# NTSB FTW04LA236: Lancair 360, N163DS, Orange, TX, September 10, 2004 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: September 10, 2004, 14:40 local (19:40 UTC) - Place: Orange, TX - Coordinates: 30.069166, -93.803611 - Nearby events: https://openairdocs.org/map.md?lat=30.0692&lon=-93.8036&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 28, 2004 - Report: Approved by Office Director - Parties: Houston FSDO - NTSB case key (mKey): 60107 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW04LA236 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/60107/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=60107 - Page: https://openairdocs.org/ntsb/FTW04LA236 ## Probable cause The pilot's failure to maintain adequate airspeed during takeoff resulting in an inadvertent stall and loss of aircraft control. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - airspeed - inadequate, pilot in command (cause) - stall - inadvertent, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis A 642-hour pilot departed from an airfield and announced that he would be circling around the traffic pattern to make a low pass. A witness stated that he observed the airplane as it approached the runway with the landing gear extended. The witness described the airplane's speed as "moderate" as it passed over the runway at a height of 50 feet above the ground. As the airplane reached the end of the runway it began to climb at a pitch attitude of approximately 10-15 degrees. As the witness began to enter a building, he looked back toward the departure end of the runway and saw the airplane in a rapid descent. It was approximately 600 feet above the ground, the nose of the airplane was pitched down about 30 degrees, and it was in a 10-15 degree right bank. When the airplane was approximately 100-150 feet above the ground, the witness stated the airplane pitched up (about five degrees) and the wings leveled out, but it still continued to descend. The witness did not hear any engine noise during this time. The nose of the airplane continued to pitch up and it banked slightly to the left as it descended behind a tree line. He then heard the engine "roar to what sounded like full power," followed by the sound of an impact. The pilot's total flight time in the make and model could not be determined; however, it was determined that the pilot had recently purchased the airplane as the registration was still pending. ## Factual narrative On September 10, 2004, approximately 1440 central daylight time, a homebuilt Lancair 360 single-engine airplane, N163DS, was destroyed following a loss of control during takeoff from Orange County Airport (ORG), near Orange, Texas. The non-instrument rated private pilot, sole occupant of the airplane, was fatally injured. The aircraft's registration was pending. Visual meteorological conditions prevailed and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The airplane was operating in the airport's traffic pattern at the time of the accident. In a written statement, a witness who had administered the pilot's biennial flight review the day before, reported that prior to the flight, the pilot topped-off the airplane's fuel system, and then taxied to Runway 04. He watched the airplane depart and noticed that the landing gear was still extended as the airplane began to climb-out. A few minutes later, the witness heard the pilot make an announcement over the airport's common traffic advisory frequency (CTAF) stating that he intended to execute a low pass over the runway, so he returned his attention back to the airplane. The witness added that he observed the airplane as it approached the runway with the landing gear extended. The witness described the airplane's speed as "moderate" as it passed over the runway at a height of 50 feet above the ground. As the airplane reached the end of the runway, it began to climb at a pitch attitude of approximately 10-15 degrees. When the airplane was approximately 800 to 1200 feet above the ground, the witness returned to the Fixed Base Operation (FBO), where he was working. As he began to enter the building, he looked back toward the departure end of the runway and saw the airplane in a rapid descent. It was approximately 600 feet above the ground, the nose of the airplane was pitched down about 30 degrees, and it was in a 10-15 degree right bank. When the airplane was approximately 100-150 feet above the ground, the witness stated the airplane pitched up (about five degrees) and the wings leveled out, but it still continued to descend. The witness did not hear any engine noise during this time. The nose of the airplane continued to pitch up and it banked slightly to the left as it descended behind a tree line. He then heard the engine "roar to what sounded like full power," followed by the sound of impact. Two other witnesses provided statements with similar descriptions of the event. A Federal Aviation Administration (FAA) inspector, who responded to the accident site, performed an on-scene examination of the airplane. According to the inspector, the airplane came to rest in a field and all major components of the airplane were accounted for at the scene. These components were dispersed in a west-northwesterly heading within a radius of 400 feet from the point of initial impact, which was approximately 18 inches deep. The 642-hour pilot held a private pilot certificate with a rating for single-engine airplane. The pilot's most recent biennial flight review was satisfactorily completed on September 9, 2004, the day before the accident. His Federal Aviation Administration (FAA) third class medical was issued on September 8, 2004, just two days prior to the accident, with a "holder shall wear corrective lenses" limitation. The pilot's total flight time in the make and model could not be determined; however, it was determined that the pilot had recently purchased the airplane as the registration was still pending. An autopsy was performed on the pilot by the Jefferson County Medical Examiner on September 11, 2004. The pilot's death was determined to be the result of blunt force injuries to the head and chest. The FAA's Civil Aeromedical Institute's (CAMI) Forensic and Accident Research Center examined toxicology specimens taken by the medical examiner. Toxicological tests of the specimens were negative for carbon monoxide, cyanide, alcohol, and drugs. At 1353, the weather observing system at the Southeast Texas Regional Airport, near Beaumont, Texas, approximately 14 nautical miles southwest of the accident site, reported calm winds, visibility nine statute miles, scattered clouds at 5,000 feet, temperature 33 degrees Fahrenheit, dew point 19 degrees Fahrenheit, and a barometric pressure setting of 30.03 inches of Mercury. ## Aircraft - Registration: [N163DS](https://openairdocs.org/deregistered/N163DS-2012-08-21), registration cancelled 2012-08-21, S/N 751, built 1993 (OpenAirDocs) - Reported make and model: Lancair 360 - Registry model: [Smith Donald J LANCAIR 360](https://openairdocs.org/model/smith-donald-j-lancair-360) (registry code 05626W7) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 751 - Engines: Lycoming IO-360-B 180 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Departed: KORG, Orange, TX - Flight plan: Unknown - Airport: ORG, Orange County, runway 4, 4,396 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; last flight review September 9, 2004; seat: left; toxicology performed; flight hours: 642 total, 515 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 0° at 0 knots - Visibility: 9 statute miles - Lowest ceiling: none - Temperature: 91 °F, dew point 66 °F - Altimeter: 30.03 inHg - Observed at: KBPT, 14 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 20040910035389A](https://openairdocs.org/incident/20040910035389A), Sep 10, 2004: Amtr LANCAIR360, Orange, TX, Destroyed, 1 fatal. (-23) At approximately 14:46 hours on 09/10/2004, aircraft N163DS, a Lancair 360 registered to the pilot, impacted the ground in a field approximately 1/2… ## Other investigations on N163DS (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 CHI01IA248](https://openairdocs.org/ntsb/CHI01IA248), Jul 27, 2001: Smith Lancair 360 (N163DS), Oshkosh, WI, incident, no damage. Probable cause: The unsafe condition caused when the pilot taxied onto the runway. Factors relating to this accident were the pilot not following the instructions given him by the ground marshaller, his wrong taxi… ## Docket (5 files) The files NTSB released with the investigation on October 28, 2004, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=60107. 312 KB in all. - Witness Statement (Trahan) (item 1, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384975&FileExtension=.PDF&FileName=Witness%20Statement%20(Trahan)-Redacted.PDF - Witness Statement (Sand) (item 2, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384976&FileExtension=.PDF&FileName=Witness%20Statement%20(Sand)-Redacted.PDF - Witness Statement (Nelson) (item 3, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384977&FileExtension=.PDF&FileName=Witness%20Statement%20(Nelson)-Redacted.PDF - Reports from Federal Agencies (item 4, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40220879&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies-Master.PDF - Toxicological Report (item 5, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40384978&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.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.