# NTSB ERA09LA356: Chris Mitchell Titan Tornado, N259CM, Chadbourn, NC, June 18, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: June 18, 2009, 19:07 local (23:07 UTC) - Place: Chadbourn, NC - Coordinates: 34.303054, -78.822502 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.3031&lon=-78.8225&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Defining event: [Emergency descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 22, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Jabiru USA, FAA/FSDO - NTSB case key (mKey): 74080 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA356 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74080/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74080 - Page: https://openairdocs.org/ntsb/ERA09LA356 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Mitchell Chris TITAN TORNADO II S, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05619JP), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Mitchell Chris TITAN TORNADO II S, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=05619JP), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01050000): Aircraft › Aircraft power plant · Not specified; cases with it: [Mitchell Chris TITAN TORNADO II S, 1 case](https://openairdocs.org/ntsb-findings/01050000/cases.md?model=05619JP), [All aircraft, 151 cases](https://openairdocs.org/ntsb-findings/01050000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Mitchell Chris TITAN TORNADO II S, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=05619JP), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Emergency descent: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Mitchell Chris TITAN TORNADO II S, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05619JP), [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: [Mitchell Chris TITAN TORNADO II S, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05619JP), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N259CM-2017-04-25), registration cancelled 2017-04-25, S/N S03J22SOHK0451, built 2005 (OpenAirDocs) - Reported make and model: Chris Mitchell TITAN TORNADO (II S) - Registry model: [Mitchell Chris TITAN TORNADO II S](https://openairdocs.org/model/mitchell-chris-titan-tornado-ii-s) (registry code 05619JP) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: S03J22SOHK0451 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - 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 ## 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 20090618011689A](https://openairdocs.org/incident/20090618011689A), Jun 18, 2009: Amtr TITANTORNADO, Chadbourn, NC, Destroyed, 1 fatal. (-23) Pilot taxied aircraft to end of runway and performed an engine run up inspection. Engine sound seemed normal. Aircraft proceeded to takeoff. At about the… ## Docket (11 files) The files NTSB released with the investigation on February 19, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74080. 5.1 MB in all. - Toxicological Report (item 1, .PDF, 106 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324816&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - FAA Inspector Notes (item 2, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324821&FileExtension=.PDF&FileName=FAA%20Inspector%20Notes-Redacted.PDF - Memo of Record - Engine Exam (item 3, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324817&FileExtension=.PDF&FileName=Memo%20of%20Record%20-%20Engine%20Exam-Master.PDF - Memo of Record - R. Harrelson (item 4, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324818&FileExtension=.PDF&FileName=Memo%20of%20Record%20-%20R.%20Harrelson-Master.PDF - Memo of Record - D. Long (item 5, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324819&FileExtension=.PDF&FileName=Memo%20of%20Record%20-%20D.%20Long-Master.PDF - Photo 1: Main Wreckage, View from Front (FAA Digital Photo) (item 6, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324822&FileExtension=.PDF&FileName=Photo%201%3A%20Main%20Wreckage,%20View%20from%20Front%20(FAA%20Digital%20Photo)-Master.PDF - Photo 2: Main Wreckage, View from Rear (FAA Digital Photo) (item 7, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324823&FileExtension=.PDF&FileName=Photo%202%3A%20Main%20Wreckage,%20View%20from%20Rear%20(FAA%20Digital%20Photo)-Master.PDF - Photo 3: Cockpit Area (FAA Digital Photo) (item 8, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324824&FileExtension=.PDF&FileName=Photo%203%3A%20Cockpit%20Area%20(FAA%20Digital%20Photo)-Master.PDF - Photo 4: Engine and Propeller (FAA Digital Photo) (item 9, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324825&FileExtension=.PDF&FileName=Photo%204%3A%20Engine%20and%20Propeller%20(FAA%20Digital%20Photo)-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40325849&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Memo for Record - Fuel Source (item 11, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326407&FileExtension=.PDF&FileName=Memo%20for%20Record%20-%20Fuel%20Source-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.