# NTSB CEN21FA424: Boeing A75, N19BB, Delta, CO, September 17, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: September 17, 2021, 08:00 local (14:00 UTC) - Place: Delta, CO - Coordinates: 38.83478, -108.02654 - Nearby events: https://openairdocs.org/map.md?lat=38.8348&lon=-108.0265&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-aerobatics: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 103896 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21FA424 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103896/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103896 - Page: https://openairdocs.org/ntsb/CEN21FA424 ## Probable cause The pilot’s loss of control during an aerobatic maneuver, resulting in the airplane impacting terrain. ## 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: [Boeing A75, 4 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=1380108), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Boeing A75, 1 case](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=1380108), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Performance/control parameters: yaw control](https://openairdocs.org/ntsb-findings/01062024): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Boeing A75, 1 case](https://openairdocs.org/ntsb-findings/01062024/cases.md?model=1380108), [All aircraft, 149 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-aerobatics: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Boeing A75, 2 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=1380108), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot took off and proceeded to an area northeast of the airport where he began performing aerobatic maneuvers. Witnesses reported that the airplane began a loop maneuver and, at the top of the loop while inverted, the airplane entered a flat spin. They observed the airplane recover from the spin. The airplane then gained altitude and entered another loop. At the top of that loop, while inverted, the airplane entered another flat spin, but this time the pilot did not recover. The airplane descended to impact with rugged terrain. The witnesses reported that the engine could be heard running during the descent to the point of impact. A postaccident examination revealed no preaccident failures or malfunctions with the airplane that would have precluded normal operation. The pilot had used the sedating antihistamine diphenhydramine, which has a potential to cause cognitive and psychomotor slowing and drowsiness. There was insufficient evidence to determine whether the pilot was experiencing impairing diphenhydramine effects at the time of the crash, and no specific evidence that pilot impairment contributed to the crash. ## Factual narrative According to an acquaintance of the pilot, who also witnessed the accident, he and the pilot flew the airplane to AJZ a few days before the accident flight. The acquaintance stated that the airplane operated normally. On September 17, 2021, about 0800 central daylight time, a Boeing A75 airplane, N19BB, was substantially damaged when it was involved in an accident near Delta, Colorado. The pilot sustained fatal injuries. The flight was operated under the provisions of Title 14 Federal Code of Regulations Part 91 as a personal flight. The airplane took off from runway 3 at Blake Field Airport (AJZ), Delta, Colorado. Two witnesses observed the airplane climb out and begin aerobatic maneuvers about 5 miles to the northeast of AJZ. Both witnesses reported that the airplane began a loop maneuver, and at the top of the loop while inverted, the airplane entered a flat spin. They observed the airplane recover from that spin. The airplane then gained altitude and they observed the airplane begin another loop maneuver. At the top of that loop, while inverted, the airplane entered another flat spin, but this time the pilot did not recover. The airplane impacted rugged, sloped terrain about 5 miles to the northeast of AJZ. First responders located the airplane wreckage and notified authorities. There were no radio or distress calls heard from the pilot. The witnesses reported that the engine could be heard running during the descent to the point of impact. The Pathology Group, P.C., Grand Junction, Colorado, performed the pilot’ s autopsy as authorized by the Delta County Coroner’s Office, Delta, Colorado. According to the pilot’s autopsy report, his cause of death was multiple blunt force injuries, and his manner of death was accident. The autopsy did not identify significant natural disease. The Federal Aviation Administration Forensic Sciences laboratory performed toxicology testing of postmortem specimens from the pilot. Diphenhydramine, famotidine, desloratadine, and pseudoephedrine were detected in cavity blood and urine. The wreckage was found resting inverted on a 45-degree sloped hill. The fuselage was oriented downslope and crushed inward from impact forces. The engine was partially separated from its mounts. The empennage section was bent rearward, the upper wings were bent upward, and lower wings were separated from their respective mounting braces, consistent with a flat impact. One blade of the two-bladed propeller had no damage while the other blade was bent aft 45o with no twisting. Flight control continuity was confirmed from the cockpit to all flight control surfaces. The engine throttle control was found in the idle position. Engine rotation continuity (compression resistance) was confirmed. The smell of fuel was present. The airplane was not equipped with inverted fuel or oil supply systems. ## Aircraft - Registration: [N19BB](https://openairdocs.org/aircraft/N19BB), registered now, S/N 75-293 (OpenAirDocs) - Reported make and model: BOEING A75 (NO SERIES) - Registry model: [Boeing A75](https://openairdocs.org/model/boeing-a75) (registry code 1380108) (OpenAirDocs) - Registry engine: [Pratt & Whitney R-985-AN-1](https://openairdocs.org/engine/pratt-whitney-r-985-an-1) (registry code 51659, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 75-293 - Year built: 1940 - Airframe hours: 4872.7 - Engines: Pratt & Whitney R985-AN1 reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Friendshuh Timothy G - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 17, 2021 - Destination: Same as departure - Airport: AJZ, Delta County Airport Blake Field ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: fatal; commercial; airplane ratings: single-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: rear; restraint: 4-point; toxicology performed; flight hours: 1,104 total, 71 in this make and model, 54 in the last 90 days, 37 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 28 °F - Altimeter: 30.22 inHg - Observed at: KAJZ, 4 nm away - METAR: KAJZ 171355Z Auto 08003KT 10SM 15/M02 A3022 RMK A02 T01471023 ## 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 20210917015839A](https://openairdocs.org/incident/20210917015839A), Sep 17, 2021: Boeing A75, Delta, CO, Substantial damage, 1 fatal. Witnesses noticed the aircraft north east of the airfield doing aerobatic maneuvers. The witnesses stated that the aircraft completed a loop and entered an… ## Docket (6 files) The files NTSB released with the investigation on August 23, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103896. 7.2 MB in all. - Witness statement matt green (item 1, PDF, 1 page, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15832674&FileExtension=pdf&FileName=Witness%20Matt%20Green%20MOR-Rel.pdf - Witness statement, isaac berry (item 2, PDF, 1 page, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15833457&FileExtension=pdf&FileName=Witness%20Isaac%20Berry%20MOR-Rel.pdf - Summary of airplane recovery and examination (item 3, PDF, 1 page, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15833671&FileExtension=pdf&FileName=Summary%20of%20Recovery_Redacted-Rel.pdf - Toxicological report (item 4, PDF, 1 page, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15832684&FileExtension=pdf&FileName=Pilot%20Tox%20Report_Redacted-Rel.pdf - Photos (item 5, PDF, 8 pages, 6.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15833761&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Medical factual report (item 6, PDF, 5 pages, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15839592&FileExtension=pdf&FileName=CEN21FA424_MedicalFactualReport-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.