# NTSB ERA09LA250: Gladstone Kitfox, N191KF, Dubre, KY, April 18, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: April 18, 2009, 16:33 local (21:33 UTC) - Place: Dubre, KY - Coordinates: 36.840831, -85.563888 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.8408&lon=-85.5639&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 November 9, 2009 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA Louisville FSDO - NTSB case key (mKey): 73677 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA250 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73677/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73677 - Page: https://openairdocs.org/ntsb/ERA09LA250 ## Probable cause The pilot's failure to maintain airspeed while maneuvering at a low altitude, which resulted in an aerodynamic stall. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Gladstone Charles T JR KITFOX SPEEDSTER, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05602DQ), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Gladstone Charles T JR KITFOX SPEEDSTER, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05602DQ), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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: [Gladstone Charles T JR KITFOX SPEEDSTER, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05602DQ), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis A witness stated that he heard an airplane approaching his house; the airplane was about 200 feet above the trees. It made a left turn next to a creek and reversed its course. The airplane reversed its course again, and was observed above the creek coming back towards his home. The witness observed the fuselage of the airplane swaying from left to right and as well as the airplane making a steep left turn. He observed that the left wing of the airplane was perpendicular to the ground and the ground speed of the airplane appeared to be slow. The airplane continued in the steep left turn, reversed its course again, and leveled out. The wings on the airplane were observed to wobble, and the nose of the airplane pitched down. The airplane collided with the ground in a nose-down attitude and came to rest upright. The witness reported no change in engine noise during the accident sequence. No evidence of any preimpact anomalies was noted with the airframe, flight controls, or engine assembly and accessories. ## Factual narrative HISTORY OF FLIGHT On April 18, 2009, at 1633 central daylight time, an experimental amateur-built, Gladstone Kitfox, N191KF, registered to a private owner, operating as a Title 14 Code of Federal Regulations Part 91 personal flight, collided with the ground while maneuvering near Dubre, Kentucky. Visual meteorological conditions prevailed and no flight plan was filed. The airplane received substantial damage and the private pilot was killed. The flight originated from a private farm in Burkesville, Kentucky, at an undetermined time. A witness stated he heard an airplane approaching his house. The airplane was about 200 feet above the trees. It made a left turn next to a creek and reversed its course, flying back towards Burkesville. The airplane reversed its course again, and was observed above the creek coming back towards the witness' home. The fuselage of the airplane was swaying from left to right and the airplane made a steep left turn. The left wing of the airplane was perpendicular to the ground and the ground speed of the airplane appeared to be slow. The airplane continued in the steep left turn, reversed its course again, and leveled out. The wings on the airplane were observed to wobble, and the nose of the airplane pitched down. The airplane collided with the ground in a nose down attitude, and came to rest upright. The witness reported no change in engine noise during the accident sequence. PERSONNEL INFORMATION The pilot, age 51, held a private pilot certificate issued on May 19, 2004, with ratings for airplane single-engine land and airplane multiengine land. The pilot's last flight review was conducted on April 7, 2008. He received a tailwheel proficiency check on June 7, 2008. The pilot was issued a third-class medical certificate on September 5, 2008, with the limitation, "must have available glasses for near vision." The pilot indicated on his last application for the third-class medical certificate that he had accumulated 525 total flight hours. Review of the pilot's logbook revealed he had accumulated 507 total flight hours, of which 175.3 hours were in airplane multiengine land, 313.5 hours were in airplane single-engine land, 19.1 hours in helicopter rotorcraft, and 48.3 hours were in the Kitfox. The pilot had flown 3 hours in the last 90 days. These 3 hours were in the Kitfox. AIRCRAFT INFORMATION The Gladstone Kitfox is a two-place airplane with a fixed tail-wheel landing gear, serial number 1BS065, registered on November 5, 2008. The airplane was issued a Special Airworthiness Certificate and Operating Limitations on May 14, 1996. A Rotax 912, 80-horsepower engine powers the airplane. Review of the airplane logbooks revealed the last condition inspection was conducted on October 11, 2008, and the Hobbs meter indicated 427.1 hours. The Hobbs meter was destroyed during the accident and the total engine and airframe hours could not be determined. METEOROLOGICAL INFORMATION The nearest weather reporting facility is BowlingGreen, Kentucky, located about 31 miles south of the accident site. The 1753 surface weather observation was: wind 210 degrees at 8 knots, visibility 10 miles, 10,000 broken, temperature 27 degrees Celsius, dew point temperature 4 degrees Celsius, and altimeter setting 30.07 inches of mercury. WRECKAGE AND IMPACT INFORMATION Examination of the crash site revealed the airplane collided with the ground in a nose down, right wing low attitude, and came to rest upright on a heading of 178 degrees magnetic. The engine assembly was buried about 1 foot below the surface of the ground and remained attached to all engine mounts. Two composite propeller blades separated and one propeller blade remained attached to the propeller crankshaft flange. The spinner exhibited evidence of rotation. The engine cowling separated from the airframe. The forward cabin area was crushed down and aft. The instrument panel was crushed down and onto the engine. The right wing remained attached to the airframe and was pushed aft. The leading edge of the right wing exhibited accordion crushing from the wing root, extending outboard to the wing tip. The right main fuel tank was ruptured, the fuel cap had a tight seal, and the fuel vent line was clear of obstructions. Browning of vegetation was present on the ground in front of the airplane. The left wing remained attached to the airframe and was accelerated forward. The leading edge of the left wing exhibited some accordion crushing, extending outboard from the wing root to the wing tip. The left main fuel tank was ruptured, the left main fuel cap had a tight seal, and the fuel vent line was unobstructed. Continuity of the flight controls was confirmed from the flight controls aft to all flight control surfaces. No anomalies were noted with the airframe. The engine was partially disassembled. Two of the top spark plugs were removed. They had dark gray deposits and exhibited normal wear. The in-line fuel filters were examined and were clear of debris and water. The crankshaft was rotated by hand using the one main propeller blade. Valve and drive train continuity was confirmed by rotation of the crankshaft, and continuity was established with all accessory gears. Suction and compression was obtained on all cylinders. Test for spark could not be performed due to engine damage from collision with the ground. MEDICAL AND PATHOLOGICAL INFORMATION The State of Kentucky, Medical Examiner at Louisville, Kentucky, conducted a postmortem examination of the pilot, on April 19, 2009. The cause of death was “blunt force trauma." The Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma performed postmortem toxicology of specimens from the pilot. The results were negative for carbon monoxide, cyanide, and ethanol. Naproxen was detected in the blood and urine. ADDITIONAL INFORMATION Review of performance data in the Pilot's Operating Handbook states on page 5, Performance, the stall speed with a Rotax912 engine power on, full flaps, solo is 34 mph, and dual is 42 mph. The stall speed power off, full flaps, solo is 37 mph, and dual is 45 mph. Additional performance data for the Kitfox revealed the airplane would stall at 39 mph power off. ## Aircraft - Registration: [N191KF](https://openairdocs.org/deregistered/N191KF-2013-09-16), registration cancelled 2013-09-16, S/N 1BS065, built 1996 (OpenAirDocs) - Reported make and model: Gladstone Kitfox - Registry model: [Gladstone Charles T JR KITFOX SPEEDSTER](https://openairdocs.org/model/gladstone-charles-t-jr-kitfox-speedster) (registry code 05602DQ) (OpenAirDocs) - Registry engine: [Bombardier ROTAX (ALL)](https://openairdocs.org/engine/bombardier-rotax-all) (registry code 09050, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 1BS065 - Airframe hours: 422 - Engines: Rotax 912 80 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: David M. Long - Registered owner: David M. Long - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, October 11, 2008 - Departed: NONE, Burkesville, KY - Destination: Burkesville, KY ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; medical: class 3, with waivers/limitations; last flight review April 7, 2008; seat: left; toxicology performed; flight hours: 507 total, 48 in this make and model, 3 in the last 90 days ## Weather - Conditions: Visual (VMC), Dawn - Wind: 210° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft broken - Temperature: 81 °F, dew point 39 °F - Altimeter: 30.00 inHg - Observed at: BWG, 35 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 20090418004469A](https://openairdocs.org/incident/20090418004469A), Apr 18, 2009: Amtr KITFOX, Dubre, KY, Substantial damage, 1 fatal. (-23) On April 18, 2009, at 1633 central daylight time, an experimental amateur-built, gladstone Kitfox, N191KF, registered to a private owner, operating as a… ## Docket (21 files) The files NTSB released with the investigation on June 26, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73677. 28.0 MB in all. - Statements (item 1, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40311973&FileExtension=.PDF&FileName=Statements-Redacted.PDF - FAA Inspector Statement Dougherty (item 2, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312256&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement%20Dougherty-Redacted.PDF - FAA Inspector Statement Cox (item 3, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312257&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement%20Cox-Redacted.PDF - Extract Pilot Operating Handbook (item 4, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312258&FileExtension=.PDF&FileName=Extract%20Pilot%20Operating%20Handbook-Redacted.PDF - Kitfox Performance Data (item 5, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40311975&FileExtension=.PDF&FileName=Kitfox%20Performance%20Data-Master.PDF - Extract Pilot Logbooks (item 6, .PDF, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312259&FileExtension=.PDF&FileName=Extract%20Pilot%20Logbooks-Redacted.PDF - Police Report (item 7, .PDF, 270 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312027&FileExtension=.PDF&FileName=Police%20Report-Redacted.PDF - Extract Aircraft Log Books (item 8, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312260&FileExtension=.PDF&FileName=Extract%20Aircraft%20Log%20Books-Redacted.PDF - Experimental Operating Limitations (item 9, .PDF, 213 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312271&FileExtension=.PDF&FileName=Experimental%20Operating%20Limitations-Redacted.PDF - Registration and Special Airworthiness Certificate (item 10, .PDF, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312272&FileExtension=.PDF&FileName=Registration%20and%20Special%20Airworthiness%20Certificate-Master.PDF - Toxicology (item 11, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313723&FileExtension=.PDF&FileName=Toxicology-Redacted.PDF - Photo 1 - Front view of airplane. Photo FAA (item 12, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312261&FileExtension=.PDF&FileName=Photo%201%20-%20Front%20view%20of%20airplane.%20Photo%20FAA-Master.PDF - Photo 2 - Right side view of airplane. Photo FAA (item 13, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312262&FileExtension=.PDF&FileName=Photo%202%20-%20Right%20side%20view%20of%20airplane.%20Photo%20FAA-Master.PDF - Photo 3 - Right side rear view. Photo FAA (item 14, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312263&FileExtension=.PDF&FileName=Photo%203%20-%20Right%20side%20rear%20view.%20Photo%20FAA-Master.PDF - Photo 4 - Rear view of airplane. Photo FAA (item 15, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312264&FileExtension=.PDF&FileName=Photo%204%20-%20Rear%20view%20of%20airplane.%20Photo%20FAA-Master.PDF - Photo 5 - Left rear side view. Photo FAA (item 16, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312265&FileExtension=.PDF&FileName=Photo%205%20-%20Left%20rear%20side%20view.%20Photo%20FAA-Master.PDF - Photo 6 - Left front side view. Photo FAA (item 17, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312266&FileExtension=.PDF&FileName=Photo%206%20-%20Left%20front%20side%20view.%20Photo%20FAA-Master.PDF - Photo 7 - Front view with one propeller blade visible. Photo FAA (item 18, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312267&FileExtension=.PDF&FileName=Photo%207%20-%20Front%20view%20with%20one%20propeller%20blade%20visible.%20Photo%20FAA-Master.PDF - Photo 8 - View of engine assembly. Photo FAA (item 19, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312268&FileExtension=.PDF&FileName=Photo%208%20-%20View%20of%20engine%20assembly.%20Photo%20FAA-Master.PDF - Photo 9 - View of instrument panel. Photo FAA (item 20, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312269&FileExtension=.PDF&FileName=Photo%209%20-%20View%20of%20instrument%20panel.%20Photo%20FAA-Master.PDF - Photo 10 - View of fuel selector valve located under throttle quadrant. Photo FAA (item 21, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40312270&FileExtension=.PDF&FileName=Photo%2010%20-%20View%20of%20fuel%20selector%20valve%20located%20under%20throttle%20quadrant.%20Photo%20FAA-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.