CEN19FA195

NTSB accident investigation · Rans S12 · Orleans, IN · July 1, 2019

Accident · FatalClass 2 · FieldFinal report
Date
June 30, 2019, 20:45 local (Jul 1, 2019, 00:45 UTC)
Place
Orleans, IN
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N1094KRans S12
Defining event
Maneuvering: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 2
NTSB office
Central Region
Parties
Federal Aviation Administration
FAA report
20190701008759A
Case key
99748

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

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Probable cause

The pilot's exceedance of the airplane's critical angle of attack while maneuvering toward the runway, which resulted in an aerodynamic stall and a loss of control.

Findings · 2

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotJerry Klein RANS S-12: 1 caseAll aircraft: 9,295 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededJerry Klein RANS S-12: 1 caseAll aircraft: 990 casesProbable cause

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 student sport pilot was conducting a local solo flight near his private airstrip in calm wind conditions, and had performed two or three landings before the accident flight. A camera located near the airstrip captured a segment of the accident flight, during which the airplane could be seen spiraling downward and impacting the runway, followed by a postimpact fire. A witness reported that he heard the accident airplane fly over on the night of the accident. He heard the engine "die," but stated that it subsequently restarted, and the airplane proceeded directly toward the runway. The witness subsequently heard the sound of the impact and saw the fire. The airplane impacted terrain in a nose-down attitude. No preimpact structural or flight control continuity were detected during a postaccident examination. Thermal damage precluded a thorough examination of the propeller and engine. A Federal Aviation Administration Advisory Circular (AC 90-109A) classified the airplane as a low-inertia, high-drag airplane. These airplanes are particularly susceptible to unintentional aerodynamic stalls due to their low cruise speed to stall speed margin and their tendency to experience significant airspeed decay with increased load factor (such as during a turn). Based on the available information, it is likely that while maneuvering toward the runway following the loss of and restoration of engine power, the pilot exceeded the airplane's critical angle of attack, which resulted in an inadvertent aerodynamic stall and loss of control. Although medical records indicated that the pilot had been treated for an unspecified anxiety disorder for many years, whether effects from the disorder or its treatment contributed to the accident could not be determined given the available evidence.

Factual narrative

According to his wife, the pilot purchased the airplane from someone she thought was in Michigan. However, there was no FAA record of the purchase, and the listed prior owners were not able to be located. According to the pilot's flight instructor, the airplane was not equipped with a stall warning indicator or an angle of attack indicator. FAA Advisory Circular 90-109A, Transition to Unfamiliar Aircraft, in part, characterizes the Rans S12 as one of a group of low-inertia and/or high-drag airplanes, which "rapidly lose energy (airspeed and/or altitude) when there is a loss or reduction of power." These types of airplanes may also experience significant airspeed decay with increased load factor, such as during turns, making them "particularly susceptible to unintentional stalls," especially given their low cruise speed to stall speed margin. On July 1, 2019, about 2045 eastern daylight time, an experimental amateur-built Rans S12 airplane, N1094K, was substantially damaged when it was involved in an accident near Orleans, Indiana. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A Federal Aviation Administration (FAA) inspector reported that the pilot had performed two or three landings before the accident flight. A camera located near the runway captured a segment of the accident flight showing the airplane spiraling downward and impacting the runway, followed by a postimpact fire. After the accident, a neighbor who lived near the airstrip advised a family member of the pilot's that he heard the airplane fly over his barn on the night of the accident. He heard the motor "die," then walked out of the barn. The witness stated that the motor restarted and the airplane proceeded straight toward the runway. He then heard the crash and observed the fire. The Lawrence County Forensic Services Center conducted an autopsy on the pilot. The cause of death was listed as head, chest, and abdominal injuries. No significant natural disease was identified. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected Amino-clonazepam, Sertraline, and Desmethylsertraline in blood and urine. Sertraline is an antidepressant used to treat depression and anxiety disorders and is not known to be directly impairing. Desmethylsertraline is a metabolite of sertraline. Amino-clonazepam is a metabolite of clonazepam, which produces central nervous system depression. The parent compound, clonazepam, was not present. According to medical records obtained from the pilot's family physician for the three years preceding the accident, the pilot had been treated with sertraline and clonazepam for an unspecified anxiety disorder for many years. He had no other significant medical conditions diagnosed. The pilot had received flight training toward a sport pilot certificate and had received a flight instructor's endorsement on September 26, 2018, indicating a "solo check" in the accidentairplane. The airplane came to rest on its nose oriented on a magnetic heading about 135° on the west edge of a north/south oriented private airstrip near its north end. Grass and corn near the airplane exhibited blight and charring consistent with a ground fire. The fabric wing skins and upper fuselage were consumed by fire. The engine and its propeller exhibited discoloration, deformation, and consumption consistent with fire damage. All separations exhibited appearances consistent with overload or deformation consistent with thermal damage. No preimpact structural anomalies were detected. Flight control continuity was traced from the cockpit area to the flight control surfaces. Bolts holding the propeller hub halves were in place and no visible cracking was observed on the hubs; however, due to thermal damage of the propeller blades, it could not be determined if the blades' collars had rotated between the hub halves. The engine could not be rotated by hand due to the thermal damage.

Aircraft

Registration
N1094K
Reported as
Rans S12
Category
Airplane
Serial number
10942012
Built
2012
Engine
Rotax 582, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Departed
I42 · Paoli, IN
Destination
I42 · Paoli, IN
Airport
PVT · Private

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
42
Injuries
Fatal
Medical
Sport pilot
Toxicology
Performed
Flight hours
21.3 total · 19.2 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 68 °F
Altimeter
30.00 inHg
Observed at
FRH, 10 nm away

Docket · 11

The files NTSB released with the investigation on October 16, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 39.0 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.