ERA21FA225

NTSB accident investigation · Flight Design Ctsw · Winterville, NC · May 22, 2021

Accident · FatalClass 3 · FieldFinal report
Date
May 22, 2021, 17:42 local (21:42 UTC)
Place
Winterville, NC
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N708JMFlight Design Ctsw
Defining event
Maneuvering: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Federal Safety Investigation Authority, FAA/FSDO
FAA report
20210522009949A
Case key
103127

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot’s exceedance of the airplane’s critical angle of attack during a go-around, which resulted in an aerodynamic stall and a loss of control.

Findings · 3

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotFlight Design CTSW: 20 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedFlight Design CTSW: 4 casesAll aircraft: 1,681 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedFlight Design CTSW: 4 casesAll aircraft: 990 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

After a cross-country flight, the light sport airplane pilot and passenger arrived at the destination airport. Security camera video captured the airplane touching down normally about 122 ft past the approach end of the runway. The airplane remained on the ground for about 340 ft; afterward, the video recorded engine power increasing in a manner consistent with a go-around. The airplane became airborne and began a climbing left turn with between 15° and 20° left bank. The airplane rolled left beyond 90° of bank and descended in a left-wing-low attitude. A witness heard the sound of impact and saw a postcrash fire. Evidence at the accident site confirmed that the airplane was in a steep descent before impact. The reason for the go-around could not be determined based on the available evidence for this investigation. One of the throttle control cables was found fractured. However, no evidence indicated any preimpact mechanical failure or malfunction to the throttle control cables, flight controls, engine, or its systems. On the basis of the available evidence, the pilot likely exceeded the airplane’s critical angle of attack during the go-around, which caused the airplane to stall and descend uncontrolled.

Factual narrative

The engine was equipped with two carburetors, Nos. 1/3 and 2/4, which were connected to the cockpit throttle control by Bowden cables. According to the engine installation manual, a return spring was attached at each carburetor. With minimal friction of the Bowden cable, the spring would move the throttle completely open. 05N was privately owned and open to the public. Postaccident examination of the runway revealed that the grass on the runway was cut about 1 to 2 inches tall, and no soft spots on the runway were noted. Examination of the entire length of the runway revealed no marks that were consistent with the accident airplane, and no parts of the airplane were found on the runway surface. On May 22, 2021, about 1742 eastern daylight time, a Flight Design CTSW light sport airplane, N708JM, was destroyed when it was involved in an accident near South Oaks Aerodrome (05N), Winterville, North Carolina. The pilot and passenger were fatally injured. The airplane was operated as a Title 14?Code of Federal Regulations Part 91 personal flight. According to Federal Aviation Administration radar track data, a target was noted departing runway 23 at Cape Fear Regional Jetport/Howie Franklin Field Airport (SUT), Oak Island, North Carolina, about 1627. After takeoff, the flight turned left to a northeast heading for about 21 nautical miles and then turned slightly left to a north-northeast heading to proceed toward 05N. While en route, the passenger sent a text to a relative, “it is 5:27 [p.m.] right now and we are 12 minutes from landing.... Had a headwind that slowed us down a little bit. Will text when we get settled.” The flight continued toward 05N, but the radar target was lost at 1735:52, when the flight was about 6.2 nautical miles and 181° from 05N. According to security camera videos from houses located north and south of the runway, the airplane touched down about 122 ft from the approach end of runway 25 and remained on the ground for about 340 ft. An engine sound was heard increasing, and the video depicted the airplane in a nose-high tail low attitude. The airplane then became airborne when it was about 464 ft past the approach end of runway 25. The airplane began a climbing left turn and rolled to the left to about 90° while descending. The airplane subsequently impacted a wooded area behind a house on the airstrip. The airplane began a climbing left turn, which a pilot-rated witness located near the departure end of runway 25 reported that, at the time of the airplane’s climbing left turn, the bank angle was between 15° and 20°. The pilot-rated witness reported seeing fire about 10 seconds after hearing the impact. He added that the smoke from the postcrash fire rose vertically and that there was no or minimal wind. The East Carolina Brody School of Medicine, Department of Clinical/Forensic Pathology, performed an autopsy on the pilot. His cause of death was multiple injuries. Toxicology testing performed by the Federal AviationAdministration Forensic Sciences Laboratory identified losartan in the pilot’s blood and urine. Losartan is a blood pressure medication that is generally considered not to be impairing. The accident site was about 1,246 ft and 229° from the approach end of runway 25. Examination of the accident site revealed that a tree, which was about 10- to 12-inches in diameter was uprooted. The tree also exhibited an impact scar about 25 ft above ground level. The tree was located along a magnetic heading of 344°. The surrounding area exhibited evidence of a postcrash fire. The airplane’s fuel system was destroyed by the postcrash fire. One fuel tank pick-up screen was found attached to an end of the fuel tank, and the other fuel tank pick-up screen was found loose in the wreckage; both were free of obstructions. The airframe fuel strainer had separated from the fuel system, but the screen was clean. Examination of the engine revealed extensive heat damage that precluded rotation of the crankshaft. Borescope inspection revealed that all rods remained connected to the crankshaft. Additionally, the positions of the front and rear pistons (relative to each other) were consistent with an intact crankshaft. Examination of the camshaft, cylinders, air induction, ignition, cooling, lubricating, exhaust systems, and reduction gearbox revealed extensive heat damage and no evidence of preimpact failure or malfunction. Examination of both carburetors, which had separated from the engine, revealed extensive heat damage and both throttle plates in their wide-open position. Examination of the throttle control cables by the National Transportation Safety Board Materials Laboratory revealed that both throttle cables to the cockpit for the Nos. 1/3 and 2/4 carburetors and the choke cable to the cockpit for the No. 2/4 carburetor exhibited fracture features consistent with overstress. The choke cable for the No. 1/3 carburetor sustained extensive thermal damage.

Aircraft

Registration
N708JM
Reported as
Flight Design Ctsw (NO SERIES)
Category
Airplane
Serial number
06-08-09
Built
2006
Airframe hours
687
Engine
Rotax 912 ULS 2, 100 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
Condition · March 11, 2021
Departed
SUT · Oak Island, NC
Destination
Same as departure
Airport
05N · South Oaks Aerodrome, runway 25, 1,850 × 50 ft, grass/turf
Equipment
Handheld GPS, Airframe parachute

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
Pilot
Age
62
Injuries
Fatal
Certificate
Sport Pilot
Airplane ratings
Single-engine land
Medical
Sport pilot
Last flight review
June 13, 2020
Seat
Left
Toxicology
Performed
Flight hours
227 total · 173 in this make and model · 173 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 3 knots
Visibility
10 statute miles
Temperature
84 °F, dew point 52 °F
Altimeter
30.23 inHg
Observed at
KPGV, 9 nm away
METAR
KPGV 222155Z AUTO 27003KT 10SM CLR 29/11 A3023 RMK AO2

Docket · 11

The files NTSB released with the investigation on June 8, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 15.7 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.