# NTSB CEN19FA195: Rans S12, N1094K, Orleans, IN, July 1, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 2 · Field · Final report - Date: June 30, 2019, 20:45 local (Jul 1, 2019, 00:45 UTC) - Place: Orleans, IN - Coordinates: 38.628055, -86.47583 - Nearby events: https://openairdocs.org/map.md?lat=38.6281&lon=-86.4758&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - 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 - NTSB case key (mKey): 99748 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA195 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99748/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99748 - Page: https://openairdocs.org/ntsb/CEN19FA195 ## 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 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: [Jerry Klein RANS S-12, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=056314B), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Jerry Klein RANS S-12, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=056314B), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Jerry Klein RANS S-12, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=056314B), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Jerry Klein RANS S-12, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=056314B), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N1094K-2021-10-30), registration cancelled 2021-10-30, S/N 10942012, built 2012 (OpenAirDocs) - Reported make and model: RANS S12 - Registry model: [Jerry Klein RANS S-12](https://openairdocs.org/model/jerry-klein-rans-s-12) (registry code 056314B) (OpenAirDocs) - Registry engine: [Rotax 582UL](https://openairdocs.org/engine/rotax-582ul) (registry code 55558, 2 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 10942012 - Year built: 2012 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - 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 ## 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 20190701008759A](https://openairdocs.org/incident/20190701008759A), Jul 1, 2019: Jerry Klein RANS S-12, Orleans, IN, Destroyed, 1 fatal. On Monday, July 1, 2019, at approximately 8:43 EST, a rans S-12 model, experimental amateur build aircraft (registration N1094K, sn 10942012) crashed onto a… ## Docket (11 files) The files NTSB released with the investigation on October 16, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99748. 39.0 MB in all. - Miscellaneous information - pilot records (item 1, PDF, 15 pages, 8.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8256508&FileExtension=pdf&FileName=PilotRecords__Redacted-Rel.pdf - Memorandum for record a�� communication summary -- d holmes --- ind FSDO (item 2, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8942060&FileExtension=pdf&FileName=19Communication%20Summary195FAA-Rel.pdf - Memorandum for record a�� summary of a witness's conversation with an eyewitness (item 3, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8627082&FileExtension=pdf&FileName=19Communication%20Summary195Statement%20in%20reference%20to%20nieghbor%20witnessing%20flight%20-Rel.pdf - Memorandum for record a�� communication summary -- flight instructor k smith (item 4, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9624991&FileExtension=pdf&FileName=19Communication%20Summary195K%20Smith-Rel.pdf - Memorandum for record a�� communication summary -- d heinemann (item 5, PDF, 1 page, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9624825&FileExtension=pdf&FileName=19Communication%20Summary195D%20Heinemann-Rel.pdf - Maps or charts of accident area (item 6, PDF, 3 pages, 21.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8222128&FileExtension=pdf&FileName=Maps%20of%20the%20area-Rel.pdf - Photos (item 7, PDF, 19 pages, 19 photos, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8432100&FileExtension=pdf&FileName=19photo195Redacted-Rel.pdf - Other pertinent forms and reports - chief medical officer -- summary of findings (item 8, PDF, 1 page, 71 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9618152&FileExtension=pdf&FileName=19Communication%20Summary195Medical%20Officer-Rel.pdf - Toxicological report - cami 201900142001 (item 9, PDF, 1 page, 724 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9617864&FileExtension=pdf&FileName=2019_142_001_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9618236&FileExtension=pdf&FileName=NSTB%20Wreckage%20release%20form%20signed%20001_Redacted-Rel.pdf - Weather reports and records (item 11, PDF, 7 pages, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8221939&FileExtension=pdf&FileName=N1094K%20Wx-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.