# NTSB ERA19LA078: BRM Aero Bristell S-LSA, N587BL, Lakeland, FL, December 22, 2018 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: December 22, 2018, 10:12 local (15:12 UTC) - Place: Lakeland, FL - Coordinates: 27.986665, -82.023887 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=27.9867&lon=-82.0239&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report April 13, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/ FSDO - NTSB case key (mKey): 98855 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA078 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98855/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98855 - Page: https://openairdocs.org/ntsb/ERA19LA078 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [BRM Aero BRISTELL S-LSA, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=0600084), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [BRM Aero BRISTELL S-LSA, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=0600084), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [BRM Aero BRISTELL S-LSA, 1 case](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=0600084), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [BRM Aero BRISTELL S-LSA, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=0600084), [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. - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [BRM Aero BRISTELL S-LSA, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=0600084), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [BRM Aero BRISTELL S-LSA, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=0600084), [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: [BRM Aero BRISTELL S-LSA, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=0600084), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Post-impact: Fire/smoke (post-impact)](https://openairdocs.org/ntsb-events/170); cases with it: [BRM Aero BRISTELL S-LSA, 1 case](https://openairdocs.org/ntsb-events/170/sequence.md?model=0600084), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## 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](https://openairdocs.org/deregistered/N587BL-2020-12-08), registration cancelled 2020-12-08, S/N 087/2014, built 2014 (OpenAirDocs) - Reported make and model: BRM Aero Bristell S-LSA - Registry model: [BRM Aero BRISTELL S-LSA](https://openairdocs.org/model/brm-aero-bristell-s-lsa) (registry code 0600084) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 087/2014 - Year built: 2014 - Airframe hours: 390.8 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 64; injuries: fatal; 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 ## 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 20181222022019A](https://openairdocs.org/incident/20181222022019A), Dec 22, 2018: Brm Aero BRISTELL S-LSA, Lakeland, FL, Destroyed, 1 fatal. On December 22, 2018, at 1012 eastern standard time, a Brm Aero bristell , N587BL, was destroyed when it impacted terrain shortly after takeoff from Lakeland… ## Docket (10 files) The files NTSB released with the investigation on January 29, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98855. 24.1 MB in all. - Record of Conversation (Flight Instructor) (item 1, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480301&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Flight%20Instructor)-Master.PDF - Record of Conversation (Friend of Pilot) (item 2, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480304&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Friend%20of%20Pilot)-Master.PDF - Airframe Examination Summary (item 3, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480305&FileExtension=.PDF&FileName=Airframe%20Examination%20Summary-Master.PDF - ATC Communications Summary (item 4, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480312&FileExtension=.PDF&FileName=ATC%20Communications%20Summary-Master.PDF - Photographs of Student Pilot Logbook (item 5, .PDF, 21.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480313&FileExtension=.PDF&FileName=Photographs%20of%20Student%20Pilot%20Logbook-Master.PDF - Airplane Flight Test Procedure Documents (item 6, .PDF, 421 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480314&FileExtension=.PDF&FileName=Airplane%20Flight%20Test%20Procedure%20Documents-Master.PDF - Toxocology Report (item 7, .PDF, 293 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480315&FileExtension=.PDF&FileName=Toxocology%20Report-Master.PDF - Photo Array (item 8, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480316&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Hourly Weather Observations (item 9, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480317&FileExtension=.PDF&FileName=Hourly%20Weather%20Observations%20-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 319 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40480318&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.