# NTSB ERA21FA142: Luscombe 8E, N2960K, Jupiter, FL, February 28, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: February 28, 2021, 12:30 local (17:30 UTC) - Place: Jupiter, FL · In woods and thick brush - Coordinates: 26.978355, -80.211607 - Nearby events: https://openairdocs.org/map.md?lat=26.9784&lon=-80.2116&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, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 102683 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21FA142 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102683/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102683 - Page: https://openairdocs.org/ntsb/ERA21FA142 ## Probable cause The pilot’s exceedance of the airplane’s critical angle of attack, which led to an aerodynamic stall and loss of control. Contributing to the accident was the pilot’s inadequate preflight inspection of the airplane, resulting in an unsecured engine cowl that likely distracted the pilot during takeoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Luscombe 8E, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=8190112), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Fuselage: aerodynamic fairings structure](https://openairdocs.org/ntsb-findings/01035350): Aircraft › Aircraft structures · Inadequate inspection (probable cause); cases with it: [Luscombe 8E, 1 case](https://openairdocs.org/ntsb-findings/01035350/cases.md?model=8190112), [All aircraft, 5 cases](https://openairdocs.org/ntsb-findings/01035350/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Luscombe 8E, 19 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=8190112), [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 · Capability exceeded (probable cause); cases with it: [Luscombe 8E, 2 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=8190112), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Luscombe 8E, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=8190112), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Initial climb: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Luscombe 8E, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=8190112), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Luscombe 8E, 4 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=8190112), [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: [Luscombe 8E, 2 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=8190112), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis A witness reported that the engine sounded “strong” when the pilot and pilot-rated passenger took off from the 2,700-ft paved runway. Video of the takeoff showed a normal takeoff near the midpoint of the runway followed by a level-off about 30 ft above the ground. About that time the sound produced by the engine reduced in what appeared to be an attempt to land on the remaining runway. As the airplane passed in front of the camera, the front left engine cowl could be seen open and flapping. As the airplane proceeded to fly down the runway, the engine power increased, and the airplane began to climb. The airplane’s wings rocked left and right as the airplane climbed over the end of the runway and turned left before disappearing out of the camera’s view toward nearby trees. The airplane subsequently impacted trees and terrain about 700 ft beyond and to the left of the departure end of the runway. A postaccident examination of the airplane and test run of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The airplane’s engine cowling fasteners were unlatched, but otherwise intact and undamaged. A performance study based on video and ADS-B data revealed that, after departure, the airplane entered a climbing left turn during which it slowed to a calculated calibrated airspeed near its published stall speed. The turn, combined with the low speed, likely resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall. It is also likely that the engine cowling was not fully secured before the flight. Based on available information, it is likely that the pilot became distracted when the cowling opened during takeoff and did not maintain control of the airplane. The pilot’s post-mortem toxicology results indicated that at some point prior to the flight he had used cannabis. However, the absence of any active parent drug (delta-9-THC) or active metabolite (11-hydroxy-delta-9-THC) indicated that it was very unlikely that he was impaired by any effects from his use at the time of the accident. The detected level of cetirizine (a sedating antihistamine) in the pilot’s specimens was below the blood level thought to cause symptoms, though because the specimens were from cavity blood, they may not accurately reflect antemortem levels. Therefore, whether the pilot was impaired by effects from cetirizine and whether those effects contributed to his failure to secure the cowling and his distraction during the takeoff could not be determined. ## Factual narrative On February 28, 2021, at 1230 eastern standard time, a Luscombe 8E, N2960K, was substantially damaged when it was involved in an accident near Jupiter, Florida. The pilot was fatally injured and the pilot-rated passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. A witness reported that the pilot spent 45 minutes performing engine runups in front of his hangar the day prior to the accident and that on the day of the accident, the pilot, and his pilot-rated passenger, departed from the 2,700-ft paved runway at Tailwinds Airport (FD15). A witness, located near the midpoint of the runway, recorded video of the takeoff and stated that the engine sounded “strong” as the tailwheel airplane lifted off. The recording showed that as the airplane passed in front of the camera, the left engine cowling was open and flapping. A reduction in engine power was heard and the airplane leveled off about 30 ft above ground level (see figure 1). As the airplane leveled off, the engine power was reduced further and the airplane appeared to descend toward the runway. Engine power then increased and the airplane began to climb; the wings rocked during the level off and subsequent climb before the airplane made a gradual left turn to the north and disappeared out of camera view. Figure 1 – Still frame from video showing the accident airplane during takeoff. Note open left engine cowling. Witness accounts of the engine operation were inconsistent. Reports variously indicated that the engine was running rough, that it lost power, and that it sounded “strong.” According to the pilot-rated passenger, who had no recollection of the accident flight, a new carburetor was installed about 1 month prior to the accident, and the engine runups performed the day before the accident were due to high exhaust gas temperatures (EGT). He stated they filled up the airplane with about 30 gallons of fuel and likely used about 3 gallons of fuel during the engine runups. The airplane impacted dense woods and terrain about 700 ft northeast of the airport on a heading of about 035° from the departure end of runway 9 at an elevation of 20 ft above mean sea level. The airplane came to rest on its right side, with the left wing pointing up in a near-vertical position with leading edge exhibiting compression damage. The right wing was separated from the fuselage at the wing root and the leading edge showed damage consistent with tree impact. The right-wing strut sheared off from the wing and the fuselage and was discovered about 75 ft from the main wreckage. First responders reported a strong fuel odor at the site during rescue and recovery. On-scene examination revealed that fuel was present in the gascolator and fuel lines leading from the fuel tanks into the engine. The ground under the right wing near the wing root was saturated with fuel and fuel was dripping from a fractured fuel line. Recovered fuel was lightblue, clear, and free of water or debris. Tree damage consistent with propeller strikes was observed near the wreckage. The propeller remained attached to the hub and exhibited aft bending with a slight s-bend. The propeller had diagonal chordwise scrapes on one of the blades. Flight control continuity was confirmed on all flight control surfaces, through their respective control cables into the cockpit. The engine cowl remained attached on the right side and the wing nuts were secured in place. The left side, which had flush mounted screw fasteners, was unlatched and there was no damage noted to the fasteners or their receptacles. A postaccident engine start and run-up were conducted. New ignition leads were installed on the right magneto and the top spark plugs were replaced with serviceable units to facilitate engine start and operation. The engine was started and cycled from idle to 75% power over 90 seconds with no anomalous behavior noted. Examination of the wreckage revealed no evidence of any preimpact mechanical malfunctions or failures with the engine that would have precluded normal operation. According to the autopsy report prepared by the Medical Examiner Department, District 19, State of Florida, the pilot’s cause of death was blunt impact trauma and manner of death was accident. No significant natural disease was identified. According to toxicology testing performed on the pilot by the Steward Reference Laboratory at the request of the medical examiner, delta-9-THC (tetrahydrocannabinol, the primary active component in cannabis) was identified at less than 1.0 ng/ml in chest blood. None of the active metabolite, 11- Hydroxy-delta-9 THC was detected. The inactive metabolite, carboxy-delta-9-THC was found at 18.9 ng/ml. According to toxicology testing performed by the Federal Aviation Administration’s (FAA) Forensic Sciences Laboratory, cetirizine (a sedating antihistamine) was detected at 177 ng/ml in cavity blood. In addition, although no delta-9- THC or 11-hydroxy- delta-9-THC were detected in cavity blood, 11-hydroxy- delta-9-THC was detected in liver (not quantified), and carboxy-delta-9-THC was found at 18.3 ng/ml in cavity blood and in liver (not quantified). An engine data monitor (EDM) was recovered from the airplane and sent to the National Transportation Safety Board (NTSB) Vehicle Recorders Laboratory for data download. The EDM recorded EGT, cylinder head temperature (CHT), fuel flow in gallons per hour (GPH), voltage, and time. The data showed that the CHT and EGT remained consistent throughout the takeoff and fuel flow increased from 2.6 GPH to a maximum of 7.4 GPH before decreasing to 3 GPH over 24 seconds until recorded data ceased. The video of the flight was sent to the NTSB Vehicle Performance Division where a performance study was accomplished. Based on the video, the airplane’s height above ground, speed, and the sound of the engine rpm, were calculated and combined with automatic dependentsurveillance-broadcast (ADS-B) data provided by the FAA. It was determined that the video recorded 28 seconds of flight as the airplane overflew the runway. Location, altitude, and roll data were determined from video time 7 seconds until 28 seconds. Additionally, engine rpm was determined from the video sound for the duration of the video. During the initial seconds of the takeoff climb, the airplane gained altitude and speed. At 10 seconds, the engine rpm dropped and then decreased further at 17 seconds; this corresponded to a point on the video where the left cowl flap was open and flapping. After the second decrease in rpm, the airplane lost altitude and the speed reduced. The airplane again climbed as the rpm steadily increased up to about 1,850 before the video portion of the flight ended. ADS-B data showed that the airplane was about 50 ft above the ground as it flew beyond the end of the runway; it continued to slow and had slowed to below a calculated calibrated airspeed of 40 kts by the end of the ADS-B data. The airplane’s Owner’s Handbook reported that the airplane’s stall speed was 48 mph, indicated airspeed, or 42 kts. As the airplane turned left, the bank angle increased to more than 20°, which would have increased the stall speed. ## Aircraft - Registration: [N2960K](https://openairdocs.org/deregistered/N2960K-2022-05-25), registration cancelled 2022-05-25, S/N 5687, built 1947 (OpenAirDocs) - Reported make and model: LUSCOMBE 8E - Registry model: [Luscombe 8E](https://openairdocs.org/model/luscombe-8e) (registry code 8190112) (OpenAirDocs) - Registry engine: [Continental C90 series](https://openairdocs.org/engine/continental-c90-series) (registry code 17009, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 5687 - Year built: 1947 - Engines: Continental C90-12F 90 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 22, 2020, 12 hours before - Airport: FD15, Tailwinds Airpark, runway 09, 2,700 × 50 ft, asphalt - Equipment: ADS-B, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 3; last flight review June 10, 2019; seat: left; toxicology performed; flight hours: 3,600 total, 9.4 in this make and model, 3,816.3 as pilot in command, 65.2 in the last 90 days, 12 in the last 30 days - Pilot-rated passenger; age 18; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review January 21, 2021; seat: right; flight hours: 256.9 total, 2.4 in this make and model, 201.2 as pilot in command, 58 in the last 90 days, 45 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 9 knots, gusting 18 - Visibility: 10 statute miles - Lowest ceiling: 3,600 ft broken - Temperature: 82 °F, dew point 66 °F - Altimeter: 3020.00 inHg - Observed at: F45, 8 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 20210228002999A](https://openairdocs.org/incident/20210228002999A), Feb 28, 2021: Luscombe 8E, Jupiter, FL, Destroyed, 1 fatal. Part 91 operator, operating 1947 Luscombe, model 8E, serial number 5687 and registration number N2960K. Two pilots on board take off form Tailwinds Airport… ## Other investigations on N2960K (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 MKC66D0519](https://openairdocs.org/ntsb/MKC66D0519), Apr 2, 1966: Luscombe 8E (N2960K), St. Charles, MO, substantial damage ## Docket (15 files) The files NTSB released with the investigation on December 13, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102683. 208 MB in all. - Record of conversation - pilot-rated passenger (item 1, PDF, 2 pages, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12058661&FileExtension=pdf&FileName=Record%20of%20Coversation_Second%20Pilot-Rel.pdf - Record of conversation_witness and mechanic (item 2, PDF, 3 pages, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13329814&FileExtension=pdf&FileName=Record%20of%20Conversation_Witness%20and%20Mechanic-Rel.pdf - FAA inspector's statement (item 3, PDF, 3 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13367669&FileExtension=pdf&FileName=Inspector%20Statement%20N2960K_Redacted-Rel.pdf - Maintenance logs excerpts (item 4, PDF, 5 pages, 10.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13329711&FileExtension=pdf&FileName=Maintenance%20Logs%20Excerpt_Redacted-Rel.pdf - Airplane operations manual excerpts (item 5, PDF, 11 pages, 11.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13345407&FileExtension=pdf&FileName=Luscombe%20Operations%20and%20Specifications%20Excerpt-Rel.pdf - Photo array_accident site and damage (item 6, PDF, 10 pages, 6.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13347411&FileExtension=pdf&FileName=Accident%20Site%20and%20Damage%20Photographs_N2960K-Rel.pdf - Video of accident flight (item 7, MOV, 171 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13177296&FileExtension=MOV&FileName=IMG_0180-Rel.MOV - Engine data monitor - specialist's factual report (item 8, PDF, 4 pages, 534 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12401006&FileExtension=pdf&FileName=ERA21FA142%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to engine data monitor - specialist's factual report (item 9, CSV, 5 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12401343&FileExtension=csv&FileName=ERA21FA142%20Attachment%201%20to%20Engine%20Data%20Monitor%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Aircraft performance study (item 10, PDF, 4 pages, 596 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12474738&FileExtension=pdf&FileName=ERA21FA142_Performance_Study-Rel.pdf - Toxicological report (item 11, PDF, 1 page, 246 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13347653&FileExtension=pdf&FileName=Tox_2021_029_001_Redacted-Rel.pdf - Memorandum for record_autopsy and tox (item 12, PDF, 1 page, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13352237&FileExtension=pdf&FileName=MOR%20Autopsy%20and%20Tox-Rel.pdf - Site and wreckage examination (item 13, PDF, 8 pages, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13371115&FileExtension=pdf&FileName=ERA21FA142_Site%20%26%20Wreckage%20Examination_Redacted-Rel.pdf - Wreckage release (item 14, PDF, 1 page, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13330488&FileExtension=pdf&FileName=N2960K%20Wreckage%20Release%20Signed_redacted-Rel.pdf - Video study (item 15, PDF, 8 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13389435&FileExtension=pdf&FileName=Jupiter_Video_Study_final-Rel.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.