORMATION The following weather observation was recorded at the Johnson County Executive Airport (KOJC), Olathe, Kansas, located 41 miles north of the accident site: KOJC 312029Z (1529 CDT): Wind, 110° at 7 knots; visibility, 10 miles; sky condition, clear; temperature, 24° Celsius (C.); dew point, 1° C.; altimeter setting, 29.94 inches of mercury. AERODROME INFORMATION The accident site, a private airstrip was owned by Clarence Easley, was located about 2 miles northwest of the town of Pleasanton. According to Capt. Easley, the airstrip is situated at an elevation of about 1,020 feet msl (mean sea level). It is equipped with one grass runway, 16-34, aligned on magnetic headings of 165 and 345 degrees, respectively. The runway is approximately 2,450 feet long and 80 to 120 feet wide. The runway was in good repair and was dry at the time of the accident. The airstrip does not appear on the Kansas City Sectional Chart. WRECKAGE AND IMPACT INFORMATION Evidence collected at the accident site was consistent with the airplane striking the tops of 50-foot trees about 150 feet off the end of the runway 34, and impacting terrain in an inverted attitude on a magnetic heading of 085 degrees. Measured from the accident site to the runway, the terrain sloped upwards about 15 degrees. All of the airplane structure was accounted for. Control cable were still attached to the control surfaces and terminated in the cockpit area. The inverted Continental O-200-A engine lay next to a tree with the rest of the aircraft structure. The engine remained partially attached to the airframe. The exhaust and induction systems, starter, alternator, and both left and right magnetos were impact and thermally damaged. Both magneto drive gears would not turn by hand. The ignition harness was thermally destroyed. Only the upper portion of the carburetor remained attached to the engine. The hub of the wooden propeller remained attached to the propellerflange. Both blades were shattered, consistent with high rotation at impact. The top spark plugs were removed and the cylinder combustion chambers were inspected with a lighted borescope. No anomalies were observed. The valve covers were removed and the cylinder domes examined. They exhibited thermal damage. The overhead area of cylinder 4 exhibited oil residue. The automotive-type spark plugs exhibited worn electrodes and dark colored combustion deposits. MEDICAL AND PATHOLOGICAL INFORMATION Autopsies were performed on both the pilot and pilot-rated passenger. The pilot's death was attributed to thermal injuries. Large amounts of soot were found in the upper and lower airways. The report noted evidence of a healed myocardial infarct and "marked atherosclerosis involving all three coronary arteries and the aorta." There were "multifocal healed infarcts and stigmata of a remote coronary artery bypass graft procedure." The pilot-rated passenger's death was also attributed to thermal injuries. Large amounts of soot were found in the upper and lower airways. A toxicology screen was performed on the pilot by FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma. The screen revealed the presence of the following drugs, where they were detected, and their usage (as found on FAA's Forensic Toxicology Drug Information website): • Coreg®, or Carvedilol, detected in urine and heart blood. It is used in the treatment of high blood pressure (hypertension); • Minoxidil, detected in the urine only. It is an antihypertension and hair growth compound; • Naproxen, detected in the urine. It is a nonnarcotic analgesic and anti-inflammatory agent; • Ramipril, marketed as Tritace®, Ramace®, or Altace®, detected in the urine but not in heart blood. It is an angiotensin-converting enzyme (ACE) inhibitor, used for treating hypertension and congestive heart failure; • Rosuvastatin, detected in heart blood and urine. It is a member of the drug class of statins and is used in the treatment of high cholesterol and the prevention of cardiovascular disease; • Tamsulosin Flomax®, or Tamsulosin, detected in heart blood and urine. It is an A1A-selective alpha blocker and used in the symptomatic treatment of benign prostatic hyperplasia. Carbon monoxide was not detected in heart blood, and ethanol was not detected in vitreous humor. Heart blood was unsuitable for hemoglobin A1C testing, but 119 (mg/dl) glucose was detected in vitreous fluid and 229 (mg/dl) glucose was detected in urine. Tests for cyanide were not performed. A toxicology screen was likewise performed on the pilot-rated passenger and revealed the presence of the following drugs: • Azacyclonol, detected in blood and urine. It is a major metabolite of Terfenadine, or Seldane®, and a minor metabolite of Fexofenadine, or Allegra®, previously used as a tranquilizer; • Oxymetazoline, detected in the urine only. It is a decongestant used in the treatment of nasal congestion; • Fexofenadine, detected inurine, liver, and heart blood. It is a non-sedating antihistamine, Allegra®, and is used in the treatment of hay fever and the common cold. Tests for cyanide were not performed and no ethanol was detected in vitreous humor. Tests revealed 32 per cent carbon monoxide saturation in blood.

Aircraft

Registration
N623HS
Reported as
Aircraft Mfg & Dvlpmt CH601XL
Category
Airplane
Serial number
601-026S
Built
2006
Airframe hours
306
Engine
Continental O-200-A, 100 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
Annual · April 9, 2014
Departed
Pleasanton, KS
Airport
NONE · Easley Airstrip, runway 34, 2,450 × 120 ft, grass/turf

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
67
Injuries
Fatal
Certificates
Sport Pilot, Private
Medical
Sport pilot
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
529 total · 327 in this make and model · 25 in the last 90 days
Role
Pilot-rated passenger
Age
56
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Right
Restraint
3-point
Toxicology
Performed
Flight hours
1,800 total · 1 in this make and model · 5 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 34 °F
Altimeter
29.94 inHg
Observed at
KOJC

Docket · 10

The files NTSB released with the investigation on March 9, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 20.8 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.