CEN22FA013

NTSB accident investigation · New Glasair Glastar · Waukesha, WI · October 12, 2021

Accident · FatalClass 3 · FieldFinal report
Date
October 12, 2021, 09:30 local (14:30 UTC)
Place
Waukesha, WI
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N628RSNew Glasair Glastar
Defining event
Enroute: VFR encounter with IMC
Weather
Instrument (IMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Lycoming Engines, FAA Fight Standards
FAA report
20211012017879A
Case key
104086

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 noninstrument-rated pilot’s decision to depart and continue flight into instrument meteorological conditions, which resulted in a loss of control due to spatial disorientation.

Findings · 3

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.

Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedRandal C Reimer GLASTAR: 1 caseAll aircraft: 3,958 casesProbable cause
Ceiling/visibility/precip: cloudsEnvironmental issues › Conditions/weather/phenomena · Effect on personnelRandal C Reimer GLASTAR: 1 caseAll aircraft: 108 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 noninstrument-rated pilot departed under special visual flight rules into prevailing instrument meteorological conditions. About 2 hours before the flight, the pilot received a weather briefing that included an AIRMET for instrument flight rules conditions due to precipitation and mist. Although the departure airport was reporting cloud ceilings at 900 ft above ground level (agl) about the time of departure, nearby airports were reporting ceilings at 400 ft agl and visibilities of 3 miles in mist. The pilot departed and maintained an altitude of about 1,200 ft mean sea level (msl), which was about 300-400 ft agl. The departure controller in communication with the pilot noted that the airplane had started to climb and asked if there was a gap in the cloud ceiling and whether he was attempting to climb above the clouds. The pilot responded in the affirmative. The airplane climbed to about 2,600 ft msl before it entered a left spiraling descent and subsequently impacted a residential area. Variations in track data during the flight were inconsistent with the pilot using the airplane’s autopilot. A postaccident examination of the airplane did not reveal any anomalies that would have precluded normal operation. The reduced visibility and low cloud conditions present at the time of the accident were conducive to the development of spatial disorientation, and the airplane’s spiraling descent is consistent with the known effects of spatial disorientation. It is likely that the pilot entered instrument meteorological conditions while attempting to climb above the clouds, experienced spatial disorientation, and subsequently lost control of the airplane.

Factual narrative

The airplane was equipped with a AVMAP ELP V with a A2 ADHARS module, which allowed for an electronic primary flight display that included attitude and directional information. In addition, the airplane was equipped with an autopilot system. An instructor who had flown with the accident pilot reported that the pilot was familiar with the use of the autopilot. The airplane’s maintenance logbooks were not located during the investigation. On October 12, 2021, about 0930 central daylight time, an experimental, amateur-built Glastar airplane, N628RS, was destroyed when it was involved in an accident near Waukesha, Wisconsin. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The airplane departed Lawrence J Timmerman Airport (MWC), Milwaukee, Wisconsin, about 0915, with an intended destination of Salina Regional Airport (SLN), Salina, Kansas. The pilot received clearance for a special visual flight rules (SVFR) departure with the restriction to maintain an altitude at or below 2,300 ft mean sea level (msl). During the approximate 10 minutes between the time the pilot established contact with air traffic control and the accident time, the pilot did not respond to several controller inquiries. At 0921, a controller provided headings to help the pilot remain clear of class D airspace. When asked if he could climb, the pilot replied that he could not climb higher. At 0926, the controller queried the pilot since radar showed the airplane in a climb. The pilot responded that they needed to climb and that they hoped to get above the clouds. At 0929, the controller asked if the pilot would be able to maintain VFR or if they needed to return; however, the pilot did not respond. Radar contact was lost about this time. Automatic Dependent Surveillance-Broadcast (ADS-B) data showed the airplane as it proceeded southwest before entering a left turn at 0927:25 from an altitude of about 2,600 ft msl and a groundspeed of 95 kts. By 0928:53, the airplane had turned toward the north-northwest. Four seconds later, the airplane began a descent which began at 256 ft/min and increased to 8,640 ft/min before track data was lost in the vicinity of the accident site. Figure 1. ADS-B Data Plots The airplane collided with a tree and terrain in a residential area. There were no injuries to persons on the ground. Meteorological information revealed that a low-pressure system center, conducive to the formation of clouds and precipitation, was present in the immediate vicinity of the departure airport. At 0845, the MWC surface observation reported an overcast ceiling at 900 ft above ground level (agl) and 10 miles visibility. At 0845, the Waukesha County Airport (UES) surface observation noted an overcast ceiling at 400 ft agl and 2.5 miles visibility in mist. Forecasts indicated a probability of clouds from 1,200 ft msl (300 ft above ground level) through 12,000 ft msl. Weathersatellite imagery for the accident site showed cloud tops near 7,000 ft msl. In addition, solid cloud coverage was shown over most of the state of Wisconsin. AIRMET Sierra forecast instrument flight rules conditions due to precipitation and mist for the area of the accident site. The pilot requested weather information from Leidos Flight Service about 0731 on the morning of the accident. A specialist provided all standard weather information for the proposed flight. A search of ForeFlight information indicated that the pilot did not request a ForeFlight weather briefing, but did enter several flight routes into the app. No weather imagery was viewed within the app. The pilot held a private pilot certificate with a rating for airplane single-engine land. He did not hold an instrument rating. Figure 2. Wreckage Plots The initial impact point was identified as a tree, after which the wreckage path continued 90 ft toward a slight ravine then up an embankment, generally following a 134° magnetic heading. Both wings separated from the fuselage and were found in the debris path near the ravine. The main wreckage, which comprised the fuselage and empennage, came to rest against trees. The engine separated and came to rest 58 ft past the main wreckage. The propeller was separated from the propeller flange and was found near the main wreckage. All major airplane components were accounted for at the accident site. The flight control cables were separated in multiple locations with evidence of tension overload. An examination of the airframe and engine did not reveal any preimpact anomalies.

Aircraft

Registration
N628RS
Reported as
New Glasair Glastar
Category
Airplane, amateur-built
Serial number
5784
Built
2017
Engine
Lycoming O-320-A2B, 150 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Reimer Randal C
Airworthiness certificate
Special, Experimental (Special)
Departed
KMWC · Milwaukee, WI
Destination
KSLN · Salina, KS
Flight plan
VFR
Equipment
Electronic multifunction display

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
74
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
500 total

Weather

Conditions
Instrument (IMC) · Day
Wind
270° at 7 knots
Visibility
5 statute miles
Lowest ceiling
400 ft overcast
Temperature
59 °F, dew point 59 °F
Altimeter
29.83 inHg
Observed at
KUES, 6 nm away
METAR
KUES 121445Z 27007KT 5SM BR OVC004 15/15 A2983

Docket · 15

The files NTSB released with the investigation on March 22, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 90.9 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.