WPR19FA106

NTSB accident investigation · Tecnam P2002 · Santa Fe, NM · April 8, 2019

Accident · FatalClass 3 · FieldFinal report
Date
April 8, 2019, 15:38 local (21:38 UTC)
Place
Santa Fe, NM
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Initial climb
Aircraft
N118LSTecnam P2002
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20190408006309A
Case key
99233

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight instructor’s failure to maintain adequate airspeed during the initial climb after takeoff, which resulted in an exceedance of the airplane's critical angle of attack, an aerodynamic stall, and loss of control.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotCostruzioni Aeronautiche Tecna P2002 SIERRA: 7 casesAll aircraft: 9,295 casesProbable cause
Wind: gustsEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentCostruzioni Aeronautiche Tecna P2002 SIERRA: 2 casesAll aircraft: 1,199 cases
Temp/humidity/pressure: high density altitudeEnvironmental issues › Conditions/weather/phenomena · Effect on operationCostruzioni Aeronautiche Tecna P2002 SIERRA: 1 caseAll aircraft: 278 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The flight instructor and student pilot were conducting a touch-and-go landing. Surveillance footage showed that, shortly after takeoff, the airplane appeared to stop climbing. The right wing then dropped and the airplane entered a steep, nose-down attitude and impacted the ground. A postimpact fire ensued. Examination of the airframe and engine revealed no anomalies that would have precluded normal operation. At the time of the accident, the density altitude was calculated to be about 8,600 ft. Given the available evidence, it is likely that the engine’s performance was degraded by the high density altitude and the airplane’s critical angle of attack was exceeded during the initial climb after takeoff, which resulted in an aerodynamic stall and loss of control.

Factual narrative

The low-wing airplane was powered by a 100-horsepower Rotax 912 UL S2 series reciprocating engine. The engine was equipped with a GT Propellers fixed pitch propeller. A review of the airframe logbook revealed that the most recent condition inspection was completed on February 1, 2019, at an airframe total time of 1,962.5 hours and an engine time of 491.7 hours. Santa Fe Municipal Airport is a publicly owned, towered airport, with a reported field elevation of 6,348 ft mean sea level (msl). The airport was equipped with three asphalt runways; runway 15/33 was 6,316 ft long by 100 ft wide. On April 8, 2019, about 1538 mountain daylight time, a Costruzioni Aeronautiche Tecnam P2002 Sierra light sport airplane, N118LS, was destroyed when it was involved in an accident near Santa Fe, New Mexico. The flight instructor and student pilot were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The student and instructor were conducting a touch-and-go landing. A witness located near the departure end of the runway reported that the airplane did not climb very high before it appeared to "go sideways" and "nosedived sideways into the ground." Review of the surveillance camera video showed the accident airplane departing from runway 33. The airplane appeared to stop climbing; shortly thereafter, the right wing dropped, and the airplane entered a steep nose-down attitude and impacted the ground. A postimpact fire ensued. The Santa Fe County Coroner’s Office, Santa Fe, New Mexico, conducted the autopsy on the pilots. The medical examiner determined that the causes of death for both were attributed to “multiple blunt force injuries.” The FAA Forensic Sciences Laboratory performed toxicological testing on the instructor and student pilot. Specimens from the instructor were negative for carbon monoxide, cyanide, volatiles, and all tested-for drugs. Specimens from the student pilot were negative for carbon monoxide and ethanol. Tetrahydrocannabinol (THC, the primary psychoactive component of marijuana) was detected in blood and urine, and carboxy-delta-9-tetrahydrocannabinol was detected in the blood and urine. Pioglitazone was also detected in the blood. Pioglitazone is a prescription medication used with a diet and exercise program and sometimes with other medications, to treat type 2 diabetes. At 1453, the recorded weather conditions at Santa Fe Regional Airport (SAF), Santa Fe, New Mexico, included wind from 240° at 6 knots with gusts to 14 knots, 10 statute miles visibility, clear sky, temperature 23°C, dew point 8°C, and an altimeter setting of 30.15 inches of mercury. The density altitude was calculated to be about 8,600 ft. Review of weather conditions at SAF at the time of the accident revealed no forecasts for any moderate turbulence or low-level windshear. No AIRMETS, SIGMETS, or CWAs for significant weather were active in the area. A weather sounding model depicted no turbulence other thangusting wind at the accident site. The instructor, age 72, held a flight instructor certificate with a rating for airplane single engine. He held a commercial pilot certificate with ratings for airplane single-engine land, instrument airplane, and glider. His most recent second-class Federal Aviation Administration (FAA) airman medical certificate was issued on December 21, 2018, with a limitation for corrective lenses. The pilot reported on his medical certificate application that he had accumulated 10,589 total hours of flight experience, with 291 hours in the previous 6 months. The student pilot was issued an FAA third-class airman medical and student pilot certificate on June 15, 2001, which was not valid for any class after June 30, 2003. The pilot reported on the application for the medical certificate that he had accumulated 60 total hours of flight experience, with no flight time in the previous 6 months. The airplane first impacted terrain about 527 ft northeast of the departure end of runway 33, at an elevation of about 6,303 ft. All major components of the airplane were contained within the main wreckage site. Wreckage debris was scattered about 100 ft from the main wreckage. The first identified point of contact was a large area of disturbed dirt, about 2 ft long by 2 ft wide and 2 inches deep, where several pieces of green position light lens were located. The disturbance was about 91 ft from the main wreckage. Another ground disturbance, about 2.5 ft long, 2 ft wide, and an inch deep, was located about 18 ft further along the wreckage path, where propeller splinters and the top third of a blade were located. Ground scars emanated from this area of disturbed dirt to the main wreckage. The debris path was oriented on an approximate 005° magnetic heading. The fuselage came to rest upright on a heading of about 175° magnetic. A postimpact fire consumed the left wing and cabin area. Postaccident examination of the airframe and engine revealed no preimpact anomalies that would have prevented normal operation.

Aircraft

Registration
N118LS
Reported as
Tecnam P2002
Category
Airplane
Serial number
174
Built
2006
Airframe hours
1,962.5
Engine
Rotax 912 UL S2, 100 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Instructional · Part 91
Airworthiness certificate
Special, Special light-sport (Special)
Last inspection
Condition · February 1, 2019
Departed
SAF · Santa Fe, NM
Airport
SAF · Santa Fe Muni, runway 33, 6,316 × 100 ft, asphalt
Equipment
Unknown

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Student pilot
Age
60
Injuries
Fatal
Certificate
Student
Medical
Sport pilot
Seat
Left
Toxicology
Performed
Flight hours
60 total
Role
Flight instructor
Age
60
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Right
Toxicology
Performed
Flight hours
10,589 total

Weather

Conditions
Visual (VMC) · Day
Wind
240° at 6 knots, gusting 14
Visibility
10 statute miles
Temperature
73 °F, dew point 46 °F
Altimeter
30.15 inHg
Observed at
KSAF

Docket · 13

The files NTSB released with the investigation on June 3, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 33.7 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.