# NTSB ERA19FA225: Quicksilver Mxii, N3889Z, Oliver Springs, TN, July 13, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: July 13, 2019, 17:12 local (21:12 UTC) - Place: Oliver Springs, TN - Coordinates: 36.040554, -84.306114 - Nearby events: https://openairdocs.org/map.md?lat=36.0406&lon=-84.3061&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: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 99831 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19FA225 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99831/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99831 - Page: https://openairdocs.org/ntsb/ERA19FA225 ## Probable cause The noncertificated pilot’s decision to continue to takeoff and climb after encountering an undetermined airplane control issue that he was unable to counteract, which resulted in collision with trees and subsequent impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) - [Performance/control parameters: yaw control](https://openairdocs.org/ntsb-findings/01062024): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [All aircraft, 149 cases](https://openairdocs.org/ntsb-findings/01062024/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [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. - [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333); cases with it: [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [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: [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The noncertificated pilot had purchased the aircraft several weeks before the accident and had flown it before the accident flight. However, the pilot’s flight experience could not be determined. A friend of the pilot indicated that the pilot was making modifications to the airplane, including a new instrument panel, steerable nosewheel, and spoilers. However, no maintenance records were located. A camera mounted to the airplane had recorded the accident flight. The video showed that after the airplane lifted off the runway and as it pitched up, it immediately entered a left bank and yaw and began drifting sharply to the left. This was immediately followed decrease in engine power, which indicates that the pilot likely attempted to abort the climb. However, as the airplane continued left over tall grass, the engine power increased, consistent with the pilot attempting to climb out. The airplane continued to make a flat climbing left turn toward a tree line perpendicular to the runway. Seventeen seconds after takeoff, the aircraft struck the top of a tree, rolled left, and descended toward the ground as the video recording ended. Examination of the airframe and engine did not reveal any evidence of preimpact mechanical malfunctions that would have precluded normal operation. The rudder trim was bent in a right 35° angle; however, it could not be determined the trim had placed in this position prior to the accident flight, or as a result of the impact. Even if the rudder trim were bent before impact, it is unlikely that the rudder trim would create an abrupt turning of the airplane that could not be counteracted. Videos that the pilot took with his cell phone from the ground 6 days before the accident showed the airplane maneuvering and landing several times. Another video taken that day showed two individuals taxiing in the accident airplane likely after a flight. The accident pilot asked, "What do you think about that?" The individual in the right seat responded, "It still, freaking, pulls hard to the right." It is unknown if the comment referenced ground control or flight control. The comment indicates that a potential control irregularity of the airplane existed before the accident flight; however, the individual did not specify the nature of the control irregularity, and the investigation could not determine what the control irregularity was, based on the available evidence. It is likely that the noncertificated pilot was faced an airplane control issue immediately after takeoff and elected to continue the flight instead of landing in the grass. ## Factual narrative According to Federal Aviation Administration airworthiness and airplane maintenance records, the airplane was originally issued a special airworthiness certificate in the experimental, amateur-built category on May 11, 1983. The airplane registration had expired and was subsequently cancelled in 2012. A friend of the pilot stated that the airplane had changed hands several times and that the pilot was making modifications to the airplane, including a new instrument panel, a steerable nosewheel, and spoilers. No airframe or engine logbooks were recovered, and no maintenance history could be ascertained. A MobileSpec Dash Cam was recovered from the wreckage and sent to the National Transportation Safety Board Vehicle Recorder Division, Washington, DC, for examination and download. The camera, a compact digital recording device capable of recording high definition video and audio, was mounted to the frame of the airplane and showed a forward field of view that included the instrument panel and left control pedals. On July 13, 2019, at 1712 eastern daylight time, an experimental, amateur-built light sport Quicksilver MXII, N3889Z, was substantially damaged when it was involved in an accident near Oliver Springs Inc Airport (TN08), Oliver Springs, Tennessee. The noncertificated pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. A camera mounted to the frame of the airplane recorded the accident flight beginning at 1707:21. The camera recorded the pilot/owner seated in the left seat of the airplane. He started the engine and began to taxi. The pilot back-taxied north on runway 15, turned around at the start of the runway, paused briefly, increased power, and taxied into position for a runway 15 departure. The pilot then increased engine power and began the takeoff roll. The airplane lifted off the runway as the airspeed indicator was just below the green arc, showing about 30-33 mph. As the airplane pitched up, it immediately entered a left bank and yaw and began drifting sharply to the left over tall grass bordering the runway; this was immediately followed by a decrease in engine rpm. The airplane continued left over the tall grass, and the engine rpm increased. The pilot added right pedal input. The airplane continued to make a flat climbing left turn and was headed for a tree line about 500 ft northeast of the runway. Twelve seconds after takeoff, the airplane was perpendicular to the runway, facing the tree line and below the treetops. The airplane continued to climb away from the runway toward the trees. Fifteen seconds after takeoff, there was a quick, slight right bank and nose down pitch, and the airplane appeared to stop the left turn, then returned to wings level and continued the left turn. Seventeen seconds after takeoff, the airplane approached the top of a tree. The airplane then suddenly jerked into a left yaw, which developed into a steep left descending roll untilthe airplane was inverted. The video ended at 1712:40 just before ground impact. A witness observed the airplane taxi and take off. He reported that after takeoff, the airplane appeared to crab into the wind and then started turning left toward the trees bordering the northeast side of the airport. He also noted that the wings were rocking. The airplane climbed over the trees, turned left, and descended out of view. He heard the airplane impact terrain. The pilot’s mobile phone was recovered, and three videos from about a week before the accident (July 7) showed the airplane maneuvering over and landing at the airport. Another video taken that day by the pilot showed two individuals seated in the accident airplane, taxiing toward the camera likely after a flight. The airplane stopped directly in front of the camera; the accident pilot was recording and asked "What do you think about that?" The person in the right seat motioned to the right with his hand and said, "It still, freaking, pulls hard to the right." It is unknown if the person was referring to ground control or flight control. The Knox County Regional Forensic Center, Knoxville, Tennessee, performed an autopsy on the pilot. The autopsy report stated that the cause of death was "multiple blunt force injuries." The FAA Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot and the results were negative for carbon monoxide, ethanol, and illicit or impairing drugs. No pilot logbooks were recovered, and no flight hours could be ascertained. A friend of the pilot stated that the pilot had purchased the airplane several weeks before the accident and that he believed the pilot had flying experience in other Quicksilver airplanes. The airplane was found in a steep nose-down attitude on a heading of about 200° magnetic about 650 ft northeast of runway 15 on flat grassy terrain adjacent to 75-ft-tall trees. The wreckage path was compact; all engine components, structural components, and flight control surfaces were accounted for at the scene. The three-blade propeller remained attached to the flange and was intact except for several nicks and gouges on the leading edges of the blades. The engine remained attached to the fuselage keel beam (root assembly), and the propeller shaft remained attached to the propeller. The carburetor had detached from the engine and was held in place by the fuel lines, one of which was torn and leaking fuel. The fuel tank was compromised, and there was a strong smell of automobile fuel at the scene, as well as browning of ground vegetation in the immediate vicinity of the wreckage site. The empennage was in a vertical position off the ground. The elevator and rudder remained attached. The rudder trim was bent in a right 35° angle (left rudder deflection). There was numerous bending of the fuselage tubes throughout the entire airframe. Both wings remained attached, with the fabric covering thewings torn in multiple locations, but the internal ribs and wing spars exhibited little damage. Flight control continuity was confirmed from the flight control surfaces to the cockpit. The spoilers functioned and remained attached to their respective surfaces. The king-post and all structural cable assemblies remained attached to their respective locations. There was no evidence of postaccident fire. Engine cylinder compression and powertrain continuity were established by rotating the propeller by hand 720°. The fuel filter container was clean and about 1/2 full of fuel. When placed under pressure, fuel flowed smoothly from the fuel line into the carburetor. The carburetor was removed and disassembled. The carburetor gaskets were examined with no anomalies noted. The float assembly remained intact with no anomalies noted. The air filter was free of obstructions. The engine cylinder head was removed and revealed no anomalies. Two pistons appeared to be well lubricated, shiny with no damage or irregularity noted, and the Nos. 1 and 2 spark plugs were unremarkable in appearance. No mechanical deficiencies were found that would have precluded normal operation of the engine. ## Aircraft - Registration: N3889Z (not matched to a registry record) - Reported make and model: QUICKSILVER MXII - Category: Airplane, amateur-built - Serial number: 1141 - Year built: 1983 - Engines: Rotax 503 50 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental light sport (Special) - Departed: TN08, Oliver Springs, TN - Destination: TN08, Oliver Springs, TN - Airport: TN08, Oliver Springs Inc, runway 15, 2,800 × 200 ft, grass/turf - Equipment: Video recording device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: fatal; seat: left; toxicology performed ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 70 °F - Altimeter: 30.05 inHg - Observed at: OQT, 5 nm away ## Docket (9 files) The files NTSB released with the investigation on January 8, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99831. 7.6 MB in all. - Record of conversation_witnesses (item 1, PDF, 3 pages, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9372192&FileExtension=pdf&FileName=Record%20of%20Conversation_Witnesses-Rel.pdf - Sheriffs office_witness statement (item 2, PDF, 1 page, 568 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9379877&FileExtension=pdf&FileName=Sheriffs%20Office%20Voluntary%20Statement_Redacted-Rel.pdf - Memorandum of record_FAA (item 3, PDF, 1 page, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9380260&FileExtension=pdf&FileName=Memorandum%20for%20Record-FAA_Redacted-Rel.pdf - Memorandum for record-mobile phone video recording (item 4, PDF, 1 page, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9380904&FileExtension=pdf&FileName=Memorandum%20for%20Record-Mobile%20Phone%20Video%20Recording-Rel.pdf - Toxicological report (item 5, PDF, 1 page, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9304246&FileExtension=pdf&FileName=Pilot_Toxicology_Redacted-Rel.pdf - Photo array-accident site and damage (item 6, PDF, 4 pages, 778 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9587989&FileExtension=pdf&FileName=Accident%20Site%20and%20Damage%20Photographs-Rel.pdf - Airport and accident site overview map (item 7, PDF, 1 page, 321 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9372489&FileExtension=pdf&FileName=Airport%20Overview%20Map-Rel.pdf - Wreckage and evidence release documentation (item 8, PDF, 4 pages, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9586222&FileExtension=pdf&FileName=Wreckage%20Release%20Airplane_Redacted-Rel.pdf - Onboard image recorder specialist's factual report (item 9, PDF, 5 pages, 338 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11742927&FileExtension=pdf&FileName=ERA19FA225_SummaryReport-Rel.pdf From the NTSB's public API. 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