# NTSB ERA19FA036: Titan Tornado 1, N38FD, Louisa, VA, November 4, 2018 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 4, 2018, 14:15 local (19:15 UTC) - Place: Louisa, VA - Coordinates: 38.024444, -77.960556 - Nearby events: https://openairdocs.org/map.md?lat=38.0244&lon=-77.9606&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 20, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 98594 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19FA036 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98594/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98594 - Page: https://openairdocs.org/ntsb/ERA19FA036 ## Probable cause The pilot's failure to maintain airspeed and the airplane's exceedance of its critical angle of attack, which resulted in an aerodynamic stall and spin at a low altitude. ## 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: [Dean Fredrick TITAN TORNADO 1, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05624I4), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Dean Fredrick TITAN TORNADO 1, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=05624I4), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/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: [Dean Fredrick TITAN TORNADO 1, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05624I4), [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. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Dean Fredrick TITAN TORNADO 1, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05624I4), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Dean Fredrick TITAN TORNADO 1, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05624I4), [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: [Dean Fredrick TITAN TORNADO 1, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05624I4), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot of the experimental amateur-built airplane took off and made a left turn to travel north of the airport. A witness at the airport reported that the airplane sounded louder than normal during departure. About 1 minute 18 seconds after takeoff, the airplane climbed to an altitude of about 400 feet above ground level at a groundspeed of 60 knots. During the next 22 seconds, the airplane descended about 300 ft and slowed to a groundspeed of 34 knots before impacting a field. The lack of a discernable debris path, asymmetric damage to both wings, and the airplane's relatively low ground speed immediately before the accident all suggest that the airplane likely departed controlled flight after entering an aerodynamic stall and spin. Examination of the engine revealed no preimpact mechanical malfunctions that would have precluded the engine from operating normally. The muffler had a hole measuring about 2 inches in diameter where the muffler rear mount attached to the engine. Although the pilot had a headset, if the separation of the muffler had occurred during the accident flight, the increased engine noise due to the hole in the muffler could have distracted the him, and resulted in his subsequent loss of control and an aerodynamic stall/spin. The pilot had longstanding hypertensive cardiomyopathy, which could have increased his risk of an arrhythmia that could have caused palpitations, shortness of breath, anxiety, and/or fainting. However, the pilot's medications may have mitigated that risk. Therefore, the investigation could not determine from the available information whether the pilot's heart disease contributed to the circumstances of the accident. ## Factual narrative The single-seat, high-wing, fixed-tricycle gear airplane was assembled from a kit in January 2016. The airplane was powered by a Rotax 503 52-horsepower engine equipped with a ground-adjustable, two-blade Ivoprop propeller. A review of the maintenance records revealed that the airplane's most recent condition inspection was completed on March 6, 2018. At that time, the airplane and engine had been operated 244 hours since new. The airplane flew an additional 21 hours from the time of that inspection to the accident. On November 4, 2018, about 1415 eastern standard time, an experimental amateur-built Titan Tornado 1 airplane, N38FD, was substantially damaged when it impacted a field during initial climb from Louisa County Airport (LKU), Louisa, Virginia. The sport pilot was fatally injured. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed for the local flight. A witness, who worked at the fixed-based operator at the airport, stated that she was inside the fixed-based operator and heard the accident airplane take off sometime between 1400 and 1430. She reported that the takeoff sounded louder than usual and that, as the airplane flew away from the airport area, she heard an expletive over the common traffic advisory frequency and then no further communications from the pilot. The witness also reported that she went outside to see if "something occurred" but didn't see anything. The airport manager at LKU stated that he landed his airplane about 1415, which was about the time that the accident airplane departed. About 1500, the accident airplane was located in a field about 1-mile northeast of the airport. An autopsy of the pilot was performed by the Department of Health, Office of the Chief Medical Examiner, Richmond Virginia. According to the autopsy report, the cause of death was blunt force trauma. The autopsy results also showed that the pilot had an enlarged heart, very mild coronary artery disease, and increased wall thicknesses for the left and right ventricle and septum. Microscopy showed scattered areas of parenchymal and perivascular fibrosis. In addition, the pilot had emphysema and severe atherosclerosis of his aorta. Toxicology testing performed at the FAA Forensic Sciences Laboratory identified atenolol and amlodipine in the pilot's urine and blood specimens and dextrorphan in the pilot's urine specimens. Atenolol and amlodipine are prescription blood pressure medications that are not considered impairing. Dextrorphan, a metabolite of dextromethorphan, would not have been impairing because the level was too low to be detected in the pilot's blood specimens. The pilot's specimens tested negative for carbon monoxide and ethanol. Personal medical records were obtained from the pilot's primary care provider for the 3 years preceding the accident. The pilot was seenregularly during this period for various minor illnesses. He was continually treated for hypertension and high cholesterol. Beginning in 2018, he was diagnosed with neurogenic claudication resulting from spinal stenosis (narrowing of the lumbar spine that squeezes the nerves to the legs), causing pain when walking, which should not have been an issue while the pilot was sitting in the cockpit. At the time of the pilot's last routine visit in June 2018, his medications included amlodipine, atenolol, and lisinopril-hydrochlorothiazide to treat hypertension, low-dose aspirin to prevent heart attacks, and simvastatin to treat cholesterol. None of these medications are considered impairing. The recorded weather at LKU at 1415 indicated the following: wind from 090° at 6 knots, visibility 10 miles, clear sky, temperature 15°C, dew point 3°C, and altimeter setting 30.46 inches of mercury. The pilot, age 70, held a sport pilot certificate with a rating for airplane single-engine land. He was not required to have a current medical certificate as a sport pilot. A review of the pilot's logbook revealed that he had 636 hours of total flight experience, of which about 48 hours were in the accident airplane make and model. The pilot had flown about 6 hours during the 90 days preceding the accident; all of that time was in the accident airplane make and model. His last flight review occurred on June 7, 2015. The airplane came to rest on its right side and was oriented on a magnetic heading of 220°. No debris path was observed. All major components of the airplane were accounted for at the accident site. The wing separated from the airframe, and more leading-edge damage was noted on the right side than the left side of the wing. The flaps and ailerons remained attached to the wing, and the flaps were in the retracted position. The empennage remained intact and undamaged. The elevator, elevator trim tab, and rudder remained attached. Control continuity was confirmed from all control surfaces to the cockpit area. The cockpit was crushed, but the pilot's four-point harness remained intact before it was cut by emergency response personnel. A pair of headsets was found in the cockpit. A single 15-gallon fuel tank was located behind the pilot seat, and a strong smell of fuel was present at the accident site. The engine remained attached to the airframe and appeared undamaged. The rear-mounted propeller remained attached to the engine and was undamaged. The muffler remained attached to the engine at the front mount and was partially attached to the engine at the rear mount. The muffler had a hole that was about 2 inches in diameter, in which corrosion was present, where the muffler attached to its rear mount. Fuel was recovered from the fuel filter and both carburetors. The fuel was clear blue and consistent in color and smell with automobile gasoline that had 1% blue two-cycle aviation oil mixed in. When the propeller was manually rotated, camshaft, crankshaft, valvetrain, and compression were confirmed. A test run of the engine was attempted but was unsuccessful because multiple sections of the electrical system, including the electronic ignition, had been cut by rescue personnel. The four spark plug electrodes were intact and light gray in color. Both carburetors remained intact with no anomalies noted. The engine examinations revealed no preimpact mechanical malfunctions that would have precluded normal operations. A handheld Garmin 295 GPS was found in the wreckage and was forwarded to the National Transportation Safety Board's Vehicle Recorders Laboratory, Washington, DC, where the data were successfully downloaded. The data revealed that the accident flight lasted about 2 minutes. The airplane departed at 1756 universal coordinated time (UTC); based on witness statements regarding the time of departure, it is likely the time recorded by the GPS receiver was in error. The accident airplane made a left turn (to travel to the north) and, about 1 minute 18 seconds after takeoff, was at an altitude of about 400 feet above ground level (agl) at a groundspeed of 60 knots. The data then showed that, over the next 22 seconds, the airplane descended about 300 ft agl and slowed to a groundspeed of 34 knots. The data ended at 1758 UTC with the airplane over the accident site. ## Aircraft - Registration: [N38FD](https://openairdocs.org/deregistered/N38FD-2019-04-11), registration cancelled 2019-04-11, S/N T00503SOHK0383, built 2016 (OpenAirDocs) - Reported make and model: Titan TORNADO 1 - Registry model: [Dean Fredrick TITAN TORNADO 1](https://openairdocs.org/model/dean-fredrick-titan-tornado-1) (registry code 05624I4) (OpenAirDocs) - Registry engine: [Rotax 503 DCDI](https://openairdocs.org/engine/rotax-503-dcdi) (registry code 55566, 2 cycle) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: T00503SOHK0383 - Year built: 2016 - Airframe hours: 265 - Engines: Rotax 503 52 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, March 6, 2018, 21 hours before - Departed: LKU, Louisa, VA - Destination: LKU, Louisa, VA - Airport: LKU, Louisa County, runway 09, 4,300 × 100 ft, asphalt - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 70; injuries: fatal; sport pilot; airplane ratings: single-engine land; medical: sport pilot; last flight review June 7, 2015; seat: single; restraint: 4-point; toxicology performed; flight hours: 613 total, 48 in this make and model, 6 in the last 90 days, 0 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 90° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 59 °F, dew point 37 °F - Altimeter: 30.45 inHg - Observed at: KLKU, 1 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 20181104016929A](https://openairdocs.org/incident/20181104016929A), Nov 4, 2018: Dean Fredrick TITAN TORNADO 1, Louisa, VA, Destroyed, 1 fatal. Aircraft crashed shortly after takeoff for unknown reasons in a field near a solar power station. ## Docket (10 files) The files NTSB released with the investigation on January 23, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98594. 4.8 MB in all. - Interview Summaries (item 1, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480190&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Witness Statement (item 2, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480191&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Excertps From Pilot Logbook (item 3, .PDF, 396 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480192&FileExtension=.PDF&FileName=Excertps%20From%20Pilot%20Logbook-Master.PDF - Excerpts From Maintenance Records (item 4, .PDF, 215 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480193&FileExtension=.PDF&FileName=Excerpts%20From%20Maintenance%20Records-Master.PDF - Photo Array (item 5, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480194&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Toxicological Report (item 6, .PDF, 331 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480195&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Global Positioning System - Specialist's Factual Report (item 7, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480196&FileExtension=.PDF&FileName=Global%20Positioning%20System%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Global Positioning System - Specialist's Factual Report - Attachment 1 (item 8, .CSV, 2 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480197&FileExtension=.csv&FileName=Global%20Positioning%20System%20-%20Specialist%27s%20Factual%20Report%20-%20Attachment%201-Master.csv - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480198&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Evidence Control Form (item 10, .PDF, 229 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480199&FileExtension=.PDF&FileName=Evidence%20Control%20Form-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.