CEN21FA177

NTSB accident investigation · Magnus Fusion 212 · Conifer, CO · April 3, 2021

Accident · FatalClass 3 · FieldFinal report
Date
April 3, 2021, 17:35 local (23:35 UTC)
Place
Conifer, CO · Heavily wooded
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N434MAMagnus Fusion 212
Defining event
Maneuvering-low-alt flying: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Flight Standards District Office, Ministry of Innovation and Technology Transport Safety Bureau, Civil Aviation Safety Investigation Authority
FAA report
20210403003759A
Case key
102862

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 pilot’s decision to fly at low altitude toward a mountainous canyon, and his exceedance of the airplane’s critical angle of attack while maneuvering to avoid rising terrain, which resulted in an aerodynamic stall and loss of airplane control.

Findings · 4

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.

Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Decision related to conditionMagnus FUSION 212: 1 caseAll aircraft: 329 cases
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleMagnus FUSION 212: 1 caseAll aircraft: 1,681 cases
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleMagnus FUSION 212: 1 caseAll aircraft: 990 cases

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 pilot flew the light sport airplane toward a mountainous canyon while at low altitude. When the pilot attempted to turn away from rising terrain in the canyon, the airplane decelerated toward stall speed and impacted the ground in a nose-low attitude that was consistent with a stalled condition. The airplane sustained substantial damage to both wings, empennage, and fuselage. Density altitude at the accident site was 11,365 ft. Post-accident examination of the airplane, as well as downloaded flight data, showed no evidence of pre-impact mechanical malfunctions. The pilot started flying about 3 years before the accident and was involved in 2 previous accidents and 4 pilot deviations that involved poor decision making and/or situational awareness. Toxicology testing detected the stimulant amphetamine, the antidepressants bupropion and citalopram, and the chronic nerve pain medication gabapentin. Although these medications can negatively affect psychomotor performance, based on the pilot’s flying history and the circumstances of the accident, it is unlikely they were factors in the accident. The circumstances of the accident are consistent with the pilot’s decision to fly toward a canyon at low altitude in high density altitude conditions, and his exceedance of the airplane’s critical angle of attack while maneuvering to avoid terrain, which resulted in an aerodynamic stall and loss of airplane control.

Factual narrative

According to the manufacturer, the flaps 0° stall speeds with a bank angle of 0°, 30°, and 45° were about 43, 46, and 52 knots, respectively, at the airplane’s estimated accident weight. The installed Dynon avionics system provides an aural stall warning that beeps faster as the airplane approaches a stall. On April 3, 2021, about 1735 central daylight time, a Magnus Aircraft Fusion 212, N434MA, was substantially damaged when it was involved in an accident near Conifer, Colorado. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to onboard flight data, the airplane departed about 1658 from Colorado Air and Space Port Airport (FCO), Denver, Colorado. The airplane flew southwest from FCO and maneuvered near the mountain community of Deckers, Colorado, about 800 ft above ground level (agl), then continued southwest toward rising terrain. An emergency locator transmitter (ELT) beacon was recorded about 1735. A witness near Wigwam Trail in the Pike National Forest observed the airplane on a northwest heading and then it turned left to enter a canyon at less than 500 ft agl. After the airplane entered the canyon, the airplane turned right, and the witness lost sight of the airplane. Onboard flight data showed the airplane fly toward the canyon, about 9,200 ft mean sea level (msl) and 75-81 knots groundspeed. The airplane began a climbing right turn as it approached higher terrain. At 17:35:40, the airplane climbed to a maximum altitude of 9,457 ft msl and decelerated to 49 knots indicated airspeed and 62 knots groundspeed, with a ground track of 054°. The last recorded flight data showed the airplane near the accident site at 9,398 ft msl, 69 knots indicated airspeed and 58 knots groundspeed, with a ground track of 110° (see Figure 1.) Figure 1. Accident Flight Path Altitude and Groundspeed. Toxicology testing detected amphetamine in the pilot’s iliac blood at 313 ng/mL and liver tissue. The metabolite of clonazepam, 7-amino-clonazepam, was detected in iliac blood at 11 ng/mL and liver tissue. Bupropion, its metabolite hydroxybupropion, and citalopram, its metabolite n-desmethylcitalopram, were detected in the pilot’s liver and muscle tissue. Gabapentin was also detected in the pilot’s liver and muscle tissue. A High Resolution Rapid Refresh (HRRR) numerical model sounding was obtained from the NOAA Air Resource Laboratory archive over the accident site coordinates for 1700. The HRRR wind profile indicated a near surface wind from 070° at 6 knots with little variation in wind through 13,000 ft msl. The wind profile did not depict any strong vertical or horizontal wind shear, which was consistent with no more than light inflight turbulence. According to downloaded flight data, the density altitude was 11,365 ft when the airplane climbed to the highest altitude of 9,457 ft msl. According to Federal Aviation Administration records, the pilot started flying in 2018 and wasthe pilot in command for 2 previous accidents and 4 pilot deviations. The first accident involved fuel exhaustion due to the pilot not securing a fuel cap and the second accident involved the pilot’s loss of directional control during landing. The four pilot deviations involved Class B and Class D airspace violations. The pilot completed Magnus Fusion 212 ground and flight training on March 16, 2021. The flight instructor stated that the pilot received training on the basics of mountain flying, including a discussion of the hazards associated with high density altitude flying and rugged terrain. The flight instructor who provided the training was not aware of the pilot’s previous accidents and airspace violations. The airplane impacted into mountainous, forested terrain in a nose-down attitude and low forward groundspeed (reference Figure 2) which damaged both wings, empennage, and fuselage. The accident site elevation was about 9,101 ft msl. Figure 2 – Airplane at Accident Site The airplane was equipped with an airframe parachute recovery system that was not deployed. During post-accident detonation of the ballistic charge by an explosives specialist, no anomalies were noted. All flight control surfaces were accounted for at the accident site. The wing flaps were retracted, and no flight control continuity anomalies were observed. Manual rotation of the propeller and accessories was prevented due to the engine’s position and rugged terrain at the accident site. Both left and right carburetor float bowls were removed and contained a small amount of fuel, with no contamination noted. No evidence of pre-impact mechanical malfunctions was observed during examinations of the engine and airframe. A Dynon primary flight display (PFD) was downloaded. Reviewed data from the accident flight showed nominal values throughout the flight for engine rpm, exhaust gas temperature, cylinder head temperature, manifold pressure, oil temperature, and oil pressure. During the last 5 seconds of recorded data, the airplane pitched down from about +19° to -10°.

Aircraft

Registration
N434MA
Reported as
Magnus Fusion 212
Category
Airplane
Serial number
MF-212-16-0001
Built
2016
Airframe hours
227
Engine
Rotax 912, 100 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental light sport (Special)
Last inspection
Condition · March 5, 2021 · 14 hours before
Departed
CFO · Denver, CO
Destination
CFO · Denver, CO
Equipment
Electronic primary flight display, Electronic multifunction display, Airframe parachute, 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
66
Injuries
Fatal
Certificate
Sport Pilot
Airplane ratings
Single-engine land
Seat
Left
Toxicology
Performed
Flight hours
350 total · 14 in this make and model · 14 in the last 90 days · 14 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
50 °F, dew point 1 °F
Altimeter
30.50 inHg
Observed at
K4BM, 14 nm away
METAR
K4BM 032335Z AUTO 18008KT 10SM CLR 10/M17 A3050 RMK AO2

Docket · 17

The files NTSB released with the investigation on April 27, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 22.2 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.