# NTSB WPR20LA237: Vans Vans RV-8, N138PM, Tehachapi, CA, July 24, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: July 24, 2020, 11:59 local (18:59 UTC) - Place: Tehachapi, CA - Coordinates: 35.136112, -118.44638 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.1361&lon=-118.4464&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Van Nuys FSDO, Lycoming Engines - NTSB case key (mKey): 101665 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR20LA237 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101665/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101665 - Page: https://openairdocs.org/ntsb/WPR20LA237 ## Probable cause The pilot’s failure to maintain airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall at too low of an altitude to recover. ## 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: [Phillips Michael G VANS RV-8, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05637FK), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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: [Phillips Michael G VANS RV-8, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=05637FK), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/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: [Phillips Michael G VANS RV-8, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=05637FK), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-aborted after touchdown: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Phillips Michael G VANS RV-8, 1 case](https://openairdocs.org/ntsb-events/060/sequence.md?model=05637FK), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Phillips Michael G VANS RV-8, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=05637FK), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Phillips Michael G VANS RV-8, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=05637FK), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis Witnesses reported that the accident airplane made a straight-in approach to land. The airplane touched down onto the runway tailwheel first and oscillated between its tailwheel and main landing gear several times. It then tipped up onto the left main gear and turned toward the right edge of the runway surface. The pilot initiated an aborted landing and according to a witness, the airplane lifted off quickly but made a "perceivably slow" turn to a left crosswind. The nose of the airplane was "alarmingly" high, and the airplane did not appear to be accelerating. The left turn steepened as the airplane descended behind buildings in a nose-up attitude with the wings wobbling. The engine "cut out" and, almost immediately thereafter. they heard the impact. The airframe and engine examination did not reveal any anomalies that would have precluded normal operation. Recorded data from the airplane was consistent with what the witnesses reported. The engine power never exceeded 67%, which is likely why the airplane did not appear to accelerate during the takeoff; however, this would not have resulted in the loss of control. Given the reported nose-high attitude and steep left turn, it is likely the pilot exceeded the airplane’s critical angle of attack and that it stalled at an altitude too low for the pilot to recover before it impacted the building. ## Factual narrative On July 24, 2020, about 1159 Pacific daylight time, a Vans RV-8, N138PM, was substantially damaged when it was involved in an accident near Tehachapi Municipal Airport (TSP), Tehachapi, California. The private pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Witnesses reported that the accident airplane made a straight-in approach to land. The airplane touched down onto the runway tailwheel first and oscillated between its tailwheel and main landing gear several times. It then tipped up onto the left main gear and turned toward the right edge of the runway. The airplane appeared to slow when the pilot transmitted “going around.” The witness reported the pilot applied the engine power so abruptly that the engine “coughed” a number of times before it smoothed out. The airplane lifted off quickly but made a "perceivably slow" turn to a left crosswind. The nose of the airplane was "alarmingly" high, and the airplane did not appear to be accelerating. The left turn steepened as the airplane descended behind buildings in a nose up attitude with the wings wobbling. The engine "cut out," and, almost immediately thereafter, they heard the impact. Video taken from a security camera showed the airplane in a descending left turn just prior to impact. Its left wing appeared to raise slightly before it descended behind a building roofline. Immediately thereafter, dirt and debris were observed. A distant away video of the runway showed the accident airplane come into land on the runway before taking off again. The airplane started a shallow climb, then initiated a nose high, left turn. About halfway through the turn, the nose of the airplane lowered, and the airplane descended toward the ground left wing low. A different video showed the airplane in a descent. Its left wing appeared to raise slightly before it descended behind a building roofline. Immediately thereafter, dirt and debris were observed. The Advanced Flight Systems multifunction display recorded data from the entire flight. Data recovered revealed that the airplane’s airspeed decreased to 47 knots during the landing roll at TSP. The engine power and airspeed then increased, and the airplane lifted off about 10 seconds later at an airspeed of about 64 knots. The airplane continued to climb as it entered a left bank. The airplane’s maximum rate of climb was 760 ft/min at an airspeed of 64 knots while in a 38° left bank. About 6 seconds later, while still at 64 knots, the airplane entered a descent and the left bank had increased to about 50°. The last data recorded showed the airplane in a 2,180-fpm descent while in a 83.5° left bank at an altitude of 3,970 ft above mean sea level. The airplane had gained about 200 ft in altitude after it took off prior to entering the descent. The data indicated the engine was operating at a maximum of 67% following the aborted landing. The Kern County Sheriff’s Office, Bakersfield, Californiaperformed an autopsy of the pilot. The pilot’s cause of death was multiple blunt force trauma. The Federal Aviation Administration (FAA) Forensic Sciences Laboratory performed toxicological testing on specimens from the pilot with a positive result for Tamsulosin (Flomax) in urine. Tamsulosin is acceptable for FAA medical certification. The airplane breached the roof of a building about 350 yards southwest of the departure end of the runway. The airplane entered the roof, went through the upper portion of one wall, and came to rest on top of a second wall. Both wings were bent aft, and the left wing was found positioned lower than the right. The aft fuselage and empennage extended upward and remained above the roofline. Postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. Both wings were bent aft and partially separated from the fuselage. The left wing outboard leading edge was crushed aft and upward; and the right wing inboard leading edge was crushed aft. The fuel caps remained secured on the left- and right-wing fuel tanks; however, the tanks themselves were breached and no fuel was noted. Flight control continuity was established from the forward control stick to both the left and right aileron bellcranks. The aileron surfaces themselves were fracture separated. Rudder and elevator control continuity was established from their cockpit controls to their respective flight control surfaces. The throttle and mixture controls in the cockpit remained secured to their respective control arms on the fuel servo. The upper spark plugs were removed from the engine and their appearance was consistent with normal operations. All engine fuel lines remained secured. The fuel pump, fuel servo, and fuel divider were disassembled and unremarkable. The engine was borescoped; the cylinder walls, piston heads, valves, and lower spark plugs were all consistent with normal operations. The engine was rotated by hand at the propeller hub. Thumb compression was established on all cylinders and drivetrain continuity was established to the accessory section. The magnetos remained secured on their mounting pads and spark was obtained on all ignition leads. ## Aircraft - Registration: [N138PM](https://openairdocs.org/deregistered/N138PM-2021-06-05), registration cancelled 2021-06-05, S/N 81895, built 2018 (OpenAirDocs) - Reported make and model: Vans VANS RV-8 (Undesignat) - Registry model: [Phillips Michael G VANS RV-8](https://openairdocs.org/model/phillips-michael-g-vans-rv-8) (registry code 05637FK) (OpenAirDocs) - Registry engine: [Lycoming AEIO-360-A1E](https://openairdocs.org/engine/lycoming-aeio-360-a1e) (registry code 41851, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 81895 - Year built: 2018 - Engines: Lycoming AE-IO-360-A1E 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Departed: WHP, Los Angeles, CA - Destination: TSP, Tehachapi, CA - Flight plan: VFR - Airport: TSP, Tehachapi Municipal Airport, runway 29, 4,040 × 75 ft, asphalt - Equipment: Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; private; airplane ratings: single-engine land; medical: basicmed; seat: front; restraint: 5-point; toxicology performed; flight hours: 92 total, 1 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 3 knots - Visibility: 10 statute miles - Temperature: 77 °F, dew point 55 °F - Altimeter: 29.93 inHg - Observed at: KTSP, 5 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 20200724011529A](https://openairdocs.org/incident/20200724011529A), Jul 24, 2020: Phillips Michael G VANS RV-8, Tehachapi, CA, Destroyed, 1 fatal. On July 24, 2020, at 1159 PDT, N138PM, an experimental, operating amateur built RV-8, stalled/spun and impacted the roof of a commercial building at the… ## Docket (15 files) The files NTSB released with the investigation on June 1, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101665. 281 MB in all. - Cockpit displays - specialist's factual report (item 1, PDF, 10 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12433661&FileExtension=pdf&FileName=WPR20LA237%20Cockpit%20Displays%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to cockpit displays - specialist's factual report (item 2, CSV, 341 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12433186&FileExtension=csv&FileName=WPR20LA237%20Attachment%201%20to%20Cockpit%20Displays%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Attachment 2 to cockpit displays - specialist's factual report (item 3, CSV, 343 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12433567&FileExtension=csv&FileName=WPR20LA237%20Attachment%202%20to%20Cockpit%20Displays%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Witness statements (item 4, PDF, 2 pages, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9999826&FileExtension=pdf&FileName=ROE%20witness-Rel.pdf - Record of email - wingman statement (item 5, PDF, 2 pages, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9996892&FileExtension=pdf&FileName=ROE%20Wingman-Rel.pdf - Record of conversation - FAA regarding on scene observations (item 6, PDF, 1 page, 463 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13801407&FileExtension=pdf&FileName=ROC%20FAA%20On%20scene-Rel.pdf - Airframe and engine examination (item 7, PDF, 15 pages, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13802323&FileExtension=pdf&FileName=airframe%20and%20engine%20notes-Rel.pdf - Radar data (item 8, KML, 247 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13801417&FileExtension=kml&FileName=250702ca-Rel.kml - Record of memorandum - autopsy (item 9, PDF, 1 page, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11980361&FileExtension=pdf&FileName=ROM%20autopsy-Rel.pdf - Evidence control form (item 10, PDF, 5 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13802111&FileExtension=pdf&FileName=Evidence%20form%20completed-Rel.pdf - Statement of party representatives to NTSB investigation (item 11, PDF, 1 page, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12159017&FileExtension=pdf&FileName=Party%20Form%20Lycoming%20printed_Redacted-Rel.pdf - Toxicological report (item 12, PDF, 1 page, 700 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11979799&FileExtension=pdf&FileName=tox_Redacted-Rel.pdf - On scene photos - courtesy of the FAA and air transport (item 13, PDF, 3 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13800646&FileExtension=pdf&FileName=on%20scene%20photos%20from%20faa-Rel.pdf - Video file - view of runway (item 14, AVI, 228 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10072660&FileExtension=avi&FileName=07242020%20Video%20-%20runway-Rel.avi - Video file - view of final descent (item 15, AVI, 39.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13385312&FileExtension=avi&FileName=07242020%20Video%20-%20Green%20St%20impact-Rel.avi 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.