WPR21FA170

NTSB accident investigation · Consolidated Vultee BT-13A · Camas, WA · April 21, 2021

Accident · FatalClass 3 · FieldFinal report
Date
April 21, 2021, 15:13 local (22:13 UTC)
Place
Camas, WA · Airport
Injuries
1 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N53331Consolidated Vultee BT-13A
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
FAA
FAA report
20210421005389A
Case key
102959

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 pilot’s exceedance of the airplane’s critical angle of attack during an aborted landing, resulting in an aerodynamic stall and impact with terrain.

Findings · 2

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.

Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededConsolidated Vultee BT-13A: 1 caseAll aircraft: 990 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · Student/instructed pilotConsolidated Vultee BT-13A: 2 casesAll aircraft: 9,295 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 was providing recurrent training to the pilot in the tailwheel-equipped airplane. They had completed several takeoffs and landings at a nearby airport before returning to the departure airport. The first approach to the runway resulted in a go-around due to an unstable approach, and following the second approach, the pilot receiving instruction performed a three-point landing. During the landing roll, the airplane veered left and exited the runway, and the pilot applied full power and “immediately pitched up.” The airplane climbed in ground effect to about 30 ft, then entered a left turn, and its bank angle continued to increase before the airplane impacted terrain. The airplane came to rest adjacent to a hangar in a nose-low, near-vertical attitude. The pilot was fatally injured. The instructor added that, although he had been guarding the flight controls, due to the low altitude of the event, he did not have time to react before impact. Toxicology testing of the pilot receiving instruction detected diphenhydramine, a sedating antihistamine commonly available over the counter in a host of preparations intended to treat cold and allergy symptoms and to induce sleep. The range of levels where effects are expected are above 25 ng/ml, but the drug undergoes significant post-mortem redistribution and levels found in cavity blood likely do not accurately reflect antemortem levels. Although the pilot receiving instruction could have been impaired somewhat by the effects of a small amount of diphenhydramine in his system, some of those effects would have most likely been overcome by the adrenalin naturally produced in the emergency situation. It is therefore unlikely that the small amount of diphenhydramine contributed to the accident circumstances. The accident is consistent with the pilot’s exceedance of the airplane’s critical angle of attack during an aborted landing, which resulted in an aerodynamic stall and impact with terrain.

Factual narrative

The FAA publication H-8083-25A, Pilot's Handbook of Aeronautical Knowledge, stated that an aerodynamic stall results from a rapid decrease in lift caused by the separation of airflow from the wing's surface brought on by exceeding the critical angle of attack (AOA). AOA is defined as the acute angle between the chord line of the airfoil and the direction of the relative wind. An aerodynamic stall can occur when the airplane flies too slowly, or when higher wing loads are imposed due to maneuvers such as pull-ups or banked flight. On April 21, 2021, about 1513 Pacific standard time, a Consolidated Vultee BT-13A, N53331, was substantially damaged when it was involved in an accident near Camas, Washington. The pilot receiving instruction was fatally injured and the flight instructor sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The instructor, who was seated in the aft seat, reported that the purpose of the accident flight was to provide recurrent training to the pilot receiving instruction. They departed, flew to a nearby airport, and conducted several takeoffs and landings in the tailwheel-equipped airplane before returning to the departure airport. The instructor stated that the first approach to land on runway 25 resulted in go-around, due to a confusion with the power setting and altitude and airspeed fluctuations to the runway. Following the second approach, the pilot performed a three-point landing, and during the landing roll, the airplane veered left and exited the runway. The instructor stated that the pilot did not attempt to return to the runway, but at an airspeed of about 35 miles per hour, “the pilot added full power and immediately pitched up.” The airplane climbed in ground effect to about 30 ft above the ground, then entered a “stalling left turn.” The instructor stated that the bank angle to the left continued to increase as the nose dropped before the airplane impacted terrain. The instructor further added that he had been guarding the flight controls but because of the low altitude, he did not have time to correct. The instructor reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. An autopsy of the pilot was performed by the Clark County Medical Examiner’s Office in Vancouver, Washington, which listed the cause of death as “multiple blunt force injuries.” Toxicology testing performed at the Federal Aviation Administration Forensic Sciences Laboratory found diphenhydramine at 92 ng/ml in blood, as well as acetaminophen. Both were also identified in urine. Diphenhydramine is a sedating antihistamine commonly available over the counter in a host of preparations intended to treat cold and allergy symptoms, and to induce sleep. The range of levels where effects are expected are above 25 g/ml, but the drug undergoes significant post-mortem redistribution and levels foundin cavity blood likely do not accurately reflect antemortem levels. Acetaminophen, a pain and fever medication commonly known as Tylenol, is not considered impairing. The pilot receiving instruction held a private pilot certificate with an airplane single-engine land rating. At the time of the accident, he had accumulated about 274 total hours of flight experience, of which 177 hours were in the accident airplane from November 2014 to April 2021. He completed about 9 flight hours of dual instruction with a flight instructor in the accident airplane about 6 months before the accident flight. Postaccident examination of the accident site revealed that the airplane impacted terrain about 890 ft from the approach end of runway 25, and 95 ft south of the runway, as seen in figure 1. A damaged runway light was observed about 570 ft from the runway threshold. The first identified point of impact with terrain was a ground impression that was about 6 ft in length and contained red navigation light lens fragments. The debris path was oriented along a 215° magnetic heading and extended about 120 ft from the initial point of impact to the main wreckage. The airplane came to rest in a near-vertical attitude against a hangar on a heading of 141° magnetic. The fuselage and wings remained intact except for the forward portion of the fuselage, which had sustained impact damage; the engine and engine mount separated from the firewall. Flight control continuity was established from both cockpit controls to all primary flight control surfaces. Figure 1: Overview of the accident site

Aircraft

Registration
N53331
Reported as
Consolidated Vultee BT-13A
Category
Airplane
Serial number
1491
Built
1941
Airframe hours
2,955.2
Engine
P&W R-985-14B, 450 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
None
Last inspection
Annual · February 2, 2021
Departed
4S2 · Hood River, OR
Destination
Same as departure
Airport
1W1 · Grove Fld, runway 25, 2,710 × 40 ft, asphalt

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
Pilot
Age
69
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Seat
Front
Restraint
4-point
Toxicology
Performed
Flight hours
274 total · 177 in this make and model · 160 as pilot in command
Role
Flight instructor
Age
75
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
January 11, 2020
Seat
Rear
Restraint
4-point
Flight hours
11,090 total · 100 in this make and model · 10,939 as pilot in command · 180 in the last 90 days · 26 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 32 °F
Altimeter
29.97 inHg
Observed at
KTTD, 5 nm away
METAR
KTTD 212153Z VRB06KT 10SM CLR 24/00 A2997 RMK AO2 SLP148 T02390000

Docket · 7

The files NTSB released with the investigation on May 17, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.8 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.

Other investigations on N53331 · 1

Matched to the same aircraft by N-number and date.