# NTSB CEN21FA238: Lancair Evolution, N515DL, McDermott, OH, May 28, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: May 28, 2021, 10:48 local (14:48 UTC) - Place: McDermott, OH - Coordinates: 38.81828, -83.02776 - Nearby events: https://openairdocs.org/map.md?lat=38.8183&lon=-83.0278&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: 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: Lancair Owners and Builders Organization, Evolution Aircraft Company, Flight Standards District Office, Transportation Safety Board of Canada, Hartzell Propeller Inc. - NTSB case key (mKey): 103162 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21FA238 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103162/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103162 - Page: https://openairdocs.org/ntsb/CEN21FA238 ## Probable cause The pilot’s failure to recognize and avoid airframe icing conditions, which resulted in a loss of airplane performance and a subsequent loss of control and in-flight break-up. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: understanding/comprehension](https://openairdocs.org/ntsb-findings/02041515): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [David James LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-findings/02041515/cases.md?model=05633Y7), [All aircraft, 70 cases](https://openairdocs.org/ntsb-findings/02041515/cases.md) - [Ceiling/visibility/precip](https://openairdocs.org/ntsb-findings/03035000): Environmental issues › Conditions/weather/phenomena · Awareness of condition (probable cause); cases with it: [David James LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-findings/03035000/cases.md?model=05633Y7), [All aircraft, 65 cases](https://openairdocs.org/ntsb-findings/03035000/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [David James LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05633Y7), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [David James LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=05633Y7), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [David James LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05633Y7), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Enroute: Structural icing](https://openairdocs.org/ntsb-events/210); cases with it: [David James LANCAIR EVOLUTION, 1 case](https://openairdocs.org/ntsb-events/210/sequence.md?model=05633Y7), [All aircraft, 102 cases](https://openairdocs.org/ntsb-events/210/sequence.md) ## Analysis The pilot departed on a cross-country flight and climbed the airplane to a cruise altitude of 25,000 ft mean sea level (msl). The airplane encountered an area of moderate icing and decelerated to near its stall speed. It then entered a rapid left turning descent. Sections of the right wing and tail separated in flight, and the airplane impacted terrain in a near-vertical attitude. A postimpact fire ensued, and the airplane was destroyed. Examination revealed that the in-flight separations of the wing and tail sections were consistent with overstress, and no pre-accident mechanical anomalies were observed that would have precluded normal operation. Although toxicological testing detected ethanol in the pilot’s muscle and liver, the ethanol was likely not from alcohol consumption based on tissue concentrations and the absence of ethanol in urine. Review of forecasted weather information indicated that the pilot was likely operating in instrument meteorological and icing conditions for about 20 minutes before the accident, with the potential for supercooled large droplets along the flightpath and structural icing at the airplane’s cruise altitude. There was no indication that the pilot obtained a weather briefing from an access-controlled source before the accident, and his awareness of the icing conditions was not determined. The airplane was not equipped for flight in icing conditions. Based on the available information, the pilot failed to recognize and avoid icing conditions during cruise flight, which resulted in a loss of airplane performance, an aerodynamic stall, and a subsequent loss of airplane control followed by an in-flight break-up. ## Factual narrative FAA Advisory Circular AC91-74B, Pilot Guide: Flight in Icing Conditions, included the following information: Aircraft icing remains a key aviation safety issue. Accident data has shown that pilots are (intentionally or inadvertently) flying aircraft not certificated for flight in icing conditions into such conditions, often with fatal results. Such accidents are often the result of pilot complacency, lack of situational awareness (e.g., lack of awareness of loss of airspeed), poor technique, poor understanding of the airplane’s limitations and performance in icing conditions, misconceptions about certification of the airplane and systems for flight in icing, or a misunderstanding of icing terminology. If an aircraft is not certificated for flight in icing conditions, each flight should be planned carefully so that icing conditions are avoided. During a flight, the pilots should monitor available weather information and be aware of conditions that might require a change of flight plan to avoid icing conditions. In the event of an inadvertent icing encounter, the pilot should take appropriate action to exit the conditions immediately, coordinating with air traffic control as necessary, and declaring an emergency. The airplane was not equipped for flight in icing conditions. The onboard Garmin 900X did not incorporate a stall warning and the airplane was not equipped with an angle of attack system. The flight manual stall speed at maximum gross weight with the flaps retracted was 76 knots. On May 28, 2021, about 1048 eastern daylight time, a Lancair Evolution airplane, N515DL, was destroyed when it was involved in an accident near McDermott, Ohio. The private pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A review of air traffic control (ATC) information revealed that the airplane departed about 1014 from Bellefontaine Regional Airport (EDJ), Bellefontaine, Ohio, on an instrument flight rules (IFR) flight plan, with a destination of Charleston International Airport (CHS), Charleston, South Carolina. After departure from EDJ, the airplane climbed to 25,000 ft mean sea level (msl) and accelerated to 215 knots groundspeed. During the next 1 minute and 43 seconds, the airplane gradually decelerated to a groundspeed of 146 knots while in level flight on a southeast heading. Based on winds aloft of 265° at 47 knots, the airplane had decelerated to a calibrated airspeed of about 76 knots. The airplane subsequently entered a left turn and descended rapidly. A distressed conversation between the pilot and passenger was transmitted, during which the pilot stated, “I don’t know what happened….it won’t perform.” The controller attempted unsuccessfully to contact the pilot and radar contact was lost. A witness on the ground saw the airplane in a spiral descent. The airplane impacted wooded terrain and a postimpact fire ensued. Toxicology testing detected ethanol in thepilot’s liver at 0.047 gm/hg and muscle tissue at 0.023 gm/hg. No ethanol was found in the pilot’s urine. An AIRMET for moderate icing was valid between the freezing level and 22,000 ft msl. An AIRMET for moderate turbulence was valid from 25,000 ft to 42,000 ft msl. Both AIRMETs covered EDJ and the accident location. Supplemental National Weather Service forecast products indicated a 10% to 60% probability of icing at 20,000 to 25,000 ft msl near the accident site and that the icing intensity near the accident site would range from “light” to “heavy” categories. Current Icing Potential (CIP) products indicated that the probability of supercooled large droplets (SLD) near the accident site was 10% to 40% between 20,000 and 22,000 ft msl, with an unknown probability of SLD above 22,000 ft msl. Weather radar and upper air sounding data indicated that the airplane passed through areas of precipitation and icing during the flight and areas of SLD likely existed at the airplane’s altitude near the accident location. The accident pilot did not request or receive weather information from Leidos Flight Service. A search of archived ForeFlight information indicated that the accident pilot did not request or receive weather information from ForeFlight before the accident flight. The air traffic controller did not read the AIRMET information to the pilot or solicit and disseminate pilot weather reports (PIREPs). Dissemination of PIREPs alerts pilots to weather conditions and provides information useful to forecasters in the development of aviation forecasts. PIREPs also provide information required by ATC in the provision of safe and efficient use of airspace. According to a Lancair Owner and Builders Organization (LOBO) representative, the pilot received Lancair Evolution transition training from Elite Pilot Services in 2015 and recurrent training from Evolution Flight Services in 2017, 2018, and 2019. The pilot did not complete recurrent training in 2020 or 2021. The pilot attended five LOBO events from 2016 to 2021, each of which included weather flying and aeronautical decision-making topics. During the 2019 event, the pilot attended a seminar on icing considerations. The airplane descended at a nearly vertical angle and impacted a wooded area. The wreckage was significantly fire damaged (reference Photo 1). Photo 1 - Accident Site The airplane was equipped with a ballistic recovery system; the ballistic charge for the system expended during the fire. The right wing (outboard 11 ft) separated in flight and was located about ½ mile northeast of the main wreckage. Most of the horizontal stabilizer and a 3-ft section of the left elevator were recovered about ¾ mile northeast of the main wreckage. Examined fracture surfaces of the separated right wing, horizontal stabilizer, and left elevator were consistent with overstress. Engine and propeller rotational signatures were consistent with the propeller not being feathered and the engine producing powerduring ground impact. No preaccident mechanical malfunctions were observed that would have precluded normal operation. ## Aircraft - Registration: [N515DL](https://openairdocs.org/aircraft/N515DL), registered now, S/N EVO-0060, built 2015 (OpenAirDocs) - Reported make and model: LANCAIR EVOLUTION - Registry model: [David James LANCAIR EVOLUTION](https://openairdocs.org/model/david-james-lancair-evolution) (registry code 05633Y7) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-135A](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-135a) (registry code 52260, turbo-prop) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: EVO0060 - Year built: 2015 - Airframe hours: 469 - Engines: Pratt & Whitney PT6A-135A 750 horsepower turbo prop - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Davlor Aircraft Leasing LLC - Registered owner: Davlor Aircraft Leasing LLC - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, October 1, 2020, 48 hours before - Departed: EDJ, Bellefontaine, OH - Destination: CHS, Charleston, SC - Flight plan: IFR - Equipment: Electronic primary flight display, Airframe parachute, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review May 9, 2019; seat: left; toxicology performed; flight hours: 1,733 total, 469 in this make and model, 27 in the last 90 days, 8 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: 2,300 ft overcast - Temperature: 70 °F, dew point 68 °F - Altimeter: 29.83 inHg - Icing: Unknown - Turbulence: Unknown - Observed at: KDWU, 21 nm away - METAR: KDWU 281456Z AUTO 21004KT 10SM FEW011 OVC023 21/20 A2983 RMK AO2 SLP097 6//// T02110200 57006 ## 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 20210528007029A](https://openairdocs.org/incident/20210528007029A), May 28, 2021: David James LANCAIR EVOLUTION, Mcdermott, OH, Destroyed, 2 fatal. On may 28, 2021, about 1048 eastern daylight time, a Lancair Evolution airplane, N515DL, was destroyed when it was involved in an accident near Mcdermott,… ## Docket (20 files) The files NTSB released with the investigation on July 7, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103162. 154 MB in all. - Witness statement (item 1, PDF, 1 page, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13588398&FileExtension=pdf&FileName=Witness%20Statement_Redacted-Rel.pdf - Pilot experience information (item 2, PDF, 2 pages, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13599507&FileExtension=pdf&FileName=Pilot%20Experience%20Infomation_Redacted-Rel.pdf - NTSB weather report - factual (item 3, PDF, 43 pages, 6.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12738157&FileExtension=pdf&FileName=CEN21FA238_weatherfactualsuffernfinal-Rel.pdf - Weather report - attachment 1 (item 4, GIF, 8.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12738571&FileExtension=gif&FileName=attachment1_animationSAT_VIS_1401to1501utc_CODNEXLAB-GOES-East-local-Ohio-02-15_01Z-20210528_map-id_-13-1n-10-100-Rel.gif - Weather report - attachment 2 (item 5, PDF, 206 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12738023&FileExtension=pdf&FileName=attachment2_PIREP_PROD_BOTH_May-28_0000_May-29_0000_Redacted-Rel.pdf - Weather report - attachment 3 (item 6, ZIP, 70.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12738581&FileExtension=zip&FileName=attachment3_drive-download-20210529T214357Z-001-Rel.zip - Weather report - attachment 4 (item 7, PDF, 1 page, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12738373&FileExtension=pdf&FileName=attachment4_Weather%20Products%20Dissemination%205-28-21%20(N515DL)-Rel.pdf - Weather report - attachment 5 (item 8, PDF, 5 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12738430&FileExtension=pdf&FileName=attachment5_GFAimagedata-Rel.pdf - Weather report - attachment 6 (item 9, PDF, 2 pages, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12738232&FileExtension=pdf&FileName=attachment6_foreflight_cen21fa238_Redacted-Rel.pdf - Weather report - attachment 7 (item 10, ZIP, 50.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12737906&FileExtension=zip&FileName=attachment7_CIP_FIP_images_CEN21FA238-Rel.zip - Transponder data of accident flight (item 11, CSV, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13397729&FileExtension=csv&FileName=ATC%20Transponder%20Information%20of%20Accident%20Flight-Rel.csv - FAA air traffic control report - excerpt (item 12, PDF, 4 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13584728&FileExtension=pdf&FileName=ATC%20-%20FAA%20Accident%20Report%20-%20Excerpt-Rel.pdf - NTSB air traffic control specialist's factual report (item 13, PDF, 8 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13584600&FileExtension=pdf&FileName=ATC%20Specialist%20-%20Factual%20Report---Rel.pdf - Accident site diagram (item 14, PDF, 1 page, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13397288&FileExtension=pdf&FileName=Plane%20Crash%20Diagram-Rel.pdf - Wreckage photos and examination summary (item 15, PDF, 5 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13586617&FileExtension=pdf&FileName=Wreckage%20Photos%20and%20Examination%20Summary-Rel.pdf - Windshield exam - NTSB materials laboratory factual report (item 16, PDF, 6 pages, 7 photos, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13628363&FileExtension=pdf&FileName=22-012-Rel.pdf - Toxicological report (item 17, PDF, 1 page, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13397360&FileExtension=pdf&FileName=tox%20report%20---_Redacted-Rel.pdf - Autopsy memorandum (item 18, PDF, 1 page, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13397578&FileExtension=pdf&FileName=Autopsy%20Memorandum-Rel.pdf - Statement of party representatives to NTSB investigation (item 19, PDF, 3 pages, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13598201&FileExtension=pdf&FileName=Statement%20of%20Party%20Members_Redacted-Rel.pdf - Wreckage release (item 20, PDF, 1 page, 737 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13397452&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.