CEN20LA354

NTSB accident investigation · Lancair Lancair Super ES · Ely, MN · August 21, 2020

Accident · FatalClass 3 · LimitedFinal report
Date
August 20, 2020, 23:06 local (Aug 21, 2020, 04:06 UTC)
Place
Ely, MN · Underwater
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N997SLancair Lancair Super ES
Defining event
Enroute: Loss of control in flight
Weather
Instrument (IMC) · Night/dark
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Federal Aviation Administration; MSP FSDO
FAA report
20200820014309A
Case key
101839

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 non-instrument rated pilot’s improper decision to attempt flight into instrument meteorological conditions, which resulted in spatial disorientation and loss of control and subsequent impact with terrain.

Findings · 3

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 parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedMiller Stuart E LANCAIR SUPER ES: 1 caseAll aircraft: 1,269 casesProbable cause
Ceiling/visibility/precip: below VFR minimaEnvironmental issues › Conditions/weather/phenomena · Effect on personnelMiller Stuart E LANCAIR SUPER ES: 1 caseAll aircraft: 184 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 non-instrument rated private pilot delayed his departure to wait for fog to clear at the planned destination airport, which was located about 58 miles east of the departure airport. Enroute instrument meteorological conditions were forecast at the time of the accident. Radar track data showed that, after takeoff, the airplane proceeded on a northeasterly track from the departure airport and made several turns at a low altitude, which was indicative of the pilot’s attempt to maintain visual reference by avoiding enroute weather at night. The track kept the pilot near the city of Ely and developed areas around White Iron Lake, and avoided a prohibited area further north and to the east that required a minimum overflight altitude of 4,000 ft msl. Witnesses near the accident site location saw the airplane descend, then climb into a cloud layer, and then descend into terrain. Postaccident examination of recovered airframe components revealed no mechanical anomalies that would have precluded normal operation. The pilot had received airplane instrument flight instruction toward an instrument rating. The pilot’s flight instructor reported that the pilot was not ready for flight in instrument meteorological conditions and was “nowhere near ready for a [instrument rating] checkride.” The non-instrument rated pilot’s flight in dark night conditions in an area of sparse cultural lighting, with clouds in the vicinity of the airplane’s reported path was conducive to the development of spatial disorientation and loss of control.

Factual narrative

On August 20, 2020, about 2306 central daylight time, an experimental amateur built, Lancair Super ES airplane, N997S, was destroyed when it was involved in an accident near Ely, Minnesota. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot arrived at Ely Municipal Airport (ELO), Ely, Minnesota, about 1200, and was given a minivan to use. The pilot returned to the airport between 1600-1700 and asked airport personnel if he could continue to use the minivan. The fixed base operator at ELO closed at 1700. The pilot was waiting for the destination weather at Grand Marais, Minnesota, located about 58 nm east of ELO and was fogged in, to clear A playback of recorded ATC radar data showed that the airplane departed ELO about 2201 and proceeded on a northeasterly course after departure at an altitude that ranged from about 2,500-2,900 ft. msl or about 1,000 – 1,500 ft agl. The radar track indicated several turns while the airplane proceeded northeast. The radar track had its highest altitude over White Iron Lake, which was about 3,200 ft msl. The last data point was recorded at 2206 over the lake. Although the direct course to the destination airport was about 97 degrees, it intersected a large prohibited area P-204 located about 8 nm east of ELO prohibiting aircraft activity below 4000 ft msl over the Boundary Waters Canoe Wilderness Area. The accident pilot’s track towards and over White Iron Lake was outside the prohibited area. Two witnesses at White Iron Beach Resort, located on the north end of White Iron Lake, stated they, when they first sat down on the end of a dock, the sky was clear, and they could see the stars. However, over the next hour and a half, a cloud layer began to develop, and they could not see the stars anymore. They continued to have very good lateral visibility and could see an island out in front of them from the dock. All was quiet until they heard the noise of an airplane. They looked out past the island and to the left of it and saw an airplane diving down toward the water; they could see lights from the airplane and its silhouette. The airplane then climbed up and disappeared into the clouds. The airplane then came back down through the clouds and was aimed directly at the witnesses. They thought the airplane was going to hit the water in front of the dock, but one wing was lower than the other, and the airplane pulled up just in front of them, turned left and climbed back into the clouds, disappearing from their view in a steep, straight-up climb. One witness reported that the engine noise was very loud and not running smoothly. The engine seemed to cut out and then “rev” up. The other witness reported that engine noise got louder and “revved” in the climb. Seconds later, the airplane descended in a straight down nosedive; a "boom" sound followed. From the time they heard and saw the airplane’s first dive to the third impact dive, theyestimated that less than 3 minutes had passed. The pilot had not filed a flight plan and there was no record he obtained a weather forecast through an automated flight service station. There was no air traffic control contact with N997S for the accident flight. At 1945, the National Weather Service (NWS) Aviation Weather Center issued an Airmen's Meteorological Information (AIRMET) SIERRA advisory for instrument flight rule (IFR) conditions in mist and fog, ceilings below 1,000 ft., visibility below 3 sm due to mist/fog, for an area that included the accident location. This AIRMET was valid at the accident time. At 1956, the NWS Weather Forecast Office in Duluth, Minnesota, issued an Aviation Forecast Discussion (AFD) that included a synopsis and forecast for aviation-specific weather for the region. The "Aviation section of that AFD, which was originally issued at 1645, stated: Mainly VFR conditions were in place around the terminals this evening aside from low IFR conditions at DLH. A back door cold front was sliding to the southwest and moved through the Twin Ports late this afternoon, allowing the marine layer to move inland and bring low IFR ceilings and visibilities to DLH. Expect this activity to oscillate over the next few hours as waves of cloud cover move up over the hill. Heading into the overnight hours, temperatures are expected to cool and with a moist airmass in place, this will lead to the development of fog at all the terminals. Expecting IFR or low IFR ceilings and visibilities to affect DLH (Duluth, Minnesota), INL (International Falls, Minnesota), HIB (Hibbing, Minnesota) and HYR (Hayward, Wisconsin) in the hours around sunrise with marginal visual flight rules (VFR) conditions before then. Periods of very low IFR conditions cannot be ruled out as well. Have added a period of marginal VFR visibilities at BRD (Brainerd, Minnesota), but they could go even lower if temperatures are able to cool more than expected overnight. Improving conditions to VFR are expected by mid to late morning, although the lower ceilings may stick around a bit longer. Chances for showers and a few thunderstorms will arrive during the afternoon hours, but the best chances look to hold off until very late in the period or into the next period, so have held off mention at this point and have focused on the tonight's fog potential. Figure 1 – Graphical Forecasts for Aviation (GFA) forecast imagery depicted sky condition and icing and mountain obscuration Graphical - AIRMETs. Issued about 2000 and valid for 2200. This GFA forecast imagery depicted few or scattered to broken sky conditions near the accident site with a point to the south of the accident site identifying overcast clouds at 1,800 ft above ground level (agl) and layered to 8,000 ft agl. The accident location is located within the red circle. The ELO Automated Weather Observing System recorded at 2335: visibility - 10 statute miles, ceiling - broken at 700 ft agl, temperature and dewpoint -both 16 degrees Celsius. The pilot’s flight instructor had provided the pilot with about 10-15 flights instrument training flights that totaled about 15 hours using a view limiting device. He last flew with the pilot on August 16, 2020. The flight instructor said that the pilot struggled to maintain an RNAV course and on one flight he had to take the flight controls from the pilot during an approach in actual meteorological conditions. He said the pilot was not ready for flight in instrument meteorological conditions and was “nowhere near ready for a [instrument rating] checkride.” The airplane wreckage was about 25 ft. under water in White Iron Lake, which had an elevation of about 1,384 ft. The airplane wreckage exhibited impact damage consistent with a high-speed impact with terrain. Postaccident examination of recovered airplane components revealed that the flight control cables exhibited features of overstress. The engine and propeller were not recovered.

Aircraft

Registration
N997S
Reported as
Lancair Lancair Super ES (No Series)
Category
Airplane, amateur-built
Serial number
ES-121
Built
2010
Airframe hours
358.71
Engine
Teledyne Continental Motors IO-550-N19B, 310 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Pilot
Registered owner
St Croix Aviation Of Woodbury Llc
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · November 26, 2019
Departed
ELO · Ely, MN
Destination
CKC · Grand Marais, MN
Airport
ELO · Ely Municipal Airport
Equipment
ADS-B

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
58
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
400 total

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
140° at 8 knots
Visibility
10 statute miles
Lowest ceiling
4,100 ft broken
Temperature
63 °F, dew point 61 °F
Altimeter
29.87 inHg
Observed at
ELO, 5 nm away

Docket · 13

The files NTSB released with the investigation on June 17, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.9 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.