# NTSB CEN19FA144: Vans RV6, N596JB, Chillicothe, OH, May 18, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 2 · Field · Final report - Date: May 18, 2019, 12:45 local (16:45 UTC) - Place: Chillicothe, OH - Coordinates: 39.284168, -82.874443 - Nearby events: https://openairdocs.org/map.md?lat=39.2842&lon=-82.8744&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 2 - NTSB office: Central Region - Parties: Federal Aviation Administration, Van's Aircraft, Continental Motors - NTSB case key (mKey): 99446 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA144 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99446/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99446 - Page: https://openairdocs.org/ntsb/CEN19FA144 ## Probable cause The pilot's failure to maintain control of the airplane following an intermittent loss of engine power during cruise flight that resulted in him impacting trees. The reason for the loss of engine power could not be determined based on the available information. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Bass Jerry VANS RV6A, 1 case](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=05605Z4), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Bass Jerry VANS RV6A, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05605Z4), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome (probable cause); cases with it: [Bass Jerry VANS RV6A, 1 case](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=05605Z4), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Malfunction (probable cause); cases with it: [Bass Jerry VANS RV6A, 1 case](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=05605Z4), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Bass Jerry VANS RV6A, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=05605Z4), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: Unknown or undetermined](https://openairdocs.org/ntsb-events/000); cases with it: [Bass Jerry VANS RV6A, 1 case](https://openairdocs.org/ntsb-events/000/sequence.md?model=05605Z4), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) - [Enroute: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Bass Jerry VANS RV6A, 1 case](https://openairdocs.org/ntsb-events/342/sequence.md?model=05605Z4), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Enroute: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Bass Jerry VANS RV6A, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05605Z4), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot departed an experimental, amateur-built airplane on a cross-country flight in day visual meteorological conditions. A witness near the accident site said the airplane "engine slowed or stalled," then the engine "refired" and subsequently "stalled" Again. He then observed the airplane in a left bank turn and the engine sounded "wide open" until the airplane impacted trees and terrain. Examination of the wreckage did not reveal any preimpact mechanical anomalies that would have precluded normal operation. The airplane's full authority digital engine control (FADEC) system components were operational. Although toxicology testing detected ethanol, its presence could be attributed to postmortem production. During a flight review a few weeks before the accident, the pilot told a flight instructor that he previously had trouble with the airplane's ignition system. The flight instructor reported that there were no ignition issues during the flight review. Based on the available information, it is likely that the airplane had intermittent engine issues, which could not be replicated during postaccident examination and testing. When the engine lost power, the pilot did not maintain airplane control and impacted trees and terrain. ## Factual narrative According to the flight instructor who conducted the pilot's flight review, the pilot indicated that he previously had trouble with the accident airplane's engine ignition system but that it was working properly at that time. The flight instructor did not notice any problems with the engine ignition during the flight review. The airplane was equipped with a full authority digital engine control (FADEC) system, which controlled the ignition spark and fuel mixture in the engine. On May 18, 2019, about 1245 eastern daylight time, a Vans RV6A experimental, amateur-built airplane, N596JB, was destroyed when it was involved in an accident near Chillicothe, Ohio. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airplane departed Pickaway County Memorial Airport (CYO), Circleville, Ohio, about 1235 and was destined for Pike County Airport (EOP), Waverly, Ohio. According to a witness near the accident site, the airplane "engine slowed or stalled," then the engine "refired" and subsequently "stalled" Again. He observed the airplane in a left bank turn and stated that the engine sounded "wide open" until the crash. The Montgomery County Coroner's Office, Dayton, Ohio, performed an autopsy on the pilot. The autopsy listed the pilot's cause of death as multiple trauma . Toxicology testing performed at the FAA Forensic Sciences Laboratory indicated that the samples sustained putrefaction and ethanol was detected in muscle, liver, and lung tissue. No tested-for substances were detected in the liver. The pilot's last third-class FAA medical certificate was issued to him on February 6, 2017, with no limitations and expired on February 28, 2019. According to information from the FAA, the pilot completed the BasicMed comprehensive medical examination checklist on December 13, 2017, completed the BasicMed course on February 27, 2018, and satisfied the requirements for BasicMed. A review of the pilot's logbook showed that he completed a flight review on April 24, 2019. One accident FADEC master power control (MPC) was destroyed and one sustained minor damage; it and the speed sensor were shipped to the engine manufacturer, and found the MPC was operationally capable of producing spark at each spark plug tower. The manufacturer connected the speed sensor to a testing system and it operated correctly when a metal target was moved near its sensors. The airplane wreckage came to rest in a wooded area about 145° and 12 nautical miles from Ross County Airport (RZT). During the on-scene investigation, investigators found fragments of the airplane in both a tree trunk that had been separated about 30 ft above ground level and in the branches of the upper portion of the separated tree. The rear section of the fuselage and empennage came to rest about 57 ft and 70° from the separated tree, and the engine came to rest about 33 ft and 70° from the separated tree. The engine cowling, canopy, wings,and forward portion of the fuselage were highly fragmented and found in the branches of trees and on the ground between the separated tree and the empennage. Tree leaves near the empennage exhibited an appearance consistent with blight. The rudder cables were traced from the rudder to the rear section of the fuselage. Elevator flight control continuity was traced from its servo at the rear portion of the fuselage aft to its control surface. All separations in flight control tubing were consistent with overload. The engine control cable was fragmented and was not able to be traced. The engine speed sensor also exhibited minor damage. The engine was disassembled and no preimpact anomalies were observed. ## Aircraft - Registration: [N596JB](https://openairdocs.org/deregistered/N596JB-2020-05-01), registration cancelled 2020-05-01, S/N 24723, built 2000 (OpenAirDocs) - Reported make and model: Vans RV6 (A) - Registry model: [Bass Jerry VANS RV6A](https://openairdocs.org/model/bass-jerry-vans-rv6a) (registry code 05605Z4) (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: 24723 - Year built: 2000 - Airframe hours: 830 - Engines: Mattituck TMXOF-360 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, September 4, 2018 - Departed: CYO, Circleville, OH - Destination: EOP, Waverly, OH ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 90; injuries: fatal; private; airplane ratings: single-engine land; medical: sport pilot, without waivers/limitations; last flight review April 24, 2019; seat: left; restraint: 4-point; toxicology performed; flight hours: 1,967 total ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 10 knots - Visibility: 10 statute miles - Temperature: 81 °F, dew point 61 °F - Altimeter: 29.96 inHg - Observed at: RZT, 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 20190518004819A](https://openairdocs.org/incident/20190518004819A), May 18, 2019: Bass Jerry VANS RV6A, Chillicothe, OH, Destroyed, 1 fatal. Aircraft was observed descending at a steep angle and a high rate of speed. Aircraft impacted trees in a sparsely populated area. All the flight controls were… ## Other investigations on N596JB (1) 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. - [NTSB NYC07LA191](https://openairdocs.org/ntsb/NYC07LA191), Aug 4, 2007: Bass RV-6A (N596JB), Harrisonburg, VA, substantial damage. Probable cause: The limited fork-to-ground clearance provided by the nose gear design. Contributing to the accident was the uneven turf/dirt surface of the runway. ## Docket (20 files) The files NTSB released with the investigation on October 9, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99446. 24.5 MB in all. - Witness statements - diagram (item 1, PDF, 1 page, 728 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7990947&FileExtension=pdf&FileName=Witness%20Diagram_-Rel.pdf - Witness statement - m. wright (item 2, PDF, 1 page, 315 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8658311&FileExtension=pdf&FileName=1995_001_Redacted-Rel.pdf - Memorandum for record a�� communication summary -- c. palmer CFI (item 3, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8657851&FileExtension=pdf&FileName=19Communication%20Summary144CFI-Rel.pdf - Memorandum for record a�� communication summary -- j. farington, witness at cto (item 4, PDF, 1 page, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8015347&FileExtension=pdf&FileName=19Communication%20Summary144-Rel.pdf - Air traffic control - radar data plots (item 5, PDF, 11 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9111899&FileExtension=pdf&FileName=N596JB,%205-18-2019,%201645%20UTC-Rel.pdf - Air traffic control - radar data - csv (item 6, CSV, 4 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9112167&FileExtension=csv&FileName=N596JB%20(2)-Rel.csv - Air traffic control - radar data - kml (item 7, KMZ, 4 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9112300&FileExtension=kmz&FileName=N596JB-2.csv-Rel.kmz - Miscellaneous information - pilot logbook excerpt (item 8, PDF, 4 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8009118&FileExtension=pdf&FileName=Pilot%20Log%20Excerpt_Redacted-Rel.pdf - Maintenance records - logbook excerpt (item 9, PDF, 3 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7990965&FileExtension=pdf&FileName=Airplane%20Log%20Excerpt_Redacted-Rel.pdf - Photos - on scene (item 10, PDF, 20 pages, 20 photos, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8657161&FileExtension=pdf&FileName=19photo144-Rel.pdf - Miscellaneous information - continued airwothiness excerpts (item 11, PDF, 6 pages, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8698177&FileExtension=pdf&FileName=Continued%20Airworthiness%20Excerpts-Rel.pdf - Photos - fadec mpc and speed sensor exam (item 12, PDF, 10 pages, 10 photos, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8660310&FileExtension=pdf&FileName=19photo144Engine%20Accessories%20-Rel.pdf - Miscellaneous information - testing results -- fadec (item 13, PDF, 5 pages, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8658836&FileExtension=pdf&FileName=FadecRunSheetN596JB-Rel.pdf - Maps or charts of accident area (item 14, PDF, 3 pages, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7990938&FileExtension=pdf&FileName=Maps%20of%20the%20area_-Rel.pdf - Weather reports and records (item 15, PDF, 8 pages, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7991152&FileExtension=pdf&FileName=N596JB%20Wx-Rel.pdf - Toxicological report (item 16, PDF, 1 page, 372 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8702158&FileExtension=pdf&FileName=2019_095_001_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation - Continental (item 17, PDF, 1 page, 587 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=7991316&FileExtension=pdf&FileName=CAT%20Party%20Form_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation - vans (item 18, PDF, 1 page, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8006722&FileExtension=pdf&FileName=Chillacoathe%20Party%20Representative_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 19, PDF, 1 page, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8699999&FileExtension=pdf&FileName=N596JB%20-%2019Retention-Release-of-Wreckage-Form144a_Redacted-Rel.pdf - Evidence control form (item 20, PDF, 1 page, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8699477&FileExtension=pdf&FileName=N596JB%20-%2019Evidence%20Control%20Form144_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.