# NTSB WPR19FA212: Wheeler Express Series 2000, N43FD, Camarillo, CA, August 7, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: August 7, 2019, 13:29 local (20:29 UTC) - Place: Camarillo, CA - Coordinates: 34.21389, -119.070831 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.2139&lon=-119.0708&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Continental Motors, FAA - NTSB case key (mKey): 100013 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19FA212 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100013/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100013 - Page: https://openairdocs.org/ntsb/WPR19FA212 ## Probable cause The pilot’s failure to maintain adequate airspeed on final approach, which resulted in exceedance of the airplane’s critical angle of attack and an aerodynamic stall at an altitude that precluded recovery. ## 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 · Pilot (probable cause); cases with it: [Davis Ferril R EXPRESS SERIES 2000, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05612JI), [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: [Davis Ferril R EXPRESS SERIES 2000, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05612JI), [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 · Not attained/maintained (probable cause); cases with it: [Davis Ferril R EXPRESS SERIES 2000, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=05612JI), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Davis Ferril R EXPRESS SERIES 2000, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=05612JI), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis The pilot and passenger were landing at the destination airport following a cross-country flight. Witnesses saw the airplane on final approach for landing when it entered a right bank followed by a steep, nose-down descent. The airplane impacted the ground several hundred feet short of the runway threshold. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation. Given the available information, it is likely that the pilot failed to maintain airspeed on final approach, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall at an altitude too low for recovery. ## Factual narrative The low-wing, fixed-gear airplane was issued a Federal Aviation Administration (FAA) experimental airworthiness certificate on March 27, 2002. It was powered by a Continental IO-550-N1B 310-hp engine, serial number 685820. A review of the airplane's logbooks showed that a condition inspection was completed on April 26, 2019, at a recorded tachometer reading of 142.7 hours. At the time of the accident, the airplane had accumulated 29.4 hours since the last condition inspection. On August 7, 2019, about 1329 Pacific daylight time, an amateur built experimental Express 2000 airplane, N43FD, was substantially damaged when it was involved in an accident near Camarillo, California. The private pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The flight originated at South Valley Regional Airport (U42), Salt Lake City, Utah. The pilot refueled at Tonopah Airport (TPH), Tonopah, Nevada, then proceeded to Camarillo Airport (CMA), Camarillo, California. According to the CMA tower controller, the pilot established radio contact 5 miles north of the airport. The pilot was instructed to make right traffic for runway 26, and was subsequently instructed to turn onto a 3-mile base leg. The controller last saw the airplane on a 2-mile final approach, followed shortly thereafter by a dust cloud. A flight instructor, who was flying in a helicopter at the time of the accident, stated that he saw the accident airplane about 40 ft above the ground on short final enter into an aerodynamic stall and impact the ground. The student pilot onboard the helicopter stated that the accident airplane pitched up, entered a descending right bank, and subsequently impacted the ground. The Ventura County Medical Examiner Office, Ventura, California, conducted the autopsy on the pilot. The medical examiner determined that the cause of death for the pilot was attributed to multiple blunt force injuries. The FAA's Forensic Sciences Laboratory performed toxicological testing on the pilot. The results for the testing were negative for carbon monoxide and volatiles. Testing results were positive for Amlodipine and Tamsulosin. Amlodipine is a prescription medication used to treat high blood pressure. Tamsulosin is a prescription medication used to treat the symptoms of an enlarged prostate. The CMA recorded weather observation at 1355 included wind from 240° at 9 knots, 10 miles visibility, clear sky, temperature 23°C, dew point 16°C, and an altimeter setting of 29.95 inches of mercury. The pilot held a private pilot certificate with a rating for instrument airplane. His most recent application for a FAA third-class medical certificate was on July 5, 2018. At the time of his last medical examination, he reported 1,395 total hours of flight experience, of which 15 were within the preceding 6 months. The pilot’s logbook was not located. The airplane impacted the ground about 750 ft short of the runwayabout 100 ft north of the displaced threshold. The debris field extended about 130 ft in southeast-to-northwest orientation. The first identified point of impact was ground scarring, which contained multiple composite fragments from the right-wing tip. The main wreckage comprised the fuselage, empennage, engine, and both wings. The cabin area was mostly destroyed. Elevator, rudder, and aileron continuity was confirmed. All flight control torque tubes and control cables either remained attached or were broken under tension overload during impact. The fuel selector was found on the right tank position. The mixture control was full forward. The throttle and propeller controls were broken. The empennage remained attached to the fuselage and sustained impact damage. The elevator remained attached to the horizontal stabilizer and displayed impact damage. The elevator trim was near the neutral position. The rudder remained attached to the vertical stabilizer and no anomalies were noted. The left wing remained attached to the fuselage and displaced crushing near the leading edge and the wing tip. The aileron remained attached to the wing. The trim tab remained attached to the aileron but was bent underneath the wing. The flap separated from the fuselage and was found under the wing. The fuel cap remained secured. The wet wing fuel cell was found breached and about 2 gallons of residual fuel was drained during the recovery. The right wing remained partially attached to the fuselage and had rotated upward about 90°. The leading edge and wing tip displayed extensive crushing. The aileron remained attached to the wing. The flap separated from the fuselage and was found within about 10 ft of the main wreckage. The fuel cap remained secured. The wet wing fuel cell was found breached and about 1 gallon of residual fuel was drained during the recovery. The engine had separated from the firewall and was found next to the fuselage. All six cylinders remained attached to the engine and displayed some impact damage. The starter, air filter, air pump shear drive, and propeller were separated from the engine and located within the debris field. The engine-driven fuel pump remained attached to the engine with impact damage to the unmetered fuel pressure adjustment screw and lock nut. The fuel mixture arm remained secured to its shaft and the damaged control cable remained attached. The propeller governor was impact damaged. The propeller was located about 75 ft north of the initial impact point and exhibited compound bending, twisting, significant leading-edge gouging, and chordwise rotational abrasion, consistent with the engine producing power at the time of impact. Examination of the airframe and engine revealed no anomalies that would have precluded normal operation. ## Aircraft - Registration: [N43FD](https://openairdocs.org/deregistered/N43FD-2020-01-06), registration cancelled 2020-01-06, S/N DAVIS 001, built 2002 (OpenAirDocs) - Reported make and model: Wheeler EXPRESS SERIES 2000 (No Series) - Registry model: [Davis Ferril R EXPRESS SERIES 2000](https://openairdocs.org/model/davis-ferril-r-express-series-2000) (registry code 05612JI) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: DAVIS 001 - Year built: 2002 - Airframe hours: 172.1 - Engines: Continental IO-550-N1B 310 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: N43FD Airplane LLC. - Registered owner: N43FD Airplane LLC. - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, April 26, 2019, 29 hours before - Departed: TPH, Tonopah, NV - Destination: CMA, Camarillo, CA - Flight plan: VFR - Airport: CMA, Camarillo, runway 26, 6,013 × 150 ft, asphalt - Equipment: Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; toxicology performed; flight hours: 1,395 total ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 61 °F - Altimeter: 29.95 inHg - Observed at: KCMA, 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 20190807014149A](https://openairdocs.org/incident/20190807014149A), Aug 7, 2019: Davis Ferril R EXPRESS SERIES 2000, Camarillo, CA, Destroyed, 2 fatal. N43FD radioed cma tower 5 miles north of the airport and was in bound for landing on runway 26. According a witness from ground control N43FD appeared to be… ## Docket (11 files) The files NTSB released with the investigation on October 27, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100013. 54.6 MB in all. - Airport statements (item 1, PDF, 4 pages, 41.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12564059&FileExtension=pdf&FileName=Airport%20Statements_Redacted-Rel.pdf - Tower report (item 2, PDF, 1 page, 575 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12563567&FileExtension=pdf&FileName=CMA%20Tower%20Report%20N43FD_Redacted-Rel.pdf - Accident site notes (item 3, PDF, 6 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12563780&FileExtension=pdf&FileName=WPR19FA212%20Accident%20Site%20Notes%20Final%201-Rel.pdf - Airframe and engine examination notes (item 4, PDF, 3 pages, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12564219&FileExtension=pdf&FileName=WPR19FA212%20Airframe%20and%20Engine%20Examination%20Notes%201-Rel.pdf - Aircraft logbook (item 5, PDF, 9 pages, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12564942&FileExtension=pdf&FileName=Aircraft%20Log2_Redacted-Rel.pdf - Engine logbook (item 6, PDF, 4 pages, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12564501&FileExtension=pdf&FileName=Engine%20Log_Redacted-Rel.pdf - Propeller logbook (item 7, PDF, 2 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12564069&FileExtension=pdf&FileName=Propeller%20Log_Redacted-Rel.pdf - Fuel receipt (item 8, PDF, 1 page, 222 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12564209&FileExtension=pdf&FileName=N43FD%20Fuel%20Receipt_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 1 page, 243 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12565178&FileExtension=pdf&FileName=Signed%20NTSB%20Party%20Letter%208-2017_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 740 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8877741&FileExtension=pdf&FileName=WPR19FA212%20Signed%20Wreckage%20Release_Redacted-Rel.pdf - Toxicological report (item 11, PDF, 1 page, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12003625&FileExtension=pdf&FileName=Forensic%20Toxicology_Pilot%20Final_Redacted-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.