# NTSB CEN20LA399: Vans RV9, N94KJ, Zeeland, MI, September 19, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: September 19, 2020, 06:38 local (10:38 UTC) - Place: Zeeland, MI - Coordinates: 42.82389, -85.923889 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.8239&lon=-85.9239&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern base: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming Engines, Flight Standards District Office - NTSB case key (mKey): 101991 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA399 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101991/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101991 - Page: https://openairdocs.org/ntsb/CEN20LA399 ## Probable cause The pilot’s failure to maintain airspeed during a visual approach in dark night conditions, which resulted in an aerodynamic stall and loss of airplane control. Contributing to the accident was the pilot’s lack of recent flight experience at night. ## 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: [Byerley Kent D RV9A, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05621DM), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Byerley Kent D RV9A, 1 case](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=05621DM), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) - [Experience/qualifications: recent experience](https://openairdocs.org/ntsb-findings/02031035): Personnel issues › Experience/knowledge · Pilot; cases with it: [Byerley Kent D RV9A, 1 case](https://openairdocs.org/ntsb-findings/02031035/cases.md?model=05621DM), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/02031035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern base: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Byerley Kent D RV9A, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05621DM), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot departed under visual flight rules (VFR) from a rural airport during dark night, VFR conditions. After climbing toward the destination for about 2 minutes, the pilot turned back to the airport and flew a visual approach. The airplane’s flight track was consistent with a go-around near the runway threshold, likely due to excessive airspeed, followed by a climb toward the downwind leg of the traffic pattern for the opposite runway. On an approximate left base leg, the airplane decelerated to stall speed and entered a right spin that continued until ground impact. The disposition of the wreckage was consistent with a low forward speed indicative of a stalled condition. Two weeks before the accident, the airplane’s attitude heading reference system (AHRS) failed during a daytime flight. The pilot landed uneventfully by referencing the airplane’s backup (unlit) flight instruments located on the instrument panel’s far right side. After troubleshooting the AHRS failure, the pilot made repairs to a circuit card that involved intricate soldering of a capacitor and two diodes. The accident occurred on the second flight after this repair. Examination revealed no engine or flight control anomalies. Fire damage precluded assessment of avionics anomalies. His disease placed him at increased risk of a sudden impairing or incapacitating cardiac event. It is possible that the pilot was experiencing symptoms of a heart-related medical event and that may have been the reason for his attempt to return to the airport. Furthermore, symptoms of such an event might have impaired his performance while maneuvering. However, there is no specific evidence that a such an event occurred and a systems failure involving the AHRS repair provides a reasonable alternate explanation for the pilot’s attempted return. In such a scenario, challenges related to the failure and the dark conditions might explain his loss of control, even without impairment. Thus, whether the pilot’s severe coronary artery disease contributed to the accident could not be determined. The pilot had not flown the accident airplane at night and his most recent night landing was about 5 years before the accident. The pilot’s lack of recent night experience likely contributed to his poor airspeed control during the two attempted approaches and the subsequent loss of aircraft control. ## Factual narrative The last recorded information showed the airplane slowing to 50 knots while in a left turn. The wings-level stall speed for a Vans RV9 is reported as between 42 and 43 kts. With a bank angle of 45° the airplane’s stall speed increased to about 50 knots. The pilot recorded remarks in his logbook that, during a daytime flight 12 days before the accident in the accident airplane, he experienced an attitude heading reference system (AHRS) failure along with “burning insulation smell.” He shut down electrical equipment, including the electronic flight information system (EFIS), and landed the airplane using the analog flight instruments without incident. The analog instruments (attitude indicator, directional gyro, airspeed indicator, and altimeter) were located on the far right side of the instrument panel and were not lighted. After the AHRS failure, the pilot identified a circuit card with a capacitor and two diodes that needed to be replaced. (See Figure 2.) The pilot was a career electrical engineer and elected to remove and solder the replacement capacitor and diodes onto the circuit card himself rather than purchase a new card. The pilot completed the replacement of these components onto the circuit card and flew the airplane uneventfully the day before the accident. He noted that the AHRS and EFIS appeared to be functional. Figure 2. Photo of avionics circuit card (two failed diodes circled in red) On September 19, 2020, about 0638 eastern daylight time, an experimental, amateur-built RV9A, N94KJ, was destroyed when it was involved in an accident near Zeeland, Michigan. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The airport’s common traffic advisory frequency (CTAF) was recorded, and captured transmissions from the accident pilot that included taxi to and departure from runway 20. Shortly thereafter, the pilot reported that the airplane was on final approach for runway 02. No further transmissions from the pilot were recorded. Automatic Dependent Surveillance – Broadcast (ADS-B) information captured the airplane depart about 0633. After climbing on a southeasterly heading, the airplane turned back toward the airport. The airplane crossed the runway threshold at 95 knots and 200 ft above ground level (agl), then climbed and turned right toward the northeast. The last recorded information showed the airplane turning left on an approximate left base for runway 20 at 50 knots and 400 ft agl. (See Figure 1.) Surveillance video showed that the airplane pitched up and begin spinning to the right until ground impact; a post-impact fire ensued. Figure 1. Flight Track of Airplane The autopsy report stated that the pilot’s cause of death was atherosclerotic cardiovascular disease, and that his manner of death was natural. Autopsy of his heart identified near-complete blockage of the left anterior descending coronary artery, 50% narrowing of the leftcircumflex coronary artery, and an old area of heart muscle scarring from reduced blood supply. No tested-for substances were noted on toxicology testing, except caffeine, which generally is not considered impairing. At the NTSB’s request, an Armed Forces Medical Examiner System (AFMES) forensic pathologist reviewed evidence including the pilot’s autopsy report, toxicology information, microscope slides from the pilot’s autopsy, narrative information about the accident provided by the NTSB, and the passenger’s autopsy report. The AFMES forensic pathologist’s opinion was that the pilot’s cause of death was multiple injuries, that his manner of death was accident, and that the contribution of his atherosclerotic cardiovascular disease (severe coronary artery disease) to the accident could not be definitively determined. On the morning of the accident, sunrise occurred at 0727 and the moon did not rise until 1000. A review of pilot logs revealed about 15 flight hours of flight experience at night. The pilot’s most recent night landing occurred on October 18, 2015, and he had not flown the accident airplane at night. The airplane impacted a farm field about 1,100 ft northeast of the runway 20 threshold and a post impact fire ensued. Examination of the airplane revealed no anomalies with the engine or flight controls that would have precluded normal operation. Fire damage did not allow for assessment of avionics anomalies. ## Aircraft - Registration: [N94KJ](https://openairdocs.org/deregistered/N94KJ-2021-10-19), registration cancelled 2021-10-19, S/N 90322, built 2006 (OpenAirDocs) - Reported make and model: Vans RV9 (A) - Registry model: [Byerley Kent D RV9A](https://openairdocs.org/model/byerley-kent-d-rv9a) (registry code 05621DM) (OpenAirDocs) - Registry engine: [Lycoming IO-320 series](https://openairdocs.org/engine/lycoming-io-320-series) (registry code 41509, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 90322 - Year built: 2006 - Airframe hours: 395 - Engines: Lycoming IO320-D1A 160 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, November 8, 2019 - Departed: Z98, Zeeland, MI - Destination: 12V, Milton, WV - Airport: Z98, Ottawa Executive, runway 20, 3,800 × 60 ft, asphalt - Equipment: ADS-B, Electronic multifunction display, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review August 1, 2019; seat: left; toxicology performed; flight hours: 707 total, 222 in this make and model, 21 in the last 90 days, 9 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 100° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 36 °F, dew point 34 °F - Altimeter: 30.39 inHg - Observed at: KBIV, 9 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 20200919012319A](https://openairdocs.org/incident/20200919012319A), Sep 19, 2020: Byerley Kent D RV9A, Zeeland, MI, Destroyed, 2 fatal. On September 19, 2020, approximately 0638 eastern daylight time, an experimental, amateur-built vans RV9A Airplane, N94KJ, was destroyed when it was involved… ## Docket (14 files) The files NTSB released with the investigation on June 3, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101991. 10.7 MB in all. - Witness statements (item 1, PDF, 3 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12854196&FileExtension=pdf&FileName=Witness%20Statements_Redacted-Rel.pdf - Correspondence with FAA inspectors (item 2, PDF, 1 page, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12912488&FileExtension=pdf&FileName=Correspondence%20with%20FAA-Rel.pdf - Pilot's text communication of circuit card repair (item 3, PDF, 5 pages, 748 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12908176&FileExtension=pdf&FileName=Pilot%27s%20communication%20concerning%20avionics_Redacted-Rel.pdf - Pilot email communication of circuit card repair (item 4, PDF, 3 pages, 420 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12907120&FileExtension=pdf&FileName=Avionics%20Conversation_Redacted-Rel.pdf - Pilot's log - excerpt (item 5, PDF, 3 pages, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12909418&FileExtension=pdf&FileName=Pilot%20Logbook%20Excerpt-Rel.pdf - Air traffic control ADS-B information (item 6, XLSX, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12854332&FileExtension=xlsx&FileName=ADSB%20--%20relevant%20excerpt-Rel.xlsx - Overview of ADS-B flight track (item 7, PDF, 1 page, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12908166&FileExtension=pdf&FileName=ADS-B%20flight%20track-Rel.pdf - Photos (item 8, PDF, 6 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12911903&FileExtension=pdf&FileName=Photos-Rel.pdf - Engine examination summary (item 9, PDF, 2 pages, 179 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12908324&FileExtension=pdf&FileName=Engine%20Exam%20Summary-Rel.pdf - Toxicological report (item 10, PDF, 1 page, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12854166&FileExtension=pdf&FileName=tox_Redacted-Rel.pdf - NTSB medical factual report (item 11, PDF, 3 pages, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12853151&FileExtension=pdf&FileName=CEN20LA399_MedicalFactualReport-Rel.pdf - Aircraft performance study (item 12, PDF, 4 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12331264&FileExtension=pdf&FileName=CEN20LA399_Performance_Study-Rel.pdf - Statement of party representatives to NTSB investigation (item 13, PDF, 1 page, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12853821&FileExtension=pdf&FileName=Party%20Member_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 14, PDF, 1 page, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12854216&FileExtension=pdf&FileName=Wreckage%20Release_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.