# NTSB ERA21FA225: Flight Design Ctsw, N708JM, Winterville, NC, May 22, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: May 22, 2021, 17:42 local (21:42 UTC) - Place: Winterville, NC - Coordinates: 35.480531, -77.356106 - Nearby events: https://openairdocs.org/map.md?lat=35.4805&lon=-77.3561&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: Federal Safety Investigation Authority, FAA/FSDO - NTSB case key (mKey): 103127 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21FA225 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103127/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103127 - Page: https://openairdocs.org/ntsb/ERA21FA225 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Flight Design CTSW, 20 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=0600001), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Flight Design CTSW, 4 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=0600001), [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 · Not attained/maintained (probable cause); cases with it: [Flight Design CTSW, 4 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=0600001), [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. - [Landing-aborted after touchdown: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Flight Design CTSW, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=0600001), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Flight Design CTSW, 10 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=0600001), [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: [Flight Design CTSW, 13 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0600001), [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: [Flight Design CTSW, 1 case](https://openairdocs.org/ntsb-events/170/sequence.md?model=0600001), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## 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](https://openairdocs.org/deregistered/N708JM-2022-03-05), registration cancelled 2022-03-05, S/N 06-08-09, built 2006 (OpenAirDocs) - Reported make and model: FLIGHT DESIGN CTSW (NO SERIES) - Registry model: [Flight Design CTSW](https://openairdocs.org/model/flight-design-ctsw) (registry code 0600001) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 06-08-09 - Year built: 2006 - Airframe hours: 687 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: fatal; 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 ## 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 20210522009949A](https://openairdocs.org/incident/20210522009949A), May 22, 2021: Flight Design Gmbh CTSW, Winterville, NC, Destroyed, 2 fatal. Pilot [privacy data omitted], and his wife [privacy data omitted], who is not a certificated pilot, sustained fatal injuries in a crash and post-crash fire… ## Docket (11 files) The files NTSB released with the investigation on June 8, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103127. 15.7 MB in all. - Record of NTSB conversations (item 1, PDF, 8 pages, 916 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15415974&FileExtension=pdf&FileName=Record%20of%20NTSB%20Conversations_Redacted_Main-Rel.pdf - Excerpt from airframe logbook (item 2, PDF, 1 page, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15273893&FileExtension=pdf&FileName=Excerpt%20Fm%20Airframe%20Logbook_Redacted-Rel.pdf - Memorandum for record - airframe and engine examinations factual observations (item 3, PDF, 4 pages, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15272723&FileExtension=pdf&FileName=Memo%20For%20Record%20-%20Airframe%20and%20Engine%20Exam%20Factual%20Findings%20v01-Rel.pdf - Memorandum for record - ATC uncorrelated radar flight path information (item 4, PDF, 3 pages, 3 photos, 983 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15268979&FileExtension=pdf&FileName=Memo%20For%20Record%20-ATC%20INFORMATION-Rel.pdf - Memorandum for record - videos descriptions (item 5, PDF, 4 pages, 3 photos, 489 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15273883&FileExtension=pdf&FileName=Memo%20For%20Record%20-Videos%20Descriptions_Redacted-Rel.pdf - Investigative photographs (item 6, PDF, 6 pages, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15416203&FileExtension=pdf&FileName=Investigative%20Photographs_ERA21FA225-Rel-Rel.pdf - Toxicological reports (item 7, PDF, 3 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13405780&FileExtension=pdf&FileName=Pilot%20Tox%20Report%20Fm%20FAA%20CAMI_Redacted-Rel.pdf - Autopsy memorandum for record - pilot (item 8, PDF, 1 page, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13589612&FileExtension=pdf&FileName=Autopsy%20Memo%20for%20Record_ERA21FA225-Rel.pdf - Medical factual report (item 9, PDF, 2 pages, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13406110&FileExtension=pdf&FileName=ERA21FA225_Medical%20Factual%20ReportV2-Rel.pdf - NTSB materials laboratory factual report (item 10, PDF, 10 pages, 15 photos, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15268417&FileExtension=pdf&FileName=Materials%20Laboratory%20Factual%20Report%2022-030-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15, and NTSB evidence control form (item 11, PDF, 2 pages, 828 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15267623&FileExtension=pdf&FileName=Wreckage%20Release%20%26%20ECF_Redacted-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.