# NTSB CEN21LA088: Rans S12XL, N449JP, Port Isabel, TX, December 16, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: December 15, 2020, 23:00 local (Dec 16, 2020, 05:00 UTC) - Place: Port Isabel, TX · 78566 - Coordinates: 26.159381, -97.350071 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.1594&lon=-97.3501&mi=10 - Phase of flight: [Unknown](https://openairdocs.org/ntsb-phases/990) (OpenAirDocs' grouping) - Defining event: [Unknown: 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: Rotech Flight Safety Inc., Federal Aviation Administration - NTSB case key (mKey): 102420 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA088 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102420/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102420 - Page: https://openairdocs.org/ntsb/CEN21LA088 ## Probable cause An exceedance of the airplane’s critical angle of attack and aerodynamic stall following a loss of engine power during an unknown phase of flight, which resulted in an impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating): recip eng cyl section](https://openairdocs.org/ntsb-findings/01058530): Aircraft › Aircraft power plant · Failure (probable cause); cases with it: [Parker Jack C RANS S12XL, 1 case](https://openairdocs.org/ntsb-findings/01058530/cases.md?model=059006G), [All aircraft, 373 cases](https://openairdocs.org/ntsb-findings/01058530/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Parker Jack C RANS S12XL, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=059006G), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Action](https://openairdocs.org/ntsb-findings/02041000): Personnel issues › Action/decision · Unknown/Not determined (probable cause); cases with it: [Parker Jack C RANS S12XL, 1 case](https://openairdocs.org/ntsb-findings/02041000/cases.md?model=059006G), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02041000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Unknown: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340); cases with it: [Parker Jack C RANS S12XL, 1 case](https://openairdocs.org/ntsb-events/340/sequence.md?model=059006G), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Unknown: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Parker Jack C RANS S12XL, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=059006G), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Unknown: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Parker Jack C RANS S12XL, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=059006G), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Unknown: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Parker Jack C RANS S12XL, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=059006G), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Parker Jack C RANS S12XL, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=059006G), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The noncertificated pilot and flight instructor departed on an instructional flight in the experimental airplane. The airplane was later located about 1/3 mile south of the departure airport. There were no witnesses to the accident. The airplane sustained substantial damage to the wings and fuselage. A postaccident examination of the airplane revealed that engine exhibited detonation and scoring of its cylinders, which would have resulted in a loss of engine power. Incorrect timing, poor fuel quality, and lubrication breakdown could have contributed, however, based on the available evidence, the reason for the detonation could not be determined. The impact damage of the airplane and lack of ground scarring was characteristic of a low-speed nose-down impact with terrain, which would have resulted from an aerodynamic stall. The airplane make and model is categorized as rapidly losing energy (airspeed/altitude) when there is a loss or reduction of engine power. The airplane was equipped with a snow mobile engine. The required airplane flight testing was not performed following the installation of the engine and, as a result, may have induced negative handling qualities during low-speed flight, such as those near the stall flight regime. Although the flight instructor’s autopsy showed signs of heart disease it’s unlikely this impaired his ability to respond to the engine failure. Additionally, the noncertificated pilot’s autopsy showed cardiovascular disease that increased his risk of experiencing a sudden impairing or incapacitating medical event. Toxicology testing detected Duloxetine; a medication commonly used to treat depression. Metaxalone, cetirizine, and Chlorthalidone were also detected and combined had the potential to cause impairment. However, because the flight instructor was the only qualified pilot abord the airplane, held the responsibility for ensuring the safe operation of the flight, and for responding to the engine emergency, the noncertificated pilot would have not had the skill or experience to play more than a very limited role. Thus, it is unlikely that the effects of his medical conditions or medications contributed to the accident. ## Factual narrative The amount of fuel in the airplane at takeoff is unknown. On December 15, 2009, the Operating Limitations for Light Sport Aircraft for the airplane were issued by the Federal Aviation Administration (FAA) for the airplane showing it was equipped with a Rotax 582 engine, serial number 5503744, engine. At the time of the accident, the engine that was installed had the following data plate information: Rotax 670, serial number 4088286. An engine logbook entry dated November 18, 2014, stated that the installed engine was “custom built by Rotax Rick.” The Rotax 670 engine was designed and manufactured by Rotax as a snowmobile engine. The installation of the Rotax Rick 670 engine was a major change to the airplane and there was no record in the FAA airworthiness file and the aircraft logs stating that the airplane was flight tested in accordance with Part 91.319, which required a flight test after a major change was made to the airplane. The airplane was not equipped with nor was it required to have a stall warning system or an angle-of-attack indicator. Advisory Circular (AC) 90-109A, Transition to Unfamiliar Aircraft, states that experimental airplane flight operations represent a small percentage of flight hours but a significant percentage of general aviation accidents. The AC states that consideration should be made to add stall warning devices and that an airplane’s response to control inputs usually degrades at slower speeds, requiring larger deflections to achieve the desired response. The AC categorizes the Rans S-12 as a low-inertia and/or high-drag airplane. Appendix 4 of the AC defines low-inertia and/or high-drag airplanes as those airplanes that rapidly lose energy (airspeed/altitude) when there is a loss or reduction of engine power. According to the flight instructor’s life partner, the flight instructor flew the accident airplane by himself about 1-2 weeks prior to the accident. After the flight instructor flew the accident airplane, he tried to talk the pilot into buying an “actual” airplane because he felt the airplane was dangerous especially for someone new to flying and even more so if conditions were not perfect. There were no air traffic control communications/services provided to the airplane. On December 15, 2020, about 2300 central standard time, a Rans S-12XL, N449JP, was involved in an accident near Port Isabel, Texas. The noncertificated pilot, who was the airplane owner, and a flight instructor were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. A student pilot who had flown with the flight instructor in another airplane prior to the accident flight stated that he and the instructor landed at Port Isabel-Cameron County Airport (PIL), Port Isabel, Texas. They then taxied to a hangar on the east side of the fixed base operator at PIL. The student pilot dropped the flight instructor off, and the flight instructor walked over to the hangar and met two men,one of whom was the accident noncertificated pilot. The student pilot said he saw them move the accident airplane out of the hangar. The student pilot last saw the flight instructor about 1540. An alert notice was issued due to the airplane being overdue. The airplane was located about ½ mile south runway 35 at PIL. There were no witnesses that reported seeing the accident. An autopsy of the instructor pilot cited the cause of death as blunt force trauma due to an aircraft crash and the manner of death was an accident. Toxicology testing of the samples from the instructor pilot were negative for drugs and alcohol. An autopsy of the noncertificated pilot cited the cause of death as blunt force trauma due to an aircraft crash and the manner of death was an accident. Toxicology testing of the samples from the noncertificated pilot detected Duloxetine, Metaxalone, cetirizine, and Chlorthalidone in blood and urine. The flight instructor’s only logbook entry for flight in the accident airplane was dated December 9, 2020, for a flight that was 1.0 hour in duration. The last flight in the logbook was dated December 14, 2020, for a flight in a Cessna 172. The airplane was resting in a nose-down attitude and damage was consistent with a low-speed impact with terrain. The airplane sustained substantial damage to the wings and fuselage. There was no ground scarring that preceded the location of the wreckage. All airplane components were at the accident site. The flight controls and control surfaces were intact and connected. Examination of the engine revealed that the magneto side engine cylinder was disintegrated consistent with detonation, and the walls of both cylinders were scored. The reason for the detonation occurring could not be determined. The amount of fuel aboard the airplane at the time of the accident is unknown due to fuel spillage resulting from the airplane resting attitude. There was fuel present in the engine’s carburetor bowls at the accident site. ## Aircraft - Registration: [N449JP](https://openairdocs.org/aircraft/N449JP), registered now, S/N 08950644, built 2005 (OpenAirDocs) - Reported make and model: RANS S12XL - Registry model: [Parker Jack C RANS S12XL](https://openairdocs.org/model/parker-jack-c-rans-s12xl) (registry code 059006G) (OpenAirDocs) - Registry engine: [Rotax 582DCDI-99](https://openairdocs.org/engine/rotax-582dcdi-99) (registry code 55561, 2 cycle) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 08950644 - Year built: 2005 - Engines: Rotax Rick 670 reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Special, Experimental light sport (Special) - Last inspection: Condition, August 15, 2020 - Departed: PIL, Port Isabel, TX - Airport: PIL ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 78; injuries: fatal; seat: left; toxicology performed - Flight instructor; injuries: fatal; private, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; seat: right; toxicology performed; flight hours: 750 total, 1 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 40° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 3,400 ft broken - Temperature: 70 °F, dew point 61 °F - Altimeter: 29.80 inHg - Observed at: PIL, 0.5 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 20201215017879A](https://openairdocs.org/incident/20201215017879A), Dec 15, 2020: Parker Jack C RANS S12XL, Port Isablel, TX, Substantial damage, 2 fatal. On December 15, 2020 at approximately 15:00 local CST time, N449JP a rans S-12XL airaile serial number 08950644 departed runway 17 at Port isabel-cameron… ## Docket (12 files) The files NTSB released with the investigation on June 24, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102420. 8.3 MB in all. - Record of correspondence - oscar arroyo (item 1, PDF, 1 page, 118 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13588928&FileExtension=pdf&FileName=RECORD%20OF%20CORRESPONDENCE%20-%20Oscar%20Arroyo-Rel.pdf - Record of correspondence - kathryn williamson (item 2, PDF, 1 page, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13577085&FileExtension=pdf&FileName=RECORD%20OF%20CORRESPONDENCE%20-%20Kathryn%20Williamson-Rel.pdf - Record of examination (item 3, PDF, 1 page, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13580030&FileExtension=pdf&FileName=RECORD%20OF%20EXAMINATION-Rel.pdf - Photo log (item 4, PDF, 2 pages, 717 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13579486&FileExtension=pdf&FileName=Photo%20Log-Rel.pdf - Advisory circular A90-109A (item 5, PDF, 53 pages, 767 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13579576&FileExtension=pdf&FileName=AC_90-109A_Redacted-Rel.pdf - Aircraft specifications (item 6, PDF, 1 page, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13577228&FileExtension=pdf&FileName=Rans%20S12%20Specifications_Redacted-Rel.pdf - Aircraft records (item 7, PDF, 8 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13577075&FileExtension=pdf&FileName=Aircraft%20Records%20Master_Redacted-Rel.pdf - Engine logbook record (item 8, PDF, 2 pages, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13577467&FileExtension=pdf&FileName=Engine%20Logbook%20Excerpt%20Master_Redacted-Rel.pdf - FAA forensic toxicology - student pilot (item 9, PDF, 2 pages, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13572390&FileExtension=pdf&FileName=FAA%20Pilot%20Toxicology%20Master_Redacted-Rel.pdf - FAA forensic toxicology - flight instructor (item 10, PDF, 1 page, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13572807&FileExtension=pdf&FileName=FAA%20Flight%20Instructor%20Toxicology%20Master_Redacted-Rel.pdf - Flight instructor logbook excerpt (item 11, PDF, 2 pages, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13580266&FileExtension=pdf&FileName=Pilot%20Logbook%20Excerpt-Rel.pdf - Medical factual report (item 12, PDF, 6 pages, 243 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13583496&FileExtension=pdf&FileName=CEN21LA088_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.