# NTSB ERA09FA524: Curtis John P SEA REY, N563JL, Winter Haven, FL, September 17, 2009 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: September 17, 2009, 10:30 local (14:30 UTC) - Place: Winter Haven, FL - Coordinates: 27.979303, -81.669097 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.9793&lon=-81.6691&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: Serious injuries - Injuries: 2 serious - Status: Completed, report July 18, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Rotax Flying Safety Club, FAA / FSDO - NTSB case key (mKey): 74749 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09FA524 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74749/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74749 - Page: https://openairdocs.org/ntsb/ERA09FA524 ## Probable cause The flightcrew's failure to maintain adequate airspeed while maneuvering during a simulated engine failure, resulting in an aerodynamic stall and uncontrolled descent. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Flight crew (probable cause); cases with it: [Curtis John P SEA REY, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=05617BY), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Curtis John P SEA REY, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05617BY), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [Curtis John P SEA REY, 1 case](https://openairdocs.org/ntsb-events/600/sequence.md?model=05617BY), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md) - [Maneuvering-low-alt flying: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Curtis John P SEA REY, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05617BY), [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: [Curtis John P SEA REY, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05617BY), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight crew departed from a freshwater lake to conduct takeoffs and landings, including several simulated engine-out landings. The left-seat pilot landed in one of the lakes and then took off. When the airplane was about 400 feet above ground level, the pilot in command, seated in the right seat, announced a simulated engine failure and reduced the power to idle. The left-seat pilot pushed the stick forward to attain an approximately 15-degree nose-down attitude in order to maintain 70 mph and recalled announcing that they were at 70 mph. He then turned left to return to the lake for a landing, as there was no safe place in front to land. Halfway through the turn he visually located the landing spot. Rolling out of the turn into the final approach, in about 10 to 15 degrees of bank, the roll stopped without any change to his flight control inputs. The passenger checked the airspeed and assessed the attitude of the airplane before adding about a third of throttle for additional engine power. At this time, the airplane rolled left and the nose dropped fast. The airplane was low and impacted the water in a vertical position. A witness observed the airplane land and then take off. The plane lifted off and appeared normal until the airplane reached about 100 feet above the water. The airplane dipped to the left and then it seemed to overcorrect itself to the right as it entered the water flat. Examination of the wreckage, engine, and the turbo control unit did not reveal any discrepancies that would have prevented normal operation of the airplane. ## Factual narrative HISTORY OF FLIGHT On September 17, 2009, about 1030 eastern daylight time, an experiment amateur-built, amphibious, Curtis Sea Rey, N563JL, registered to and operated by an individual, crashed into Lake Otis, Winter Haven, Florida. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations Part 91 personal flight. The pilot and passenger received serious injuries and the airplane incurred substantial damage. The flight departed from Lake Eloise, Winter Haven, Florida, earlier that day at 0940. The certificated pilot/passenger, seated in the left seat, stated that he and the pilot in command (PIC) departed for a pleasure flight and made numerous touch and go landings in the area's lakes, which included practicing engine out landings. The touch and go landing in Lake Otis prior to the simulated engine failure was done directly into the wind, using half flaps and the airplane was airborne again about the mid lake point. The climb out was at 70 mph, with flaps in the half position and trim full up. They were at about 400 feet (ft) above ground level (agl) when the PIC said "simulated engine failure" and reduced the power to idle. The passenger pushed the stick forward to about 15 degrees nose down to keep 70 mph and recalls announcing "70 mph". He then turned left to return to Lake Otis for a landing, as there was no safe place in front to land. Half way through the turn he recalls announcing "still at 70 mph" and visually located the landing spot. Rolling out of the turn to final about in 10 to 15 degrees of bank, the roll stopped without any change to his flight control inputs. The passenger checked airspeed and assessed the attitude of airplane, which he added about a third of throttle for additional engine power. At this time, the airplane rolled left and the nose dropped fast. The characteristics of the roll and pitch change did not resemble a stall to him. The airplane was too low at this point to make any other changes and impacted the water in a vertical position. The PIC, seated in the right seat, recalls the touch and go landing at Lake Otis and the takeoff up to the 400 ft agl point. The events from that point to the water impact are vague to him but he remembers turning left toward the lake. A witness located on the west side of Lake Otis, on the second floor of a residential home, observed the airplane landing on the water from the south end of the lake. The airplane then taxied and turned around near the north end of the lake and pointed itself for a southerly departure. The plane lifted off and everything appeared normal until the airplane reached an altitude, what he believed to be, about 100 feet above the water. The airplane dipped to the left and then it seemed to overcorrect itself to the right as it entered the water flat. PERSONNEL INFORMATION The pilot, age 74, seated in the right seat, held a Federal Aviation Administration (FAA) airline transport pilotcertificate with a rating for airplane multi-engine land; commercial pilot certificate with ratings for airplane single engine land and sea, airplane multi-engine sea, and rotorcraft - helicopter; flight instructor certificate with ratings for airplane single engine and multi-engine, and instrument airplane; flight engineer certificate with ratings for turbojet powered and reciprocating engine powered. He was issued a FAA third-class medical certificate on November 14, 2008, with limitations of must wear corrective lenses. He documented 20,000 total hours at that time. He documented a total of 222 hours in the accident airplane. The passenger, age 43, seated in the left seat, held a FAA airline transport pilot certificate with a rating for airplane multi-engine land; commercial pilot certificate with ratings for airplane single engine land and sea, flight instructor certificate with ratings for airplane single engine and instrument airplane; ground instructor certificate with a rating for instrument; flight engineer certificate with a rating for turbojet powered. He was issued a FAA first-class medical certificate on April 08, 2009, with no limitations. He documented 14,500 total hours at that time. AIRCRAFT INFORMATION On March 9, 2005 the airplane was issued an FAA special airworthiness certificate and registered in the experimental category with serial number 1MK320C. The two place airplane was built by the registered owner. The amphibious airplane was equipped with retractable landing gear, of tail wheel design. The airplane was equipped with a turbo Rotax 914, 115 horsepower engine. The airplane was maintained in accordance with the manufacturers, Progressive Aerodyne Inc, maintenance program. A review of the airplane's maintenance records revealed the airplane had a condition inspection on the airframe, propeller, and engine on July 13, 2009, at which time the airplane had accumulated a total of 218 hours. METEOROLOGICAL INFORMATION The closest official weather observation was at Winter Haven's Gilbert Airport (GIF), Winter Haven, Florida, 4 miles northwest of the accident site. The GIF 1453 METAR, was winds from 120 degrees at 5 knots; visibility, 10 statute miles; clear sky; temperature 30 degrees Celsius (C); dew point 21 degrees C; altimeter 30.02 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was initially located in the center and toward the east side of the lake. It was upside down and partially submerged in the water. A 5 foot section of the front fiberglass hull structure, the windshield, and upper canopy track beam, separated and were not recovered. The cockpit frame structure, supporting the seats and flight controls system, separated from its hull attaching brackets and was displaced aft 4 inches. The instrument panel was separated from the airframe and broken in half where the flight instrument gauges were mounted. The airplane's battery and electrical wiring were attached to the main wreckage. Both wing'sleading edge surfaces were observed with hydro damage to the structure and fabric. A post recovery examination of the wreckage established all airframe structural separations were consistent with overstress. All flight control surfaces were attached to the airframe and flight control continuity was established. The main landing gear where in the retracted (up) position, the flaps were in the 15 degrees position, and the stabilator was in the full nose up position. Four and one half gallons of auto fuel were recovered. No discrepancy was noted with the fuel system. All three propeller blades were unremarkable. The engine and the engine's turbo control unit (TCU) were retained by the National Transportation Safety Board for further examination. TEST AND RESEARCH The engine was examined and prepare for a test stand run by the engine's manufacturer with Safety Board oversight. The engine started on the second attempt and performed several acceleration checks at different power settings. The engine examination and test run did not reveal any abnormalities that would have prevented normal operation and production of rated horsepower. The TCU data was downloaded at the Rotax facility in Canada with Transportation Safety Board of Canada oversight. The unit's interval memory captured the last 20 minutes of operation. The data indicated the engine was operated at high boost at a relatively low rpm, the engine was over-boosted several times in that period. The engine was running at full throttle and high boost when the boost and rpm both suddenly was reduce and power to TCU was terminated. ## Aircraft - Registration: [N563JL](https://openairdocs.org/deregistered/N563JL-2013-02-08), registration cancelled 2013-02-08, S/N 1MK320C, built 2005 (OpenAirDocs) - Reported make and model: CURTIS JOHN P SEA REY - Registry model: [Curtis John P SEA REY](https://openairdocs.org/model/curtis-john-p-sea-rey) (registry code 05617BY) (OpenAirDocs) - Registry engine: [Rotax SEE BOMBADIER](https://openairdocs.org/engine/rotax-see-bombadier) (registry code 55555, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 1MK320C - Airframe hours: 219 - Engines: ROTAX 914 reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, July 13, 2009, 3 hours before - Departed: Lake Eloise, FL - Destination: Lake Eloise, FL ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: serious; flight engineer, airline transport, flight instructor, commercial; airplane ratings: single-engine land, multi-engine land, single-engine sea, multi-engine sea; instrument ratings: airplane, helicopter; medical: class 3, with waivers/limitations; last flight review November 14, 2008; seat: right; flight hours: 20,000 total, 222 in this make and model - Other flight crew; age 43; injuries: serious; flight instructor, airline transport, commercial, flight engineer; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: left; flight hours: 14,500 total ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 5 knots - Visibility: 10 statute miles - Temperature: 86 °F, dew point 70 °F - Altimeter: 30.02 inHg - Observed at: GIF, 4 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 20090917049599A](https://openairdocs.org/incident/20090917049599A), Sep 17, 2009: Curtis John SEA REY, Winter Haven, FL, Destroyed. The aircraft crashed and flipped upside down in lake otis. Conflicting statements from all involved prevent an actual depiction of the facts. The passenger has… ## Docket (16 files) The files NTSB released with the investigation on May 24, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74749. 7.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 969 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342323&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Passenger Statement: Flying Pilot (item 2, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342328&FileExtension=.PDF&FileName=Passenger%20Statement%3A%20Flying%20Pilot-Redacted.PDF - Witness Statement (item 3, .PDF, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342353&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Miscellaneous: Excerpts From the Airplane's Flight Manual. (item 4, .PDF, 262 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342329&FileExtension=.PDF&FileName=Miscellaneous%3A%20Excerpts%20From%20the%20Airplane%27s%20Flight%20Manual.-Master.PDF - Miscellaneous: Engine Examination Field Notes. (item 5, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342331&FileExtension=.PDF&FileName=Miscellaneous%3A%20Engine%20Examination%20Field%20Notes.-Master.PDF - Miscellaneous: Excerpts From the Turbo Control Unit Examination Report (item 6, .PDF, 429 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342334&FileExtension=.PDF&FileName=Miscellaneous%3A%20Excerpts%20From%20the%20Turbo%20Control%20Unit%20Examination%20Report-Master.PDF - Miscellaneous: Excerpts From the Airplane's Maintenance Records. (item 7, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342336&FileExtension=.PDF&FileName=Miscellaneous%3A%20Excerpts%20From%20the%20Airplane%27s%20Maintenance%20Records.-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342337&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Photo 1) Northwest view of the lake. (item 9, .PDF, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342338&FileExtension=.PDF&FileName=Photo%201)%20Northwest%20view%20of%20the%20lake.-Master.PDF - Photo 2) Front View of the Recovered Wreckage. (item 10, .PDF, 289 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342339&FileExtension=.PDF&FileName=Photo%202)%20Front%20View%20of%20the%20Recovered%20Wreckage.-Master.PDF - Photo 3) Left View of the Recovered Wreckage. (item 11, .PDF, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342340&FileExtension=.PDF&FileName=Photo%203)%20Left%20View%20of%20the%20Recovered%20Wreckage.-Master.PDF - Photo 4) View of the Engine and Propeller. (item 12, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342341&FileExtension=.PDF&FileName=Photo%204)%20View%20of%20the%20Engine%20and%20Propeller.-Master.PDF - Photo 5) View of Wreckage, Hull Section. (item 13, .PDF, 257 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342342&FileExtension=.PDF&FileName=Photo%205)%20View%20of%20Wreckage,%20Hull%20Section.-Master.PDF - Photo 6) Exemplar of Airplane's Hull Section. (item 14, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342343&FileExtension=.PDF&FileName=Photo%206)%20Exemplar%20of%20Airplane%27s%20Hull%20Section.-Master.PDF - Photo 7) View of Passenger Warning Placard on Instrument Panel. (item 15, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342344&FileExtension=.PDF&FileName=Photo%207)%20View%20of%20Passenger%20Warning%20Placard%20on%20Instrument%20Panel.-Master.PDF - Photo 8) View of the Engine During Run Test. (item 16, .PDF, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40342346&FileExtension=.PDF&FileName=Photo%208)%20View%20of%20the%20Engine%20During%20Run%20Test.-Master.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.