# NTSB LAX08FA122: Carlton M. Cadwell Lancair IV-P, N25CL, Mesa, AZ, April 23, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 23, 2008, 07:09 local (14:09 UTC) - Place: Mesa, AZ - Coordinates: 33.448055, -111.73722 - Nearby events: https://openairdocs.org/map.md?lat=33.4481&lon=-111.7372&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report May 6, 2009 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, Federal Aviation Administration - NTSB case key (mKey): 67872 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX08FA122 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67872/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=67872 - Page: https://openairdocs.org/ntsb/LAX08FA122 ## Probable cause The pilot's failure to maintain an adequate airspeed during climb out resulting in an aerodynamic stall/spin. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cadwell Carlton M LANCAIR IV P, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05610HX), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cadwell Carlton M LANCAIR IV P, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05610HX), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Cadwell Carlton M LANCAIR IV P, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05610HX), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cadwell Carlton M LANCAIR IV P, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05610HX), [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: [Cadwell Carlton M LANCAIR IV P, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05610HX), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Air traffic controllers reported that shortly after takeoff, about the time the landing gear was being retracted, they observed smoke trailing from the airplane. The controller advised the pilot of the smoke, but did not receive a response. Additional witnesses reported that the airplane made an abrupt climbing left turn with the wings rocking back and forth before it nosed down and descended in a near-vertical attitude to ground impact. All flight control surfaces were accounted for at the accident site and all airplane components were found in the immediate area of the impact location. Due to fire and thermal damage to the majority of the composite airframe structure, establishment of control continuity was not possible. Teardown inspection of the engine did not disclose any evidence of a mechanical failure or malfunction. Investigators were unable to determine the cause or origin of the reported smoke during departure. ## Factual narrative HISTORY OF FLIGHT On April 23, 2008, at 0709 mountain standard time (MST), an experimental amateur-built Carlton Cadwell Lancair IV-P airplane, N25CL, experienced a loss of control during takeoff and subsequently impacted into an orange grove near Falcon Field Airport (FFZ), Mesa, Arizona. Boehle Aviation LLC, was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot, the private pilot/owner, and one passenger were killed; the airplane was destroyed by impact forces and post-crash fire. The cross-country personal flight departed Mesa with a planned destination of Santa Ana, California. Visual meteorological conditions prevailed, and an instrument flight rules (IFR) flight plan had been filed. Air traffic controllers observed the airplane during takeoff. They reported that after the airplane became airborne, about the time the gear was being retracted, they observed smoke trailing from the airplane. The controller advised the pilot of the smoke, but did not receive a response from the pilot. Witnesses observed the airplane make an abrupt climbing left turn, and then the wings rocked back and forth, followed by the airplane descending straight down into an orange grove. The airplane exploded on impact, and witnesses observed a large fireball. PERSONNEL INFORMATION COMMERCIAL PILOT A review of Federal Aviation Administration (FAA) airman records revealed that the 27-year-old pilot held a commercial pilot certificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. The pilot also held a certified flight instructor (CFI) certificate with ratings for airplane single-engine land and instrument airplane. The pilot held a second-class medical certificate issued on November 19, 2007. It had no limitations or waivers. No personal flight log records were located for the pilot. The National Transportation Safety Board investigator-in-charge (IIC) obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. The pilot reported on his medical application that he had a total time of 600 hours, with 200 hours logged in the last 6 months. The pilot had been employed by the pilot-rated passenger/owner since July 2007, as a company pilot. Insurance records dated February 25, 2008, reported that the pilot had 580 hours pilot-in-command time. The pilot completed initial training in the accident airplane during March 3-5, 2008. During the training he logged 9.4 flight hours, and received a High Altitude Endorsement. Examination of the airplane logbooks revealed that the pilot had flown the airplane a total of 20.5 hours between March 3, 2008, and the last recorded maintenance on April 18, 2008. PILOT RATED PASSENGER/OWNER A review of FAA airman records revealed that the 27-year-old passenger held a private pilot certificate with ratings for airplane single-engine land and multiengine land. The rated passenger held a third-class medical certificate issued on November 30, 2005. It had no limitations or waivers. No personal flight records were located for the rated passenger. The Safety Board IIC obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center, Oklahoma City. The rated passenger reported on his medical application that he had a total time of 60 hours, with 30 hours logged in the last 6 months. AIRCRAFT INFORMATION The airplane was an experimental amateur-built airplane, serial number LIV-424-SFB-P. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 978.2 hours at the last 100-hour annual inspection on March 3, 2008. The last logbook entry was on April 18, 2008, following tests of the static/altimeter system. At that time, the tachometer read 998.7 hours. The engine was a Teledyne Continental Motors TSIO-550-E, serial number 803125. Total time recorded on the engine at the last 100-hour inspection was 978.2 hours. Examination of the maintenance records revealed no unresolved maintenance discrepancies against the airplane prior to departure. WRECKAGE AND IMPACT INFORMATION Investigators examined the wreckage at the accident scene. The orientation of the fuselage, situated nearly perpendicular to a row of trees in the orange grove, faced in a northerly direction. A single large tree trunk was located in the midsection of the wreckage. There was an odor of aviation fuel in the immediate area of the wreckage. All flight control surfaces were accounted for at the accident site. Due to the post crash fire and the thermal consumption of a majority of the composite airframe, control continuity could not be established. The airplane and engine were recovered for further examination. MEDICAL AND PATHOLOGICAL INFORMATION The commercial pilot remains were removed by the coroner from the right front seat. The rated passenger remains were removed from the left front seat. The Maricopa County Coroner completed an autopsy of the commercial pilot. The FAA Bioaeronautical Sciences Research Laboratory Forensic Toxicology Research Team, Oklahoma City, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, volatiles, and other tested drugs. The report contained the following findings for tested drugs: Ibuprofen detected in blood. The Maricopa County Coroner completed an autopsy of the rated passenger. The FAA Bioaeronautical Sciences Research Laboratory Forensic Toxicology Research Team, Oklahoma City, performed toxicological testing of specimens of the rated passenger. Analysis of the specimens contained no findings for carbon monoxide, cyanide, and volatiles. The report contained the following findings for tested drugs: Benzoylecgonine in blood and 0.05 (ug/ml, ug/g) in urine; ecgonnine methyl ester in blood and urine; and mefloquine in blood and urine. TESTS AND RESEARCH Investigators examined the wreckage at Air Transport, Phoenix, Arizona, on April 24, 2008. No abnormalities were noted on the engine or airframe that would have precluded normal operations. Investigators were unable to determine the cause or origin of the reported "smoke" during departure. ## Aircraft - Registration: [N25CL](https://openairdocs.org/deregistered/N25CL-2008-08-21), registration cancelled 2008-08-21, S/N LIV-424-SFB-P, built 2000 (OpenAirDocs) - Reported make and model: Carlton M. Cadwell Lancair IV-P - Registry model: [Cadwell Carlton M LANCAIR IV P](https://openairdocs.org/model/cadwell-carlton-m-lancair-iv-p) (registry code 05610HX) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: LIV-242-SFB-P - Airframe hours: 978.2 - Engines: Continental TSIO-550-E 350 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Executive/Corporate, Part 91 - Operator: Boehle Aviation LLC - Registered owner: Boehle Aviation LLC - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, March 3, 2008, 20 hours before - Departed: FFZ, MESA, AZ - Destination: SNA, SANTA ANA, CA - Flight plan: IFR - Airport: FFZ, Falcon Field Airport, runway 22L, 5,101 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 27; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review June 1, 2006; seat: right; toxicology performed; flight hours: 700 total, 20 in this make and model, 580 as pilot in command, 50 in the last 90 days - Co-pilot; age 27; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; medical: class 3, without waivers/limitations; seat: left; toxicology performed; flight hours: 50 total ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 8 knots - Visibility: 30 statute miles - Lowest ceiling: none - Temperature: 61 °F, dew point 21 °F - Altimeter: 29.87 inHg - Observed at: FFZ, 8 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 20080423836689A](https://openairdocs.org/incident/20080423836689A), Apr 23, 2008: Amtr LANCAIRIVP, Mesa, AZ, Destroyed, 3 fatal. (-23)Falcon tower notified aircraft of trailing smoke and cleared to land any runway. Aircraft made a sharp left turn, then back to the right, and went into an… ## Docket (14 files) The files NTSB released with the investigation on March 2, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=67872. 11.6 MB in all. - Witness Statement - Allen (item 1, .PDF, 629 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309508&FileExtension=.PDF&FileName=Witness%20Statement%20-%20Allen-Redacted.PDF - ATC Final Report (item 2, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308391&FileExtension=.PDF&FileName=ATC%20Final%20Report-Redacted.PDF - Photo 1 - Aerial View Accident Site (item 3, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308393&FileExtension=.PDF&FileName=Photo%201%20-%20Aerial%20View%20Accident%20Site-Master.PDF - Photo 2 - Aerial View with FFZ in sight (item 4, .PDF, 327 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308394&FileExtension=.PDF&FileName=Photo%202%20-%20Aerial%20View%20with%20FFZ%20in%20sight-Master.PDF - Photo 3 - Flight Path - Takeoff to Accident Site (item 5, .PDF, 330 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308395&FileExtension=.PDF&FileName=Photo%203%20-%20Flight%20Path%20-%20Takeoff%20to%20Accident%20Site-Master.PDF - Photo 4 - N25CL Pre-accident Photos (item 6, .PDF, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308397&FileExtension=.PDF&FileName=Photo%204%20-%20N25CL%20Pre-accident%20Photos-Master.PDF - TCM Final Report (item 7, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309513&FileExtension=.PDF&FileName=TCM%20Final%20Report-Redacted.PDF - Toxicological Report- White (item 8, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308401&FileExtension=.PDF&FileName=Toxicological%20Report-%20White-Master.PDF - Toxicological Report- Boehle (item 9, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308402&FileExtension=.PDF&FileName=Toxicological%20Report-%20Boehle-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 10, .PDF, 923 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308406&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308408&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Training Certificate- White (item 12, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309510&FileExtension=.PDF&FileName=Training%20Certificate-%20White-Redacted.PDF - Airplane Logbook (item 13, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309516&FileExtension=.PDF&FileName=Airplane%20Logbook-Redacted.PDF - Flight Logbook (Excerpt) (item 14, .PDF, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40308412&FileExtension=.PDF&FileName=Flight%20Logbook%20(Excerpt)-Master.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.