ERA09LA356

NTSB accident investigation · Chris Mitchell Titan Tornado · Chadbourn, NC · June 18, 2009

Accident · FatalLimited investigationFinal report
Date
June 18, 2009, 19:07 local (23:07 UTC)
Place
Chadbourn, NC
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Emergency descent
Aircraft
N259CMChris Mitchell Titan Tornado
Defining event
Emergency descent: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report April 22, 2010
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Jabiru USA, FAA/FSDO
FAA report
20090618011689A
Case key
74080

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot’s failure to maintain aircraft control during initial climb following a loss of engine power. The reason for the power loss was not determined.

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 parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedMitchell Chris TITAN TORNADO II S: 1 caseAll aircraft: 1,269 casesProbable cause
AircraftAircraft › Aircraft power plant · Not specifiedMitchell Chris TITAN TORNADO II S: 1 caseAll aircraft: 151 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

Witnesses observed the pilot perform a normal engine run-up prior to takeoff. Shortly after takeoff they heard a momentary reduction in power, followed by an increase, before the engine completely lost power. The pilot initiated a right turn back to the airstrip and the witnesses observed the airplane stall, enter a spin, and impact the ground. Inspection of the wreckage revealed that the airplane impacted the ground at a steep angle and came to rest inverted. Fuel spillage was evident at the accident site. The fuel selector handle was found in an intermediate position (not on or off); however, this condition was observed after the extraction of the pilot from the wreckage. The engine was sent to the manufacturer’s facilities where a test run was performed. Multiple runs were accomplished and no evidence of a malfunction or failure was noted.

Factual narrative

On June 18, 2009, about 1907 eastern daylight time, an experimental, amateur-built Chris Mitchell Titan Tornado II S, N259CM, was substantially damaged following a loss of engine power and impact with terrain near Chadbourn, North Carolina. The airplane was registered to and operated by the pilot. The non-certificated pilot was killed. 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 flight originated at a private, residential airstrip in Chadbourn at the time of the accident. Witnesses reported that the pilot taxied the airplane to the end of the grass airstrip, where he performed an engine run-up; all seemed normal with the engine. Immediately after takeoff, a reduction in engine power was observed. Power then increased, followed by another power reduction and the airplane stopped climbing. The pilot initiated a right-hand turn back toward the airstrip. One witness reported that the engine completely lost power. While in the turn, the witnesses observed the airplane stall and enter a spin at about 100 feet above ground level, from which it impacted the ground. One of the witnesses owned the airstrip where accident airplane was hangared. He stated that he was a close friend of the pilot. He could not provide any details on the inspection history of the airplane or the total flight time of the pilot, however he did state that the pilot was using automotive gasoline in the airplane. He thought that the engine had been recently removed and repaired due to cylinder cracks. An inspector from the Federal Aviation Administration (FAA) visited the accident site and examined the wreckage. The wreckage came to rest in an open farm field. He reported that the airplane impacted the ground at a steep angle and there were no ground scars observed outside the radius of the wreckage. Flight control continuity was confirmed from the rudder and elevator to the cockpit. The ailerons remained connected to each other; however the aileron push/pull tube was broken from impact with the ground. One blade of the wooden propeller was splintered; the other blade was undamaged. The engine could be rotated freely by hand. Residual fuel in the fuel filter appeared clean and no contaminants were noted. There was no fuel in the carburetor bowl; however the engine remained inverted overnight prior to the examination. The air filter was clean and the spark plugs were normal in appearance. The smell of fuel was apparent in the area of the main wreckage and the ground was oil-soaked under the engine. The fuel shut-off valve was found in an intermediate position (not on or off) and there was no detent for the handle. The engine was shipped to the Jabiru USA facilities in Shelbyville, Tennessee for a test run. The examination was conducted by the NTSB Investigator-in-Charge. The engine was installed on a test stand and plumbed with a fuel source. The numbers 1 and 3 spark plugleads required changing due to impact damage. The engine started on the first attempt. White smoke was initially observed from the exhaust, which cleared in two to three seconds. The engine ran smoothly and without hesitation. A total of four engine runs were performed, each approximately two to three minutes in duration. A peak engine speed of 2,830 RPM was achieved with normal oil pressure readings. The engine examination did not reveal any evidence of a malfunction or failure. The aircraft maintenance records and pilot logbook were not recovered for inspection. According to FAA records, the pilot accumulated a total of 27 hours flight time, all in the accident airplane. A search of FAA records revealed no airman certificates or a medical certificate. Postmortem examination of the pilot was performed by the Office of the Chief Medical Examiner, Chapel Hill, North Carolina. The cause of death was listed as, “Multiple blunt force injuries secondary to airplane crash.” The autopsy report noted that the pilot “was exposed to aviation fuel during the prolonged extraction.” Forensic toxicology was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory (CAMI), Oklahoma City, Oklahoma. The CAMI toxicology report was negative with the exception of ethanol detected in the vitreous (28 mg/dL) and blood (27 mg/dL). No ethanol was detected in the urine. The pilot’s wife was interviewed following the accident. She reported that her husband had a routine day of the accident and that he was in good health. He was not taking any medications and had not consumed any alcohol prior to the accident. She described her husband as a “non-drinker.” The 1859 weather observation for Whiteville, North Carolina (CPC), located about 6 miles southeast of the accident site, included the following: sky clear, surface winds from 170 degrees at 6 knots, 10 statute miles visibility, temperature 30 degrees Celsius, dew point 22 degrees Celsius, and an altimeter setting of 29.86 inches of mercury.

Aircraft

Registration
N259CM
Reported as
Chris Mitchell Titan Tornado (II S)
Category
Airplane, amateur-built
Serial number
S03J22SOHK0451
Engine
Jabiru 2200A, 80 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Shannon L. Harrelson
Registered owner
Shannon L. Harrelson
Airworthiness certificate
Special, Experimental (Special)
Departed
Chadbourn, NC
Destination
Chadbourn, NC
Airport
runway 36, 1,500 × ft, grass/turf

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
Injuries
Fatal
Seat
Left
Toxicology
Performed
Flight hours
27 total · 27 in this make and model · 27 in the last 90 days

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
86 °F, dew point 72 °F
Altimeter
29.86 inHg
Observed at
CPC, 6 nm away

Docket · 11

The files NTSB released with the investigation on February 19, 2010, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.1 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.