# NTSB ERA22FA015: Velocity SE RG, N755V, Titusville, FL, October 14, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: October 14, 2021, 15:51 local (19:51 UTC) - Place: Titusville, FL - Coordinates: 28.513889, -80.804444 - Nearby events: https://openairdocs.org/map.md?lat=28.5139&lon=-80.8044&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Velocity Aircraft, Lycoming - NTSB case key (mKey): 104103 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22FA015 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104103/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104103 - Page: https://openairdocs.org/ntsb/ERA22FA015 ## Probable cause The separation of the airplane’s elevator control push-pull tube, which resulted in a loss of control during the approach. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: elevator control system](https://openairdocs.org/ntsb-findings/01022730): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Gietzen Albert J VELOCITY RG, 1 case](https://openairdocs.org/ntsb-findings/01022730/cases.md?model=05604B9), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022730/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Gietzen Albert J VELOCITY RG, 1 case](https://openairdocs.org/ntsb-events/333/sequence.md?model=05604B9), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) - [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Gietzen Albert J VELOCITY RG, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05604B9), [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: [Gietzen Albert J VELOCITY RG, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05604B9), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was conducting a personal flight in an experimental amateur-built airplane that he had owned for about 5 years before the accident. During short final approach, the airplane pitched up, climbed about 300 ft, descended nose down, and impacted a grass area next to the runway. A postcrash fire consumed most of the wreckage. The elevator push-pull tube section that connected to the control stick was recovered with no threaded rod end engaged, and the rod end was not recovered. Metallurgical examination of the elevator push-pull tube section revealed no contact marks from the jam nut. Also, the first three threads in the threaded plug were missing. The threads had fractured in shear overstress, and likely resulted in the push pull tube separating during flight and the pilot’s subsequent loss of airplane control. Review of the airplane kit assembly manual revealed instructions to have at least 0.5 inches of thread engagement with the rod end in the 1.5-inch threaded plug (with a note indicating that “all the way in is best”). Due to the lack of maintenance documentation, the investigation could not determine when or why the most recent adjustment to the rod end was made. Toxicology testing identified doxylamine in the pilot’s specimens. The main effect from doxylamine that can degrade performance is sleepiness. Because sleepiness would not have likely led to the airplane’s sudden pitch up during landing, the pilot’s use of doxylamine likely did not contribute to the accident. ## Factual narrative Review of the airplane kit assembly manual revealed instructions to have at least 0.5 inches of thread engagement with the rod end in the 1.5-inch threaded plug. A note indicated, “all the way in is best.” Due to a lack of maintenance documentation recovered, the investigation could not determine when the rod end had been most recently adjusted (for more information, see Materials Laboratory Factual Report in the public docket for this accident). The maintenance logbooks were not recovered. The pilot purchased the airplane in 2016, about 10 years after it was assembled. On October 14, 2021, about 1551 eastern daylight time, an experimental amateur-built Velocity SE RG airplane, N755V, was destroyed when it was involved in an accident near Space Coast Regional Airport (TIX), Titusville, Florida. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot owned the airplane, which was based at TIX. The airplane flew uneventfully from TIX to Sebastian Municipal Airport (X26), Sebastian, Florida, earlier during the day of the accident. While at X26, the pilot visited the airplane kit manufacturer’s facility to replace a landing-gear-up switch fuse because the landing gear was not retracting. Afterward, the pilot removed the pilot seat and the rear seat from the airplane and left the rear seat at the facility so that maintenance technicians could match color and specifications ahead of an interior aesthetics renovation planned for the next month. The pilot then reinstalled the pilot seat and departed X26 uneventfully about 1528 for the return flight to TIX. According to witness statements, automatic dependent surveillance-broadcast data, and airport surveillance video, while the airplane was on short final approach to runway 9 at TIX, the airplane pitched up, climbed about 300 ft, then descended nose down. The airplane impacted a grass area about 400 ft right of the runway centerline and about 2,000 ft from the runway threshold. A postcrash fire ensued that consumed most of the wreckage. An autopsy was performed on the pilot by the Office of the Medical Examiner for Brevard County, Rockledge, Florida. His cause of death was multiple blunt force injuries. Toxicology testing performed on the pilot by the Federal Aviation Administration Forensic Sciences Laboratory identified doxylamine in the pilot’s cavity blood (80 ng/ml) and in his liver. Doxylamine is a sedating antihistamine available over the counter in various products intended to treat allergy and cold symptoms and induce sleep. It carries specific warnings about sleepiness. The usual blood level in which effects would be expected in live people is between 50 and 200 ng/ml. The pilot’s logbook was not recovered. The president of the airplane kit manufacturer, who knew the pilot, estimated that the pilot had about 200 hours of total flight experience in the accident airplane make and model. The airplane came to restupright and oriented along a magnetic heading of about 230°, and no debris path was observed. The cockpit and cabin were mostly consumed by fire. The flight control stick was not recovered. The pilot seat was identified, and the four bolts and their respective hard points remained attached. The pilot seat pin was also identified, but the seat frame was bent and separated, consistent with impact forces. A Grand Rapids primary flight display and multifunction display were recovered and retained for data download. Both displays required an installed USB flash drive to record data, but no USB flash drives were installed in the units or recovered in the wreckage. The left and right ailerons separated from their respective wings and were recovered near the wings. Aileron control continuity was confirmed from the separated ailerons to cables, a bellcrank, torque tubes, and the cockpit. The canard spar was intact but fire damaged and the left and right elevators were not recovered and presumed destroyed in the fire. The elevator push-pull tube section that connected to the control stick was recovered with no threaded rod end engaged, and the rod end was not recovered. Continuity of the elevator was confirmed from the torque tubes to the cockpit except for the push-pull tube section, which was retained for metallurgical examination. The elevator trim actuator was destroyed, and the preimpact elevator trim setting could not be determined. The left rudder was identified, and the right rudder was not recovered and presumed destroyed. The left rudder bellcrank remained intact, and its cable exhibited a broomstraw separation. The engine separated from the airframe and came to rest upright. The three propeller blades remained attached to the hub, and all three blades separated about 12 inches from their respective roots. The top spark plugs were removed; their electrodes were intact and light gray in color. Borescope examination of the cylinders revealed no anomalies. The rear accessory section sustained thermal damage. After the rear accessory section was removed, the crankshaft could be rotated by hand. Camshaft, crankshaft, and valvetrain continuity were confirmed, and thumb compression was attained on all cylinders. Due to thermal damage, the ignition and fuel systems could not be tested. Metallurgical examination of the elevator push-pull tube section revealed that it had been exposed to fire, causing a portion of the tube to collapse and melt. No contact marks from the jam nut were observed, and the first three threads in the threaded plug were missing. Examination with a stereo microscope revealed that the first three threads were fractured in shear overstress and that the remaining threads remained intact. ## Aircraft - Registration: [N755V](https://openairdocs.org/deregistered/N755V-2023-04-01), registration cancelled 2023-04-01, S/N DMO408, built 2006 (OpenAirDocs) - Reported make and model: Velocity SE RG - Registry model: [Gietzen Albert J VELOCITY RG](https://openairdocs.org/model/gietzen-albert-j-velocity-rg) (registry code 05604B9) (OpenAirDocs) - Registry engine: [Superior IO-360 series](https://openairdocs.org/engine/superior-io-360-series) (registry code 59251, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: DMO408 - Year built: 2006 - Engines: Lycoming IO-390-A 215 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Departed: X26, Sebastian, FL - Destination: Same as departure - Airport: TIX, Space Coast Regional Airport, runway 09, 5,000 × 100 ft, asphalt - Equipment: Electronic multifunction display, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: fatal; airline transport, flight instructor, commercial, flight engineer; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: left; restraint: 4-point; toxicology performed; flight hours: 13,000 total, 200 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 80° at 9 knots - Visibility: 7 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 70 °F - Altimeter: 29.91 inHg - Observed at: TIX - METAR: KTIX 141947Z 08009KT 7SM SCT060 32/21 A2991 ## 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 20211014017539A](https://openairdocs.org/incident/20211014017539A), Oct 14, 2021: Gietzen Albert J VELOCITY RG, Titusville, FL, Destroyed, 1 fatal. Aircraft departed X26 with no issues noted. Aircraft flew to tix and began the approach to runway 9. Witness?s statements indicated that they noted that gear… ## Docket (15 files) The files NTSB released with the investigation on August 15, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104103. 56.4 MB in all. - Interview summary (item 1, PDF, 1 page, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14168967&FileExtension=pdf&FileName=Interview%20Summary-Rel.pdf - Witness statements (item 2, PDF, 6 pages, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14169509&FileExtension=pdf&FileName=Witness%20Statements_Redacted-Rel.pdf - Excerpts from kit assembly manual (item 3, PDF, 2 pages, 466 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14237013&FileExtension=pdf&FileName=Manual%20Excerpts-Rel.pdf - Weather report (item 4, PDF, 1 page, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14170049&FileExtension=pdf&FileName=Metars-Rel.pdf - ADS-B plots (item 5, PDF, 2 pages, 4.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14169383&FileExtension=pdf&FileName=ADSB%20Plots-Rel.pdf - Wreckage examination (item 6, PDF, 3 pages, 519 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14233744&FileExtension=pdf&FileName=Wreckage%20Examination-Rel.pdf - Photo array (item 7, PDF, 5 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14232432&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Medical factual report (item 8, PDF, 2 pages, 124 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13645226&FileExtension=pdf&FileName=ERA22FA015_Medical%20Factual%20Report-Rel.pdf - Materials laboratory factual report 22-053 (item 9, PDF, 6 pages, 5 photos, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14167269&FileExtension=pdf&FileName=Materials%20Laboratory%20Factual%20Report%2022-053-Rel.pdf - Non-volatile memory report (item 10, PDF, 1 page, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14170636&FileExtension=pdf&FileName=NVM%20Report_Redacted-Rel.pdf - Excerpt from security video (MP4, 24 sec, 38MB) (item 11, M4V, 39.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14233442&FileExtension=m4v&FileName=Video%20Excerpt-Rel.m4v - Security camera video report (item 12, PDF, 1 page, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14169519&FileExtension=pdf&FileName=Video%20Report_Redacted-Rel.pdf - Toxicological report (item 13, PDF, 1 page, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14170580&FileExtension=pdf&FileName=Tox_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 14, PDF, 10 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14169728&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Wreckage release and evidence control forms (item 15, PDF, 3 pages, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14173111&FileExtension=pdf&FileName=Wreckage%20Release%20And%20Evidence%20Control_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.