# NTSB WPR20LA303: Navion B, N37C, Van Nuys, CA, September 11, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: September 11, 2020, 15:00 local (22:00 UTC) - Place: Van Nuys, CA - Coordinates: 34.191944, -118.48916 - Nearby events: https://openairdocs.org/map.md?lat=34.1919&lon=-118.4892&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: Continental Motors, Federal Aviation Administration - NTSB case key (mKey): 101953 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR20LA303 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101953/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101953 - Page: https://openairdocs.org/ntsb/WPR20LA303 ## Probable cause The pilot’s failure to maintain control of the airplane during an abrupt turn after takeoff at a low altitude, which resulted in an aerodynamic stall. ## 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: [Navion NAVION B, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=6150112), [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: [Navion NAVION B, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=6150112), [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: [Navion NAVION B, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=6150112), [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. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Navion NAVION B, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=6150112), [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: [Navion NAVION B, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=6150112), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Navion NAVION B, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=6150112), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis Air Traffic control reported that, at the time of the accident, the traffic volume at the airport was moderate, but not complex. The pilot contacted the tower and reported that he was ready for takeoff. The controller replied that he was cleared for takeoff from 16R without delay. The airplane took off uneventfully; shortly thereafter the controller started to instruct the pilot to turn on a right crosswind but stopped and asked the pilot if he was ok. There was no response from the pilot. Witnesses reported that the airplane took off to the south and was flying lower than normal. In addition, the airplane started a right turn much earlier than most airplanes. As the airplane started its turn, they heard a “pop,” and the airplane made a “hard right” turn. The airplane then descended nose down with the wings at a slight angle as it went out of sight. Shortly thereafter, a plume of smoke was observed. The airplane impacted nose low in a narrow parking lot about ½ mile west of the runway surface. The airplane wreckage was contained to a small area in between two rows of vehicles. A post-crash fire ensued, and a large portion of the fuselage and aft fuselage were consumed by fire. Postaccident examination of the engine and remaining airframe did not reveal any anomalies that would have precluded normal operation. Given the abrupt climbing right turn it is likely the airplane stalled at a low altitude. It could not be determined if the moderate traffic at VNY was enough to cause the pilot to rush the turn to crosswind. ## Factual narrative On September 11, 2020, at 1501 Pacific daylight time, a Navion B, N37C, was destroyed when it was involved in an accident near the Van Nuys Airport (VNY), Van Nuys, California. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. Air Traffic control reported that, at the time of the accident, the traffic volume at VNY was moderate, but not complex. The pilot contacted the tower and reported that he was ready for takeoff. The controller replied that he was cleared for takeoff from 16R without delay. The airplane took off uneventfully; shortly thereafter the controller started to instruct the pilot to turn on a right crosswind but stopped and asked the pilot if he was ok. There was no response from the pilot. Witnesses reported that the airplane took off to the south and was flying lower than normal. In addition, the airplane started a right turn much earlier than most airplanes. As the airplane started its turn, they heard a “pop,” and the airplane made a “hard right” turn. The airplane then descended nose down with the wings at a slight angle as it went out of sight. Shortly thereafter, a plume of smoke was observed. The airplane impacted nose low in a narrow parking lot about ½ mile west of the runway surface. The airplane wreckage was contained to a small area in between two rows of vehicles. A post crash fire ensued; a large portion of the fuselage and aft fuselage were consumed by fire. The engine, cabin area, and wings were heavily accordioned and exhibited thermal damage. The empennage was present but exhibited extensive thermal damage. The fuel selector was located and was found in the “MAIN” position. Flight control continuity was established throughout the airframe. The engine exhibited heavy impact related damage; the crankcase had a large crack perpendicular to the split line. The cylinder valve covers were removed and exhibited normal operating signatures except for the number 5-cylinder intake valve assembly, which was fracture separated from the engine. The upper spark plugs were removed and exhibited normal operating wear signatures. The cylinders were borescoped; the valve heads were undamaged and normal combustion deposits were found on the piston head surfaces. The combustion chambers revealed normal operating signatures. Both magnetos exhibited thermal discoloration and impact related damage. The ignition leads were cut near the distributer cap. The magnetos were rotated by hand, and spark was obtained at each ignition lead end. The fuel manifold valve was disassembled, and fuel was noted in the valve chamber; the screen was clear of debris. The fuel control valve was disassembled with no anomalies noted. The Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed forensic toxicology on specimens from the pilot with positive results for Rosuvastatin. Rosuvastatin is aprescription medication that is acceptable for FAA medical certification. ## Aircraft - Registration: [N37C](https://openairdocs.org/deregistered/N37C-2021-06-10), registration cancelled 2021-06-10, S/N NAV-4-2184-B, built 1950 (OpenAirDocs) - Reported make and model: NAVION B - Registry model: [Navion NAVION B](https://openairdocs.org/model/navion-navion-b) (registry code 6150112) (OpenAirDocs) - Registry engine: [Continental IO-550 series](https://openairdocs.org/engine/continental-io-550-series) (registry code 17042, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: NAV-4-2184-B - Year built: 1950 - Engines: Continental Motors IO-550G 300 hp reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Destination: IZA, Santa Ynez, CA - Airport: VNY, Van Nuys Airport, runway 16R, 8,001 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: fatal; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 19,001 total, 14 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 6 knots - Visibility: 6 statute miles - Lowest ceiling: none - Temperature: 91 °F, dew point 34 °F - Altimeter: 29.92 inHg - Observed at: VNY ## 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 20200911013949A](https://openairdocs.org/incident/20200911013949A), Sep 11, 2020: Navion NAVION B, Van Nuys, CA, Destroyed, 2 fatal. On September 11, 2020, at 1501 pacific daylight time (PDT), a Navion B aircraft, N37C, impacted a parking lot within the city of Van Nuys, California. The… ## Docket (12 files) The files NTSB released with the investigation on May 11, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101953. 187 MB in all. - Witness statements (item 1, PDF, 1 page, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11513404&FileExtension=pdf&FileName=witness%20statements%20508-Rel.pdf - FAA on scene observations (item 2, PDF, 6 pages, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11513734&FileExtension=pdf&FileName=ROC%20FAA%20ON%20SCENE-Rel.pdf - Airframe and engine examination observations (item 3, PDF, 10 pages, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12150943&FileExtension=pdf&FileName=WPR20LA303%20Engine%20and%20Airframe%20Examination%20Summary-DMS-Rel.pdf - Radar - google earth (item 4, KML, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11513414&FileExtension=kml&FileName=N73C%20KML-Rel.kml - ATC recording - local control (item 5, MP4, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11513424&FileExtension=mp4&FileName=VNY%20LC-Rel.mp4 - ATC recording - ground control (item 6, MP4, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11513715&FileExtension=mp4&FileName=VNY%20GC-Rel.mp4 - Record of memorandum - autopsy (item 7, PDF, 1 page, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11991882&FileExtension=pdf&FileName=ROM%20auotpsy-Rel.pdf - Statement of party representatives to NTSB investigation (item 8, PDF, 1 page, 281 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12150525&FileExtension=pdf&FileName=CAT%20Party%20Form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 9, PDF, 1 page, 128 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12156662&FileExtension=pdf&FileName=Wreckage%20Release%20Final_Redacted-Rel.pdf - Toxicological report (item 10, PDF, 1 page, 303 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11583317&FileExtension=pdf&FileName=TOX%20for%20docket_Redacted-Rel.pdf - Images from second security camera (item 11, PDF, 13 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11513755&FileExtension=pdf&FileName=screenshots%20of%20second%20security%20camera%20for%20DMS-Rel.pdf - Video of accident (item 12, AVI, 173 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11513192&FileExtension=avi&FileName=ch04_20200911150000_crash_footage-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.