# NTSB ERA15LA339: Evolution Revo, N2264X, Laconia, NH, September 5, 2015 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: September 5, 2015, 15:38 local (19:38 UTC) - Place: Laconia, NH - Coordinates: 43.606388, -71.452774 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.6064&lon=-71.4528&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report June 29, 2016 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 91927 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA339 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91927/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91927 - Page: https://openairdocs.org/ntsb/ERA15LA339 ## Probable cause The sport pilot’s improper decision to operate the weight-shift-control aircraft at low altitude and his subsequent failure to maintain control of the aircraft, which resulted in a subsequent collision with terrain. ## 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: [Evolution REVO, 8 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=060009B), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Evolution REVO, 1 case](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=060009B), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Evolution REVO, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=060009B), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/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: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Evolution REVO, 6 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=060009B), [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: [Evolution REVO, 7 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=060009B), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Review of GPS information revealed that the sport pilot/owner of the weight-shift-control aircraft completed one left circuit over a beach at a low altitude. During a second circuit, the aircraft was about 100 ft or less above the ground for several minutes before it descended and impacted the backyard of a residence. Examination of the wreckage, which included a successful test run of the engine, did not reveal any preimpact mechanical malfunctions. ## Factual narrative On September 5, 2015, about 1538 eastern daylight time, a special-light-sport, weight-shift-control Evolution Aircraft Revo, N2264X, was substantially damaged when it impacted the backyard of a residence, following a loss of control while circling a nearby beach at low altitude in Laconia, New Hampshire. The sport pilot was fatally injured. The aircraft was registered to and operated by a private individual as a personal flight conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight that departed Laconia Municipal Airport (LCI), Laconia, New Hampshire, about 1530.Several witnesses reported that the aircraft circled very low over the beach and looked like it was going to land. It then banked sharply left and descended nose-down near a residence. Two of the witnesses reported a sputtering or loss of engine noise, while five witnesses reported continuous or an increase in engine noise. The wreckage came to rest inverted. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed substantial damage to both wings and the fuselage. The pilot's four-point restraint system remained intact. The inspector noted that fuel remained in the two carburetor fuel bowls and in the single-fuel tank. He was able to rotate the propeller by hand, confirm valve train continuity and attain thumb compression on all cylinders. Under the direction of the FAA inspector, a mechanic subsequently recovered the aircraft and was able to verify control continuity. Once he replaced a water pump that had sustained impact damage, he was able to successfully test-run the engine on the airframe. Review of the sport pilot's logbook revealed that he had accumulated about 102 hours of flight experience; of which, 91 hours were in the same make and model as the accident aircraft. About 7 of the hours were flown during the 30-day period preceding the accident. Additionally, the sport pilot had recently ferried the accident aircraft from Florida to New Hampshire, but had not recorded that trip in his logbook. Review of the NTSB database revealed that the sport pilot was involved in a landing accident in the same make and model aircraft on April 20, 2014. The probable cause of that accident was his failure to maintain control during a go-around (ERA14CA203). The two-seat, high-wing, fixed tricycle gear, weight-shift-control aircraft, serial number 000594, was manufactured in 2013 and issued a special-light-sport airworthiness certificate by the FAA. It was powered by a Rotax 912ULS, 100-horsepower engine, equipped with three-blade composite propeller. The aircraft logbooks were not recovered and no determination could be made regarding the aircraft's most recent inspection. The aircraft was equipped with an electronic flight information system (EFIS), which was retained and forwarded to the NTSB Vehicle Recorder Laboratory, Washington, DC. Data weresuccessfully downloaded from the EFIS and plotted. Although no engine data were recovered, a GPS plot of the accident flight was generated. Review of the plot revealed that the aircraft departed LCI at 1530, climbed to an altitude about 1,300 feet above ground level (agl), and flew west for about 1 minute. It then turned north and paralleled the shore of Lake Winnipesaukee, descended to about 300 feet agl, where it remained for the majority of the flight. The aircraft completed one left circuit near a beach uneventfully. During a second, wider left circuit, the aircraft descended to about 100 feet agl or less over the lake, where it remained until impacting the backyard of the residence approximately 2 minutes later. The pilot succumbed to his injuries on September 6, 2015 and an autopsy was not performed; however, the New Hampshire Medical Examiner's report noted the cause of death as "Complications of Blunt Head Trauma." Toxicological testing was performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma. Review of the test results revealed: "Etomidate detected in Blood Metoprolol detected in Blood" Etomidate was consistent with emergency treatment the pilot received in the hospital and Metoprolol was an antihypertensive that was not impairing. The recorded weather at LCI, at 1535, included wind from 190 degrees at 4 knots, visibility 9 miles and clear sky. ## Aircraft - Registration: [N2264X](https://openairdocs.org/deregistered/N2264X-2018-03-13), registration cancelled 2018-03-13, S/N 000594, built 2013 (OpenAirDocs) - Reported make and model: EVOLUTION AIRCRAFT INC REVO (NO SERIES) - Registry model: [Evolution REVO](https://openairdocs.org/model/evolution-revo) (registry code 060009B) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Weight-shift - Serial number: 000594 - Year built: 2013 - Engines: Rotax 912ULS 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Panuski William R - Registered owner: Panuski William R - Airworthiness certificate: Special, Experimental light sport (Special) - Departed: LCI, Laconia, NH - Destination: LCI, Laconia, NH - Airport: LCI, Laconia Municipal Airport - Equipment: Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; sport pilot; airplane ratings: single-engine land; medical: sport pilot; seat: front; restraint: 4-point; toxicology performed; flight hours: 102 total, 91 in this make and model, 38 in the last 90 days, 7 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 4 knots - Visibility: 9 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 50 °F - Altimeter: 30.20 inHg - Observed at: LCI, 2 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 20150905021379A](https://openairdocs.org/incident/20150905021379A), Sep 5, 2015: Evolution Aircraft Inc REVO, Laconia, NH, Destroyed, 1 fatal. Aircraft was reported by multiple witnesses to have been circling in the weirs Beech, NH. Area. The aircraft circled twice and each time appeared to be… ## Other investigations on N2264X (1) 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. - [NTSB ERA14CA203](https://openairdocs.org/ntsb/ERA14CA203), Apr 20, 2014: Evolution Revo (N2264X), Concord, NH, substantial damage. Probable cause: The student pilot's failure to maintain control during a go around, which resulted in a collision with terrain. ## Docket (12 files) The files NTSB released with the investigation on May 10, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91927. 5.9 MB in all. - Cockpit Display - Recorded Flight Data Factual Report (item 1, .PDF, 698 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439862&FileExtension=.PDF&FileName=Cockpit%20Display%20-%20Recorded%20Flight%20Data%20Factual%20Report-Master.PDF - Cockpit Display - Recorded Flight Data Factual Report - Attachment 1 (item 2, .CSV, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439863&FileExtension=.csv&FileName=Cockpit%20Display%20-%20Recorded%20Flight%20Data%20Factual%20Report%20-%20Attachment%201-Master.csv - Interview Summaries (item 3, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439864&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Witness Statements (item 4, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439865&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - FAA Inspector Statement (item 5, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439866&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Mechanic Statement (item 6, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439867&FileExtension=.PDF&FileName=Mechanic%20Statement-Master.PDF - Pilot Logbook (item 7, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439868&FileExtension=.PDF&FileName=Pilot%20Logbook-Master.PDF - Fueling Information (item 8, .PDF, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439869&FileExtension=.PDF&FileName=Fueling%20Information-Master.PDF - Weather Report (item 9, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439870&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Toxicological Report (item 10, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439871&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Evidence Control Form (item 11, .PDF, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40440301&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF - Photo Array (Courtesy of Laconia PD) (item 12, .PDF, 2 photos, 346 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40439872&FileExtension=.PDF&FileName=Photo%20Array%20(Courtesy%20of%20Laconia%20PD)-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.