ERA19LA078

NTSB accident investigation · BRM Aero Bristell S-LSA · Lakeland, FL · December 22, 2018

Accident · FatalLimited investigationFinal report
Date
December 22, 2018, 10:12 local (15:12 UTC)
Place
Lakeland, FL
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N587BLBRM Aero Bristell S-LSA
Defining event
Initial climb: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report April 13, 2020
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/ FSDO
FAA report
20181222022019A
Case key
98855

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 student pilot's exceedance of the airplane's critical angle of attack during the initial climb, resulting in an aerodynamic stall from which the pilot did not recover.

Findings · 4

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 parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedBRM Aero BRISTELL S-LSA: 1 caseAll aircraft: 1,681 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededBRM Aero BRISTELL S-LSA: 1 caseAll aircraft: 990 casesProbable cause
Performance/control parameters: climb rateAircraft › Aircraft oper/perf/capability · Capability exceededBRM Aero BRISTELL S-LSA: 1 caseAll aircraft: 265 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · Student/instructed pilotBRM Aero BRISTELL S-LSA: 2 casesAll aircraft: 9,295 casesProbable cause

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

The solo student pilot had completed two touch-and-go landings at his home airport in crosswind conditions. During the approach for the third touch-and-go landing, the air traffic controller instructed the pilot to fly a right closed traffic pattern, rather than a standard left traffic pattern (which was performed during the two previous touch-and-go landings), to avoid a potential conflict with another airplane. The pilot acknowledged the instruction. Surveillance video showed that, after the third touch-and-go landing, the airplane began a steep climb along the runway heading, gained altitude rapidly, entered a rapidly descending left turn, and impacted terrain in a near-vertical pitch-down attitude. Although a postcrash explosion and fire consumed most of the airplane, examination of the remaining airplane wreckage found no evidence of a preimpact mechanical malfunction or failure that would have precluded normal operation. The airplane's increased angle of attack and high rate of climb likely led to an exceedance of the critical angle of attack, causing an aerodynamic stall at low altitude from which the student pilot was unable to recover. The investigation could not determine, based on the available evidence, why the pilot did not mitigate the airplane's rapidly increasing angle of attack and climb rate shortly after takeoff given that the airplane was equipped with an angle-of-attack audio and visual stall warning indicator. The autopsy of the pilot found that he had early coronary artery disease. As a result, the pilot might have been at increased risk of a sudden cardiac event that could have caused symptoms such as palpitations, shortness of breath, chest pain, or fainting, but there was no evidence that such an event occurred. Therefore, it is unlikely that the pilot's heart disease contributed to this accident. Toxicology testing detected ethanol in one tissue at a very low level; no ethanol was found in the pilot's brain. The identified ethanol was most likely from postmortem production and therefore did not contribute to the accident circumstances. Although cetirizine, which is sedating and can affect decision-making and performance, was identified in the pilot's liver and muscle specimens, the amount of cetirizine in the pilot's blood, and thus the effects of the pilot's use of this drug, could not be determined.

Factual narrative

The National Transportation Safety Board investigator-in-charge was unable to travel to the accident site due to the lapse in appropriations funding that occurred from December 22, 2018, to January 25, 2019. According to FAA airworthiness records, the single-engine, low-wing airplane was powered by a Rotax 912 ULS engine that drove a three-blade, fixed-pitch propeller. According to airplane logbook entries, an annual and a 100-hour condition inspection were completed in April 2018. The airplane had accumulated a total of 390.8 hours of flight time at the time of that inspection. The aerodynamic stall speeds listed on flight test documents included stall speeds of 45 knots indicated airspeed (KIAS) with no flaps and 38 KIAS with fully extended flaps. According to the student pilot's flight instructor, the airplane was equipped with a Dynon Skyview primary flight display with an audio and a visual angle-of-attack stall warning indicator. On December 22, 2018, at 1012 eastern standard time, a BRM Aero Bristell special light-sport airplane, N587BL, was destroyed when it impacted terrain shortly after takeoff from Lakeland Linder International Airport (LAL), Lakeland, Florida. The solo student pilot was fatally injured. The airplane was registered to Industrial Mobile Cranes, Inc., and operated by the student pilot as a Title 14 Code of Federal Regulations Part 91 training flight. Visual meteorological conditions prevailed at the time of the accident, and no flight plan was filed for the flight, which originated about 0945. According to a friend of the student pilot who lived with him, the evening before and the morning of the accident were routine. The friend reported that the student pilot told her that he planned to stay in the traffic pattern and practice touch-and-go landings at LAL, which was his home airport. The student pilot's flight instructor reported that he had not been contacted by the student before the accident flight and was thus unaware that the student had planned to undertake a solo flight. The flight instructor reported that the student pilot had contacted him before all of the student's past solo flights and that they would normally discuss weather conditions and other aspects of planned flights. Air traffic control communications revealed that the student pilot had completed two touch-and-go landings on runway 27 in a left traffic pattern. Before the third landing, the tower controller instructed the student to fly a right traffic pattern after departure to avoid a potential conflict with another airplane. The student responded, "affirmative, right traffic after this touch and go," which was the last radio transmission from the student. A surveillance video from a building located at LAL showed the accident airplane shortly after liftoff from runway 27 following the airplane's third touch-and-go landing. After the takeoff rotation and a brief climb, the airplane maintained a level attitude over the runway for about 4 secondsand then resumed a normal climb for about 14 seconds. The video showed that, as the airplane climbed, its pitch attitude further increased, causing the airplane to rapidly gain altitude. The airplane was then out of the view of the camera; when the airplane reappeared, it was in a steep, descending left turn heading about the opposite of the takeoff heading. A surveillance video from a second airport camera showed the airplane impact terrain on the airport in a near-vertical attitude, which was followed by a postimpact explosion and fire. An autopsy of the student pilot was performed by the Office of the District Medical Examiner, Winter Haven, Florida. The autopsy results found that the pilot's cause of death was blunt impact to the head and torso. The autopsy results also showed that the pilot had early coronary artery disease. Toxicology testing performed at the FAA Forensic Sciences Laboratory identified 0.015 gm/dl of ethanol in the student pilot's muscle specimens; no ethanol was identified in the pilot's brain specimens. In addition, cetirizine was identified in the pilot's liver and muscle specimens; no blood was available for testing. Ethanol is primarily a social drug and a central nervous system depressant that is absorbed by and quickly distributed throughout the body. Ethanol can also be produced in the body after death. Cetirizine is a sedating antihistamine that is available over the counter. The LAL weather conditions reported at 0950 (about 22 minutes before the accident) included wind from 360° at 5 knots, visibility 10 statute miles, scattered clouds at 1,800 ft above ground level, temperature 12°C, dew point 8°C, and an altimeter setting of 30.18 inches of mercury. The wind reported at 1053 (about 41 minutes after the accident) was from 310° at 12 knots gusting to 16 knots. According to Federal Aviation Administration (FAA) records, the pilot held a student pilot certificate. He did not hold a medical certificate and was not required to do so while operating under sport pilot provisions. A review of his logbook revealed that his flight training began in October 2015 and that he had accumulated 108.8 hours of total flight experience. The student's first flight in the accident airplane was on November 16, 2017. He had accumulated 32.8 flight hours in the accident airplane at the time of the accident, of which 6.4 hours were accumulated during solo flights. During the preceding 90 days, the student had logged 8.6 hours, all of which were in the accident airplane. The pilot's logbook contained a valid 90-day solo endorsement, issued on October 18, 2018, for the accident airplane model, with a crosswind limitation of less than 11 knots. A review of photographs provided by LAL airport operations personnel showed that the airplane impacted an open field on the airport about 800 ft south of runway 27 and that the airplane came to rest in an upright position. A postcrash fire consumed most of the cockpit, avionics, and the fuselage.The left and right leading edges of the wings displayed significant aft crushing. The empennage remained intact and showed minimal fire damage. The engine, which was located with the fuselage, was impact and fire damaged. All three propeller blades were fragmented. Postaccident examination of the airplane established control cable continuity from the cockpit area to the respective control surfaces. When the propeller hub was manually rotated, all pistons rotated, and engine continuity was confirmed. The ignition harness was consumed by fire. Both carburetors were examined; one had some foreign material that appeared consistent with extensive postcrash fire damage, and the other was free of debris.

Aircraft

Registration
N587BL
Reported as
BRM Aero Bristell S-LSA
Category
Airplane
Serial number
087/2014
Built
2014
Airframe hours
390.8
Engine
Rotax 912 ULS, 100 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Industrial Mobile Cranes Inc
Registered owner
Industrial Mobile Cranes Inc
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
Annual · April 1, 2018
Departed
LAL · Lakeland, FL
Destination
LAL · Lakeland, FL
Airport
LAL · Lakeland Linder Rgnl, runway 27, 8,499 × 150 ft, asphalt
Equipment
Electronic primary flight display, Electronic multifunction display, Angle of attack indicator, Stall warning system

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
Student pilot
Age
64
Injuries
Fatal
Certificate
Student
Medical
Sport pilot
Seat
Left
Toxicology
Performed
Flight hours
108.8 total · 32.7 in this make and model · 6.4 as pilot in command · 8.6 in the last 90 days · 1.3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 5 knots
Visibility
10 statute miles
Temperature
54 °F, dew point 46 °F
Altimeter
30.18 inHg
Observed at
KLAL

Docket · 10

The files NTSB released with the investigation on January 29, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 24.1 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.