# NTSB CEN22FA013: New Glasair Glastar, N628RS, Waukesha, WI, October 12, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: October 12, 2021, 09:30 local (14:30 UTC) - Place: Waukesha, WI - Coordinates: 42.934475, -88.23142 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.9345&lon=-88.2314&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming Engines, FAA Fight Standards - NTSB case key (mKey): 104086 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22FA013 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104086/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104086 - Page: https://openairdocs.org/ntsb/CEN22FA013 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot; cases with it: [Randal C Reimer GLASTAR, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05635UM), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Randal C Reimer GLASTAR, 1 case](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=05635UM), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Ceiling/visibility/precip: clouds](https://openairdocs.org/ntsb-findings/03035025): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Randal C Reimer GLASTAR, 1 case](https://openairdocs.org/ntsb-findings/03035025/cases.md?model=05635UM), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/03035025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Randal C Reimer GLASTAR, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=05635UM), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Enroute: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Randal C Reimer GLASTAR, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05635UM), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Randal C Reimer GLASTAR, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05635UM), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N628RS-2022-07-16), registration cancelled 2022-07-16, S/N 5784, built 2017 (OpenAirDocs) - Reported make and model: NEW GLASAIR GLASTAR - Registry model: [Randal C Reimer GLASTAR](https://openairdocs.org/model/randal-c-reimer-glastar) (registry code 05635UM) (OpenAirDocs) - Registry engine: [Lycoming O-320-A2B](https://openairdocs.org/engine/lycoming-o-320-a2b) (registry code 42101, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 5784 - Year built: 2017 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: fatal; 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 ## 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 20211012017879A](https://openairdocs.org/incident/20211012017879A), Oct 12, 2021: Randal C Reimer GLASTAR, Waukesha, WI, Destroyed, 2 fatal. On October 12, 2021, at approximately 09:34 CDT an experimental amateur built Glastar aircraft was traveling from milwaukee, WI timmerman airport (mwc) to the… ## Docket (15 files) The files NTSB released with the investigation on March 22, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104086. 90.9 MB in all. - Photos (item 1, PDF, 4 pages, 4 photos, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14613745&FileExtension=pdf&FileName=Photos%204%20CEN22FA013-Rel.pdf - Charts (item 2, PDF, 1 page, 30.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14613299&FileExtension=pdf&FileName=Charts-Rel.pdf - Weather factual report (item 3, PDF, 22 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13171504&FileExtension=pdf&FileName=CEN22FA013_weatherfactualSuffernfinal-Rel.pdf - Weather attachment 1 (item 4, GIF, 10.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13172579&FileExtension=gif&FileName=attachment1_animationSAT_VIS_1406to1526utc_CODNEXLAB-GOES-East-local-Madison-02-15_26Z-20211012_map-id_-17-1n-10-100-Rel.gif - Weather attachment 2 (item 5, PDF, 5 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13172088&FileExtension=pdf&FileName=attachment2_GFAimagedata-Rel.pdf - Weather attachment 3 (item 6, PDF, 2 pages, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13172098&FileExtension=pdf&FileName=attachment3_N628RS_Contact%20History_Redacted-Rel.pdf - Weather attachment 4 (item 7, PDF, 83 pages, 384 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13172453&FileExtension=pdf&FileName=attachment4_N628RS_10-12-2021-1231Z_Route_Standard_Briefing_MWC_SLN_Flight_Services-Rel.pdf - Weather attachment 5 (item 8, WAV, 23.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13172463&FileExtension=wav&FileName=attachment5_N628RS_audio-Rel.wav - Weather attachment 6 (item 9, ZIP, 14.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13172677&FileExtension=zip&FileName=attachment6_N628RS%20GFA%20FILES-Rel.zip - Weather attachment 7 (item 10, PDF, 3 pages, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13172148&FileExtension=pdf&FileName=attachment7_cen22fa013foreflight_Redacted-Rel.pdf - Record of conversation sturm (item 11, PDF, 1 page, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14611792&FileExtension=pdf&FileName=ROC%20Mr.%20Sturm%20rev1-Rel.pdf - FAA accident package excerpt (item 12, PDF, 2 pages, 832 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14612201&FileExtension=pdf&FileName=FAA%20Accident%20Package%20Excerpt-Rel.pdf - Toxicological report (item 13, PDF, 1 page, 243 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14612888&FileExtension=pdf&FileName=Pilot%20Tox_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 14, PDF, 1 page, 264 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14612705&FileExtension=pdf&FileName=party%20form%20lycoming_Redacted-Rel.pdf - ADS-B data (item 15, CSV, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14614207&FileExtension=csv&FileName=20211012_A8357D_467415924_ADSB-Rel.csv 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.