# NTSB WPR19FA106: Tecnam P2002, N118LS, Santa Fe, NM, April 8, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: April 8, 2019, 15:38 local (21:38 UTC) - Place: Santa Fe, NM - Coordinates: 35.621946, -106.10339 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.6219&lon=-106.1034&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: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 99233 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19FA106 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99233/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99233 - Page: https://openairdocs.org/ntsb/WPR19FA106 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Costruzioni Aeronautiche Tecna P2002 SIERRA, 7 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=0600006), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Wind: gusts](https://openairdocs.org/ntsb-findings/03034045): Environmental issues › Conditions/weather/phenomena · Effect on equipment; cases with it: [Costruzioni Aeronautiche Tecna P2002 SIERRA, 2 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md?model=0600006), [All aircraft, 1,199 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md) - [Health/Fitness: use of medication/drugs](https://openairdocs.org/ntsb-findings/02013020): Personnel issues › Physical · Student/instructed pilot; cases with it: [Costruzioni Aeronautiche Tecna P2002 SIERRA, 1 case](https://openairdocs.org/ntsb-findings/02013020/cases.md?model=0600006), [All aircraft, 73 cases](https://openairdocs.org/ntsb-findings/02013020/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Costruzioni Aeronautiche Tecna P2002 SIERRA, 1 case](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=0600006), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/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: [Costruzioni Aeronautiche Tecna P2002 SIERRA, 6 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=0600006), [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: [Costruzioni Aeronautiche Tecna P2002 SIERRA, 5 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=0600006), [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: [Costruzioni Aeronautiche Tecna P2002 SIERRA, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0600006), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N118LS-2020-05-01), registration cancelled 2020-05-01, S/N 174, built 2006 (OpenAirDocs) - Reported make and model: TECNAM P2002 - Registry model: [Costruzioni Aeronautiche Tecna P2002 SIERRA](https://openairdocs.org/model/costruzioni-aeronautiche-tecna-p2002-sierra) (registry code 0600006) (OpenAirDocs) - Registry engine: [Rotax SEE BOMBADIER](https://openairdocs.org/engine/rotax-see-bombadier) (registry code 55555, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 174 - Year built: 2006 - Airframe hours: 1962.5 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 60; injuries: fatal; student; medical: sport pilot; seat: left; toxicology performed; flight hours: 60 total - Flight instructor; age 60; injuries: fatal; 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 ## 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 20190408006309A](https://openairdocs.org/incident/20190408006309A), Apr 8, 2019: Costruzioni Aeronautiche Tecna P2002 SIERRA, Santa Fe, NM, Destroyed, 2 fatal. On 4/08/2019, at approximately 1540 mountain daylight time (MDT), a construzioni aeronautiche Tecnam P2002 sierra aircraft bearing registration number N118LS,… ## Docket (13 files) The files NTSB released with the investigation on June 3, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99233. 33.7 MB in all. - Witness statement (item 1, PDF, 1 page, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11914614&FileExtension=pdf&FileName=Witness%20Statement_Redacted-Rel.pdf - Record of conversation - witness (item 2, PDF, 1 page, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11914644&FileExtension=pdf&FileName=Record%20of%20Conversation%201%20WPR19FA106-Rel.pdf - Record of conversation - interview (item 3, PDF, 2 pages, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11915024&FileExtension=pdf&FileName=Record%20of%20Conversation%202%20WPR19FA106-Rel.pdf - Engine examination (item 4, PDF, 3 pages, 429 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11915044&FileExtension=pdf&FileName=WPR19FA106%20Engine%20Examination-Rel.pdf - Accident site examination report (item 5, PDF, 4 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11915199&FileExtension=pdf&FileName=WPR19FA106%20On%20Site%20Examination-Rel.pdf - Logbook excerpt inspection (item 6, PDF, 1 page, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11914624&FileExtension=pdf&FileName=Inspection_Redacted-Rel.pdf - Loogbook excerpt engine inspection (item 7, PDF, 1 page, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11915014&FileExtension=pdf&FileName=Eng%20Inspection_Redacted-Rel.pdf - Flight manual stall speeds (item 8, PDF, 1 page, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11914371&FileExtension=pdf&FileName=Flight%20Manual%20Stall%20Excerpt-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 1 page, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11915117&FileExtension=pdf&FileName=Party%20Form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11954046&FileExtension=pdf&FileName=2021%20Retention-Release-of-Wreckage-Form_Redacted-Rel.pdf - Toxicological report (item 11, PDF, 3 pages, 429 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11915004&FileExtension=pdf&FileName=Toxicology%20Final%201_Redacted-Rel.pdf - Accident video courtesy of joe gamez (signature flight) (item 12, AVI, 21.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11914634&FileExtension=avi&FileName=Accident%20Video%20courtesy%20of%20Joe%20Gamez%20(Signature%20Flight)-Rel.avi - Accident pictures (item 13, PDF, 2 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12308114&FileExtension=pdf&FileName=Accident%20Pictures-Rel.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.