# NTSB WPR10LA010: Cruz SE5A Replica, N3944U, Phoenix, AZ, October 9, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: October 9, 2009, 13:54 local (20:54 UTC) - Place: Phoenix, AZ - Coordinates: 33.688056, -112.082496 - Nearby events: https://openairdocs.org/map.md?lat=33.6881&lon=-112.0825&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 19, 2011 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Continental Motors - NTSB case key (mKey): 74880 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR10LA010 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74880/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74880 - Page: https://openairdocs.org/ntsb/WPR10LA010 ## Probable cause The pilot's failure to maintain airspeed during initial climb, which resulted in a stall/spin and impact with the ground. ## 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: [Cruz Ismael SE5A REPLICA, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05663BS), [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: [Cruz Ismael SE5A REPLICA, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05663BS), [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: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cruz Ismael SE5A REPLICA, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05663BS), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cruz Ismael SE5A REPLICA, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05663BS), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cruz Ismael SE5A REPLICA, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=05663BS), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis During the initial climb after takeoff, witnesses observed the airplane make a right turn and then enter into a nose down spin before impacting a scrap metal yard where it was subsequently consumed by a postimpact fire. Witnesses further reported that the engine sounded smooth and was producing power akin to takeoff power. Federal Aviation Administration (FAA) inspectors responded to the site and were able to identify all of the hardware for the flight controls. A postaccident engine inspection revealed no mechanical difficulties that would have precluded normal operation. The owner of the airplane reported that this was the pilot's first flight in the airplane. ## Factual narrative HISTORY OF FLIGHT On October 9, 2009, at 1354 mountain standard time, an experimental Cruz SE5A Replica biplane, N3944U, crashed into a scrap metal yard about 1/2 mile north of the airport shortly after takeoff from the Phoenix Deer Valley Airport, Phoenix, Arizona. The pilot operated the borrowed airplane under the provisions of Title 14 Code of Federal Regulations Part 91, as a personal flight. The pilot, the sole occupant was killed. The airplane was thermally consumed in the post-impact fire. Visual meteorological conditions prevailed for the flight and no flight plan had been filed. One witness' attention was drawn to the accident airplane because he heard an unfamiliar sounding engine. He saw the airplane depart runway 25L at an altitude of about 150 to 200 feet, in a normal climb attitude. He stated that the airplane made a left crosswind turn; however, it rolled into a right spin. From the witnesses position he was able to see about 2.5 rotations before seeing a cloud of smoke; he estimated the airplane reached an altitude of about 500 feet. The witness reported that the climb appeared normal and the engine was running smoothly and producing takeoff power. Another witness in a parking lot reported that his attention was drawn to the airplane due to its low altitude; he estimated that the airplane was no more than 100 feet. The airplane passed overhead traveling in a westbound direction in level flight. The airplane then pitched up, and took an erratic turn to the right. As the airplane exited the turn it was in a nose up attitude, it flew another 100 feet and then started a nose down spin until it impacted the ground. PERSONNEL INFORMATION A review of Federal Aviation Administration (FAA) airman records revealed that the 37-year-old pilot held a commercial pilot certificate with ratings for airplane single and multi-engine land, and instrument airplane. The pilot also held a certified flight instructor (CFI) certificate with ratings for airplane single and multi-engine land, and instrument airplane. The pilot held a first-class medical certificate issued on August 25, 2009. It had no limitations or waivers. No personal flight records were located for the pilot. The NTSB 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 most recent FAA medical application dated August 25, 2009, a total time of 270 flight hours with 55 hours logged in the last 6 months. AIRCRAFT INFORMATION The airplane, N3994U, was an experimental-amateur built 1986 Cruz SE5A Replica biplane, serial number 074140. The airplane was powered by a Teledyne Continental Motors O-200-A, serial number 67901-7-A piston engine. According to an FAA inspector, the owner of the airplane, who was also the father of the pilot, reported that this was the pilot's first flight in the airplane.The owner also reported that all of the airplane's maintenance records were in the airplane at the time of the accident. The airplane was refueled on October 03, 2009, with 6.1 gallons of fuel. COMMUNICATIONS The pilot was in contact with the Deer Valley airport traffic control tower (ATCT). The local controller reported clearing the pilot for takeoff with a straight out restriction. At the departure end of the runway, the controller approved the pilot for a right turn. The pilot's transmission was unintelligible, and the controller reissued the right turn instruction. The controller then observed the airplane make a right turn and then go down about 1/2 mile west of the airport. Two additional controllers observed the airplane in a spin prior to impacting the ground. WRECKAGE AND IMPACT INFORMATION FAA inspectors responded to the accident site located 1.5 miles west of the departure end of runway 25L at Deer Valley Airport. The airplane came to rest in a scrap metal yard and had been thermally consumed by the postimpact fire. FAA inspectors were able to identify all the hardware for the flight controls. MEDICAL AND PATHOLOGICAL INFORMATION The Maricopa - Office of the Medical Examiner completed an autopsy on October 13, 2009. The cause of death was listed as blunt force head trauma and thermal injury. The FAA Forensic Toxicology Research Team CAMI, Oklahoma City, performed toxicological testing of specimens from the pilot. Analysis of the specimens contained no finds for carbon monoxide, cyanide, volatiles, and tested drugs. TESTS AND RESEARCH The airframe and engine were inspected by FAA inspectors along with a representative from Teledyne Continental Motors (TCM), a party to the investigation. Visual examination of the engine revealed no obvious mechanical malfunctions. It was noted that the crankshaft was pushed aft of its original position and the TCM representative was not able to rotate the engine by hand. Under the supervision of the FAA, the engine was disassembled. Damaged components included the crankshaft propeller flange, crankshaft main bearings, crankshaft oil slinger ring, and crankshaft gear cluster. The inspection revealed no abnormalities that would have prevent normal operation and production of rated horsepower. ## Aircraft - Registration: [N3944U](https://openairdocs.org/deregistered/N3944U-2014-12-02), registration cancelled 2014-12-02, S/N 074140 (OpenAirDocs) - Reported make and model: Cruz SE5A Replica - Registry model: [Cruz Ismael SE5A REPLICA](https://openairdocs.org/model/cruz-ismael-se5a-replica) (registry code 05663BS) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 074140 - Engines: Teledyne Continental Motors O-200 100 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Gary H. Steinke - Registered owner: Gary H. Steinke - Airworthiness certificate: Special, Experimental (Special) - Departed: DVT, Phoenix, AZ - Destination: DVT, Phoenix, AZ - Airport: DVT, Phoenix Deer Valley Airport, runway 25L, 8,197 × 100 ft ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; injuries: fatal; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; seat: rear; toxicology performed; flight hours: 270 total ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 27 °F - Altimeter: 29.96 inHg - Observed at: DVT, 1 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 20091009021709A](https://openairdocs.org/incident/20091009021709A), Oct 9, 2009: Amtr SE5A, Phoenix, AZ, Destroyed. Pilot took off from dvt airport from runway 25. Upon reaching the end of the runway the dvt tower cleared the pilot to turn to the north. The pilot initial… ## Docket (8 files) The files NTSB released with the investigation on June 28, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74880. 5.5 MB in all. - Photo 1 - Main wreckage (PHX PD) (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347809&FileExtension=.PDF&FileName=Photo%201%20-%20Main%20wreckage%20(PHX%20PD)-Master.PDF - Witness Statement (item 2, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347812&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Excerpt ATC package - Personnel Statements (item 3, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347811&FileExtension=.PDF&FileName=Excerpt%20ATC%20package%20-%20Personnel%20Statements-Redacted.PDF - Report from Teledyne Continental Motors (item 4, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347813&FileExtension=.PDF&FileName=Report%20from%20Teledyne%20Continental%20Motors-Redacted.PDF - Fuel Receipt (item 5, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347814&FileExtension=.PDF&FileName=Fuel%20Receipt-Redacted.PDF - Work Order (item 6, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347815&FileExtension=.PDF&FileName=Work%20Order-Redacted.PDF - Toxicological Report (item 7, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347816&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 8, .PDF, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40347818&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-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.