# NTSB WPR17FA152: Jansen Pazmany PL 2, N186EJ, El Monte, CA, July 14, 2017 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 14, 2017, 09:32 local (16:32 UTC) - Place: El Monte, CA - Coordinates: 34.086112, -118.034721 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.0861&lon=-118.0347&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report March 14, 2018 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Lycoming Engines, Federal Aviation Administration - NTSB case key (mKey): 95575 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR17FA152 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95575/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95575 - Page: https://openairdocs.org/ntsb/WPR17FA152 ## Probable cause A total loss of engine power due to fuel starvation for reasons that could not be determined based on the available evidence. Also causal was the pilot's decision to return to the runway following the loss of engine power, and his failure to maintain airspeed during the turn, which resulted in the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall/spin. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Not specified (probable cause); cases with it: [Jansen PAZMANY PL-2, 1 case](https://openairdocs.org/ntsb-findings/01071010/cases.md?model=0561312), [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Jansen PAZMANY PL-2, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=0561312), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Jansen PAZMANY PL-2, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=0561312), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Jansen PAZMANY PL-2, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=0561312), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Jansen PAZMANY PL-2, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=0561312), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Fuel starvation](https://openairdocs.org/ntsb-events/191) (defining event); cases with it: [Jansen PAZMANY PL-2, 1 case](https://openairdocs.org/ntsb-events/191/sequence.md?model=0561312), [All aircraft, 733 cases](https://openairdocs.org/ntsb-events/191/sequence.md) - [Initial climb: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Jansen PAZMANY PL-2, 1 case](https://openairdocs.org/ntsb-events/341/sequence.md?model=0561312), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Jansen PAZMANY PL-2, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=0561312), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis About 15 minutes after arriving at the airport, the private pilot departed on a local flight. A witness reported that, shortly after takeoff, the engine "sputtered and quit." The airplane appeared to continue climbing straight ahead to an altitude about 200 ft above ground level, then initiated a left turn as if attempting to return to the runway. The airplane reached an approximate 90° angle of bank and the nose dropped before the airplane descended almost vertically to ground contact, consistent with an aerodynamic stall/spin. Examination of the airframe and engine revealed no anomalies that would have precluded normal operation. The propeller did not exhibit indications of rotation at the time of impact. The fuel selector was set to the left tank position. Both left and right fuel tanks were breached and devoid of fuel; however, the asphalt surrounding the wreckage was discolored consistent with fuel spillage. The gascolator bowl contained some fuel; however, the carburetor bowl and accelerator pump well were devoid of fuel. Examination of the fuel system revealed no evidence of blockage that would have prevented fuel flow to the engine. The quantity and distribution of fuel on board the airplane at the time of the accident could not be determined; however, the lack of fuel in the carburetor bowl and accelerator pump is consistent with a fuel starvation event. The reason for the fuel starvation could not be determined based on the available information. Following the loss of engine power, the pilot attempted to return to the runway; however, the airplane did not have sufficient altitude to complete the 180° turn. During the turn, the pilot failed to maintain sufficient airspeed, which resulted in the airplane exceeding its critical angle of attack and entering an aerodynamic stall and spin. ## Factual narrative A pamphlet published by the FAA Safety Team titled, "Aircraft Control After Engine Failure on Takeoff" stated, "Studies have shown that startle responses during unexpected situations such as a powerplant failure during takeoff or initial climb have contributed to loss of control of aircraft…Research indicates a higher probability of survival if you continue straight ahead following an engine failure after takeoff. Turning back actually requires a turn of greater than 180 degrees after taking into account the turning radius. Making a turn at low altitudes and airspeeds could create a scenario for a stall/spin accident." On July 14, 2017, at 0932 Pacific daylight time, an experimental amateur-built Jansen Pazmany PL-2, N186EJ, impacted the ground following a loss of engine power after takeoff from San Gabriel Valley Airport (EMT), El Monte, California. The private pilot was fatally injured, and the airplane sustained substantial damage. The airplane was registered to Progenitech, LLC, and operated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local personal flight, which was originating at the time of the accident. According to airport gate entrance records, the pilot arrived at the airport at 0914. Information from the airport control tower indicated that the pilot contacted ground control for a taxi clearance at 0928, and contacted departure control at 0930. A witness reported that he watched the airplane take off; when it was between 50 and 75 ft above the runway, the engine "sputtered and quit." The airplane continued to climb straight ahead for a brief time, then appeared to initiate a left turn back toward the runway at an altitude about 200 ft above ground level. The witness reported that the airplane reached an approximate 90° angle of bank and its nose dropped as it descended almost vertically to ground contact. The Department of the Medical Examiner-Coroner from the County of Los Angeles, California, performed an autopsy on the pilot. The cause of death was listed as blunt trauma. The Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology testing on specimens from the pilot with negative results for carbon monoxide, cyanide, and ethanol. Specimens tested positive for valsartan, a blood pressure medication. According to the FAA, this medication is generally acceptable for use by airmen provided the underlying condition is well-controlled and there are no adverse side effects. In addition to the pilot's various ratings, in 2010, he accomplished an around-the-world flight in a single engine airplane. The pilot's logbook was not recovered for examination; during the pilot's most recent medical examination he reported 4,200 total hours, and 200 hours in the previous six months. The first identified point of contact was a ground scar with debris from the left wingtip and fuel tank. The second ground scar was from the propeller spinner, and exhibited an indentation consistent with a propeller strike. There were no indications of torsional bending of the propeller. The debris path extended along a magnetic heading of 106°. The main wreckage came to rest about 66 ft east of the first point of impact, with all debris contained within about 500 square ft. The fuel selector was set to the left fuel tank position. Fuel was drained from the gascolator; its color and odor was consistent with 100LL aviation fuel. The sample contained no debris or water. Examination of the airframe and engine revealed no anomalies that would have precluded normal operation. The engine remained attached to the damaged engine mounts and there was no evidence of catastrophic malfunction. The top spark plugs were removed and exhibited normal operating signatures when compared to the Champion 'check-a-plug' chart. The rocker covers were removed and the engine crankshaft was rotated by hand; thumb compression was established in proper firing order. In addition, the rockers appeared to move normally. The carburetor was displaced from the engine. The throttle control was attached, and the mixture cable arm was separated consistent with impact. The carburetor bowl was removed and no fuel was present. The float pontoons were intact and did not show evidence of hydrodynamic crushing. In addition, the accelerator pump well was devoid of fuel. The gascolator bowl was removed and about 1 ounce of fuel remained. The fuel selector was removed and air was blown through it; the left fuel tank was selected. Air was blown through the fuel system from the wings to the engine; all fuel lines and fuel tank vents were clear of debris and internal blockages. Air was blown through the fuel line between the fuel pump outlet and the carburetor inlet with no anomalies noted. Although the right and left wing fuel tanks were heavily damaged and contained no fuel, the asphalt surrounding the wreckage was discolored in a manner consistent with fuel spillage. ## Aircraft - Registration: [N186EJ](https://openairdocs.org/deregistered/N186EJ-2020-10-31), registration cancelled 2020-10-31, S/N 186, built 1979 (OpenAirDocs) - Reported make and model: JANSEN PAZMANY PL 2 - Registry model: [Jansen PAZMANY PL-2](https://openairdocs.org/model/jansen-pazmany-pl-2) (registry code 0561312) (OpenAirDocs) - Registry engine: [Lycoming 0-290 series](https://openairdocs.org/engine/lycoming-0-290-series) (registry code 41506, 4 cycle) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 186 - Year built: 1979 - Engines: LYCOMING O-320 SERIES 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, August 8, 2016, 451 hours before - Departed: EMT, El Monte, CA - Destination: EMT, El Monte, CA - Airport: EMT, San Gabriel Valley, runway 19, 3,995 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; toxicology performed; flight hours: 4,200 total ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 61 °F - Altimeter: 30.03 inHg - Observed at: KEMT ## 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 20170714022469A](https://openairdocs.org/incident/20170714022469A), Jul 14, 2017: Jansen PAZMANY PL-2, El Monte, CA, Destroyed, 1 fatal. On July 14, 2017, at 0932PDT, a pazmany PL-2, N186EJ registered to progenitech LLC, crashed during take-off from runway nineteen (19) of the san gabriel… ## Docket (8 files) The files NTSB released with the investigation on February 27, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95575. 5.6 MB in all. - Witness Statements (item 1, .PDF, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460354&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - FAA Statement - Regarding Control Tower Communications (item 2, .PDF, 208 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460355&FileExtension=.PDF&FileName=FAA%20Statement%20-%20Regarding%20Control%20Tower%20Communications-Master.PDF - Airframe and Engine Examination (item 3, .PDF, 7 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460356&FileExtension=.PDF&FileName=Airframe%20and%20Engine%20Examination-Master.PDF - Record of Conversation - Regarding Fuel on Scene (item 4, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460357&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Regarding%20Fuel%20on%20Scene-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 301 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460358&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460359&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Toxicological Report (item 7, .PDF, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460360&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - On Scene Photographs (item 8, .PDF, 13 photos, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40460361&FileExtension=.PDF&FileName=On%20Scene%20Photographs-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.