# NTSB CEN22FA203: American AA-1A, N6409L, Cleburne, TX, May 17, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: May 17, 2022, 17:51 local (22:51 UTC) - Place: Cleburne, TX - Coordinates: 32.266722, -97.424446 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.2667&lon=-97.4244&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming Engines, Flight Standards District Office - NTSB case key (mKey): 105095 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22FA203 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105095/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105095 - Page: https://openairdocs.org/ntsb/CEN22FA203 ## Probable cause The student pilot’s decision to operate the airplane after consuming alcohol, which led to an exceedance of the airplane’s critical angle of attack, an aerodynamic stall, and a subsequent loss of control at a low altitude. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: unnecessary action](https://openairdocs.org/ntsb-findings/02041045): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [American AA-1A, 1 case](https://openairdocs.org/ntsb-findings/02041045/cases.md?model=0630710), [All aircraft, 52 cases](https://openairdocs.org/ntsb-findings/02041045/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [American AA-1A, 6 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=0630710), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Impairment/incapacitation: alcohol](https://openairdocs.org/ntsb-findings/02012015): Personnel issues › Physical · Pilot (probable cause); cases with it: [American AA-1A, 1 case](https://openairdocs.org/ntsb-findings/02012015/cases.md?model=0630710), [All aircraft, 87 cases](https://openairdocs.org/ntsb-findings/02012015/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [American AA-1A, 3 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=0630710), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [American AA-1A, 4 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=0630710), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis The student pilot was returning to his home airport after making three stops to pick up and drop off equipment and a passenger. While the airplane was at low altitude about 5 miles from the student pilot’s home airport, the airplane made a left turn that was followed by a right turn near the airplane’s stall speed. The airplane rapidly descended and impacted a field in a nose-low attitude and with minimal forward momentum. The airplane came to rest upright, with both wings crushed downward and the engine partially separated and forward of the main wreckage. There was no evidence of preimpact mechanical malfunctions were observed during examinations of the engine and airframe. Six empty mini-sized alcohol bottles were found in the airplane’s glove box. In addition, the pilot’s toxicology results showed ethanol concentrations that were about five times the Federal Aviation Administration regulatory limit of 0.04 gm/dL. At such concentrations, the pilot would likely have experienced degradation of judgment and deficits in coordination, psychomotor skills, perception, and attention. The student pilot’s toxicology results indicated that he was drinking alcohol before the time of the accident. The student pilot’s decision to maneuver the airplane at a low altitude while under the influence of alcohol caused the airplane to exceed its critical angle of attack and enter a stall, resulting in a loss of control from which the student pilot could not recover. ## Factual narrative The airplane’s flaps-up stall speed was 70 to 72 knots with a 40° bank angle, and the flaps-up stall speed was 86 to 89 knots with a 60° bank angle. The flight instructor stated the accident airplane was “very responsive” to flight control inputs and that, during a stall, a wing would tend to “roll off abruptly.” On May 17, 2022, about 1751 central daylight time, an American Aviation AA-1A, N6409L, was substantially damaged when it was involved in an accident near Cleburne Regional Airport (CPT), Cleburne, Texas. The student pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. A review of automatic dependent surveillance-broadcast data revealed that the airplane departed CPT about 1309 and flew to Clifton Municipal Airport (7F7), Clifton, Texas. The airplane departed 7F7 with a passenger and flew to Roger M. Dreyer Memorial Airport (T20), Gonzales, Texas, to drop off equipment for oil services. The airplane was refueled at T20 and flown back to 7F7, where the passenger disembarked. About 1734, the student pilot departed 7F7 to return to CPT. About 5 miles south of CPT, the airplane made a left turn at an altitude between 200 and 300 ft above ground level and flew to the west of the student pilot’s house toward a south heading (see figure 1) at a groundspeed of about 70 knots. The airplane subsequently turned to the right at the same altitude and flew to the west of the student pilot’s house toward a north heading at a groundspeed of about 90 knots. A witness observed the airplane in a rapid descent and heard it impact the ground. Figure 1. Flight track of accident flight. The Office of Chief Medical Examiner, Tarrant County Medical Examiner’s District, Fort Worth, Texas, performed an autopsy on the student pilot. His cause of death was multiple blunt force injuries. Toxicology testing performed by the Federal Aviation Administration Forensic Sciences Laboratory detected ethanol in the student pilot’s blood at 0.145 gm/dL and in his vitreous fluid at 0.187 gm/dL. Ethanol is a social drug commonly consumed by drinking beer, wine, or liquor. Ethanol acts as a central nervous system depressant; it impairs judgment, psychomotor functioning, and vigilance. Effects of ethanol on aviators are generally well understood; it significantly impairs pilot performance, even at very low levels. Title 14 CFR 91.17(a) prohibits any person from acting or attempting to act as a crewmember of a civil aircraft “within 8 hours after the consumption of any alcoholic beverage” and “while having an alcohol concentration of 0.04 or greater in a blood or breath specimen.” The student pilot last flew with a flight instructor on October 17, 2021. The flight instructor stated the student pilot’s cross-country training was progressing well but that the student pilot was reluctant to take the private pilot written test. The flight instructor and student pilot parted ways toward the end of 2021. Thestudent pilot’s last training event entered in his logbook was dated November 22, 2021. The student pilot continued to record flight times in an informal maintenance log until the accident flight. The airplane impacted an open, grassy field in a rural area in a nose-down attitude and with minimal forward momentum. The airplane came to rest upright, with both wings crushed downward (see figure 2) and the engine partially separated forward of the main wreckage. Figure 2. Airplane at accident site. All flight control surfaces were accounted for at the accident site, and flight control continuity was confirmed for the elevator, ailerons, and rudder from their respective control surfaces to the flight deck. The flaps were in the retracted position. No evidence indicated any preimpact mechanical malfunctions. Six empty mini-sized alcohol bottles (about 1.5 ounces each) were found in the glove box of the airplane’s flight deck. ## Aircraft - Registration: [N6409L](https://openairdocs.org/aircraft/N6409L), registered now, S/N AA1A-0409, built 1972 (OpenAirDocs) - Reported make and model: AMERICAN AVIATION AA-1A - Registry model: [American AA-1A](https://openairdocs.org/model/american-aa-1a) (registry code 0630710) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: AA1A-0409 - Year built: 1972 - Airframe hours: 3782 - Engines: LYCOMING 0-290-D2 SERIES 115 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: Annual, August 12, 2021, 37 hours before - Departed: 7F7, Clifton, TX - Destination: CPT, Cleburne, TX - Equipment: ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 41; injuries: fatal; student; medical: class 3, without waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 111 total, 91 in this make and model, 10.5 in the last 90 days, 4.5 in the last 30 days, 4.5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 16 knots, gusting 27 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 91 °F, dew point 57 °F - Altimeter: 29.83 inHg - Observed at: KCPT, 5 nm away - METAR: KCPT 172255Z AUTO 17016G27KT 10SM CLR 33/14 A2983 RMK A01 ## 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 20220517007359A](https://openairdocs.org/incident/20220517007359A), May 17, 2022: American Aviation AA-1A, Cleburne, TX, Substantial damage, 1 fatal. On may 17, 2022, about 1751 central daylight time, an American Aviation AA-1A, N6409L, was substantially damaged when it was involved in an accident near… ## Docket (12 files) The files NTSB released with the investigation on August 15, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105095. 43.0 MB in all. - Witness information (item 1, PDF, 1 page, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14646569&FileExtension=pdf&FileName=Witness%20Information_Redacted-Rel.pdf - Passenger interview (item 2, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14645919&FileExtension=pdf&FileName=Passenger%20Interview-Rel.pdf - Flight instructor interview (item 3, PDF, 1 page, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14658769&FileExtension=pdf&FileName=Flight%20Instructor%20Interview-Rel.pdf - Flight track information from ADS-B data (item 4, PDF, 2 pages, 906 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14646283&FileExtension=pdf&FileName=Flight%20Track%20Information%20from%20ADS-B%20Data-Rel.pdf - ADS-B data (item 5, CSV, 6.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14646129&FileExtension=csv&FileName=ADS-B-Rel.csv - Weather information (item 6, PDF, 2 pages, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14646019&FileExtension=pdf&FileName=Weather%20Information%20-%20CPT-Rel.pdf - Excerpts of flight time logs (item 7, PDF, 5 pages, 34.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14659131&FileExtension=pdf&FileName=Excerpt%20of%20Flight%20Time%20Logs_Redacted-Rel.pdf - Flight manual excerpt - stall speeds (item 8, PDF, 1 page, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14645929&FileExtension=pdf&FileName=Flight%20Manual%20Excerpt%20-%20Stall%20Speed-Rel.pdf - Toxicological report (item 9, PDF, 2 pages, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14646029&FileExtension=pdf&FileName=Toxicology%20--_Redacted-Rel.pdf - Medical factual (item 10, PDF, 5 pages, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14625425&FileExtension=pdf&FileName=CEN22FA203_Cleburne_TX_Medical_Factual_FINAL_102522-Rel.pdf - Aircraft examinations (item 11, PDF, 3 pages, 664 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14646349&FileExtension=pdf&FileName=Aircraft%20Examination%20Summary-Rel.pdf - Wreckage release (item 12, PDF, 1 page, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15890558&FileExtension=pdf&FileName=Wreckage%20release%20-%20CEN22FA203_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.