# NTSB LAX03LA289: Butzbach Smith Miniplane DSA1, N40DB, Escondido, CA, September 16, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: September 15, 2003, 18:31 local (Sep 16, 2003, 01:31 UTC) - Place: Escondido, CA - Coordinates: 33.183334, -117 - Nearby events: https://openairdocs.org/map.md?lat=33.1833&lon=-117.0000&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 28, 2004 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 57956 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX03LA289 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/57956/pdf - Page: https://openairdocs.org/ntsb/LAX03LA289 ## Probable cause The pilot's low level aerobatic maneuver and his failure to maintain control of the airplane, which resulted in an uncontrolled descent and impact with terrain. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - low altitude flight/maneuver - attempted, pilot in command (cause) - aircraft control - not maintained, pilot in command (cause) - aerobatics - performed, pilot in command (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane collided with the ground while maneuvering. The pilot flew over the airport approximately 50 to 100 feet above ground level (agl), and then entered a barrel roll. The pilot lost altitude at the end of the maneuver and impacted the ground. The debris field was approximately 150 square feet. The top wing of the biplane was sheared off and control continuity was unable to be established due to the damage sustained to the airplane. The pilot had around 1,700 hours total flying time, with limited aerobatic experience. ## Factual narrative On September 15, 2003, at 1831 Pacific daylight time, an experimental Butzbach Smith Miniplane DSA1 biplane, N40DB, collided with the ground while maneuvering near Lake Wohlford Airport (PVT), Escondido, California. The airplane was registered to and operated by the pilot under the provisions of 14 CFR Part 91. The private pilot sustained fatal injuries; the airplane was destroyed. Visual meteorological conditions prevailed for the local area personal flight, and no flight plan had been filed. The flight departed from Lake Wohlford about 1825. The pilot succumbed to his injuries the day following the accident. The Federal Aviation Administration (FAA) inspector responded to the accident site. The debris field was approximately 150 square feet. The top wing of the biplane was sheared off and control continuity was unable to be established due to the damage sustained to the airplane. The Safety Board investigator-in-charge (IIC) interviewed a witness, who held a private pilot certificate and lived 1/4 mile behind the airport, via telephone. The witness stated that he was driving east on a road. The airplane was flying about 200 feet above ground level (agl), and fast, in an eastbound direction. It went out of view for about 10 seconds, and then the witness saw it traveling in a westbound direction. The airplane went over the airport "too fast and not at a normal landing attitude." Over the runway, at 50 feet agl, the airplane did a barrel roll. The roll was quick and to the left. He did not see the impact but immediately after the barrel roll, he observed a large cloud of dust. The witness did not feel anything was mechanically wrong with the airplane. The IIC also spoke with an acquaintance of the pilot, who also witnessed the accident. The pilot attempted an aileron roll and "fell out" at the end. The witness felt the pilot's timing was off and that he rushed into the maneuver. He stated that it was common for the pilot to do aerobatic maneuvers in his airplane. Usually, the pilot did the maneuvers between 500 to 1,000 feet agl; however, the pilot was less than 100 feet when he entered the maneuver. The pilot had around 1,700 hours total flying time, but had limited aerobatic experience. A review of FAA records indicated that the pilot's most recently recorded third class medical certificate was issued in October of 1991. Repeated attempts to contact the family by the IIC were unsuccessful. The airplane and pilot logbooks were not recovered. ## Aircraft - Registration: [N40DB](https://openairdocs.org/deregistered/N40DB-2017-04-07), registration cancelled 2017-04-07, S/N DWB-1, built 1976 (OpenAirDocs) - Reported make and model: Butzbach Smith Miniplane DSA1 - Registry model: [Butzbach SMITH MINIPLANE DSA1](https://openairdocs.org/model/butzbach-smith-miniplane-dsa1) (registry code 8350221) (OpenAirDocs) - Registry engine: [Continental C85 series](https://openairdocs.org/engine/continental-c85-series) (registry code 17008, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: DWB-1 - Engines: Continental C85 Ser reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Rodney Gagian - Airworthiness certificate: Special, Experimental (Special) - Departed: PVT, Lake Wohlford, CA - Destination: PVT ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, expired; seat: single; flight hours: 1,700 total ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 63 °F - Altimeter: 29.89 inHg - Observed at: KRMN, 10 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 20030915023349A](https://openairdocs.org/incident/20030915023349A), Sep 15, 2003: Amtr DSA1, Lake Wohlford, CA, Destroyed, 1 fatal. (-23) On September 15, 2003 at approximately 1831 local pacific time a smith mini plane, N40DB, piloted by a private pilot from Lake Wohlford, California to an… 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.