# NTSB WPR21FA288: Borom Long-EZ, N966EZ, Tucson, AZ, July 27, 2021

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Field · Final report
- Date: July 27, 2021, 07:14 local (14:14 UTC)
- Place: Tucson, AZ · Short of runway 06R
- Coordinates: 32.139081, -111.18254 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=32.1391&lon=-111.1825&mi=10
- Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping)
- Defining event: [Landing: Abnormal runway contact](https://openairdocs.org/ntsb-events/090)
- Highest injury: Fatal
- Injuries: 1 fatal, 1 serious
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Western Pacific Region
- Parties: FAA, Lycoming Engines
- NTSB case key (mKey): 103562
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR21FA288
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103562/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103562
- Page: https://openairdocs.org/ntsb/WPR21FA288

## Probable cause

The pilot's failure to maintain adequate airspeed and to retract the speed brake during the approach, which resulted in a hard landing short of the runway. Contributing to the accident was the flight instructor’s decision to conduct a flight review in an airplane without the appropriate visibility, flight instruments, and controls for him to adequately assess the airplane’s flight parameters and touchdown point and take appropriate remedial action.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Borom Marcus P LONG-EZ, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=0569077), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Borom Marcus P LONG-EZ, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=0569077), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Borom Marcus P LONG-EZ, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=0569077), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Borom Marcus P LONG-EZ, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=0569077), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md)
- [Attention/monitoring: monitoring equip/instruments](https://openairdocs.org/ntsb-findings/02021525): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Borom Marcus P LONG-EZ, 1 case](https://openairdocs.org/ntsb-findings/02021525/cases.md?model=0569077), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/02021525/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: [Borom Marcus P LONG-EZ, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=0569077), [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.

- [Approach: Simulated/training event](https://openairdocs.org/ntsb-events/600); cases with it: [Borom Marcus P LONG-EZ, 1 case](https://openairdocs.org/ntsb-events/600/sequence.md?model=0569077), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md)
- [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Borom Marcus P LONG-EZ, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=0569077), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Landing: Abnormal runway contact](https://openairdocs.org/ntsb-events/090) (defining event); cases with it: [Borom Marcus P LONG-EZ, 1 case](https://openairdocs.org/ntsb-events/090/sequence.md?model=0569077), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md)

## Analysis

The pilot receiving instruction and the flight instructor were conducting a flight review flight in the airplane. After completing some maneuvers, they returned to the airport to accomplish a simulated engine-out, straight-in approach. During the final approach, the airplane was fast on a few occasions, and the pilot used the speed brake to slow down and descend. On short final, the airplane was slow, and the flight instructor told the pilot to use power. Although the pilot added power, the airplane landed hard about 500 ft short of the runway in soft terrain, nosed over, and came to rest inverted. Postaccident examination of the airframe and engine revealed no evidence of pre-impact mechanical failures or malfunctions that would have precluded normal operation. The speed brake was found extended. It is likely that the slow airspeed on short final approach in combination with the extended speed brake resulted in a sink rate that the pilot was unable to overcome and resulted in the hard landing short of the runway. The flight instructor elected to conduct the flight review from the rear seat of the tandem seat airplane, which was not equipped with throttle or rudder controls. Additionally, the flight instructor was unable to see the flight instruments and had limited visibility outside the airplane. Due to the limited visibility and the lack of flight instruments and controls in the back seat, the flight instructor was likely unable to adequately assess the airplane’s flight parameters and touchdown point and take appropriate remedial action.

## Factual narrative

Title 14 CFR 61.56, Flight review (a), states that “a flight review consists of a minimum of 1 hour of flight training and 1 hour of ground training.” In addition, Title 14 CFR 91.109, Flight instruction; Simulated flight and certain flight tests, states that “no person may operate a civil aircraft (except a manned free balloon) that is being used for flight instruction unless that aircraft has fully functioning dual controls.” A legal interpretation by the FAA Office of Chief Counsel on June 2, 2009, states the following: “Flight instruction" and "flight training" have been used interchangeably by the FAA in several rulemakings and legal interpretations, and both terms mean "training, other than ground training, received from an authorized instructor in flight in an aircraft." Additionally, the 2009 interpretation states that on April 4, 2000, the FAA issued a different interpretation which stated that the “term 'dual control' under section 91.109(a) refers to flight controls (e.g., pitch, yaw, and roll controls).” The 2009 interpretation states the following with regard to the 2000 interpretation: That interpretation did not address whether power controls are included in the definition of "dual controls" because the question presented concerned only brakes. However, the use of "e.g., pitch, yaw, and roll controls" does not exclude power controls from the dual controls definition because pitch, yaw, and roll controls were provided as nonexclusive examples of required flight controls. Accordingly, section 91. l 09(a) requires that engine power controls must be easily reached and operable from both pilot stations during flight instruction. This conclusion is supported by similar requirements in sections 61.45(c) and 141.39(d). However, the FAA does not require aircraft to be equipped with two sets of power controls (as is implied by the term "dual controls") provided that the power controls are accessible and operable from both pilot stations. Title 14 CFR 61.56, Flight Review (d), states that “…no person may act as pilot in command of an aircraft unless, since the beginning of the 24th calendar month before the month in which that pilot acts as pilot in command, that person has (1) Accomplished a flight review given in an aircraft for which that pilot is rated by an authorized instructor and (2) A logbook endorsed from an authorized instructor who gave the review certifying that the person has satisfactorily completed the review.” Title 14 CFR 1.1, General definitions, defines the pilot in command (PIC) as “the person who has final authority and responsibility for the operation and safety of the flight; has been designated as pilot in command before or during the flight; and holds the appropriate category, class, and type ratings, if appropriate, for the conduct of the flight.” The low-swept-wing, canard-equipped, tandem seat airplane was built by the pilot in 1986. It was powered by a Lycoming O-320 series reciprocating engine driving atwo-bladed, fixed pitch, wooden propeller installed in the rear of the airplane. The composite airplane had a speed brake attached to the bottom of the fuselage. Additionally, rudders were installed on each wingtip winglet and operated outboard only. The back seat was situated near the trailing edge of the wing, and the occupant’s visibility to the front and side was limited by the wing. On July 27, 2021, about 0714 mountain standard time, an experimental amateur-built Long EZ airplane, N966EZ, was substantially damaged when it was involved in an accident near Tucson, Arizona. The pilot receiving instruction was fatally injured, and the flight instructor was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 instructional flight. A review of automatic dependent surveillance – broadcast (ADS-B) data revealed that the airplane departed from the Ryan Field Airport (RYN), Tucson, Arizona, on a northerly track. Subsequently, the airplane turned left to the west and after a few miles, to a southerly heading. About 12 miles from the airport, the airplane maneuvered and accomplished a few 360° turns. The airplane then turned to an easterly heading direct to RYN. At 0714, the last recorded data was consistent with the airplane on final approach to runway 06R. The airplane’s ground speed decreased during the last few seconds of recorded data. The pilot contacted the RYN tower controller when the airplane was about 12 miles southwest of the airport and requested to practice a power off landing. He was instructed to make a straight in approach and report a 2-mile final. The pilot acknowledged, reported a 2-mile final, and was cleared to land on runway 06R. The flight instructor who was seated in the back seat stated that the purpose of the flight was to conduct a flight review for the pilot who was seated in the front seat. He also stated that the back seat had only a control stick and no other controls or instruments, including a lack of throttle and rudder controls. He reported that he was unable to see the instruments in the front cockpit, and that he had a portable GPS device that gave him ground speed readouts. He also reported that he had very limited visibility from the back. According to the flight instructor, during the flight, they performed some maneuvers, and on the return to the airport, he told the pilot that he wanted him to simulate an engine failure on the approach. He said that the pilot stabilized the airplane at about 85 knots on the approach but was high in altitude and extended the speed brake. He further stated that the airspeed became fast on several occasions on final approach and then became slow on short final. He saw 76 knots on his GPS and told the pilot that if he got slower to use power. He stated that the pilot was gradually adding power up to the full power setting. The airplane was in a flat attitude, and the flight instructor could see that they were over dirt and dropping.He stated that the airplane sank and landed very hard. When the nose touched down, it stuck in the ground, and the airplane flipped over. He reported that there were no mechanical issues or malfunctions with the airplane. Review of a surveillance video revealed that the airplane impacted terrain in a relatively flat attitude and shortly thereafter, nosed over and came to rest inverted. The Pima County Office of the Medical Examiner, Tucson, Arizona, conducted the autopsy on the pilot. The medical examiner determined that the cause of death was “positional asphyxia in the setting of blunt force injuries.” The FAA's Forensic Sciences Research Laboratory performed toxicological testing on the pilot. The pilot’s results were negative for carbon monoxide, volatiles, and tested for drugs except for a positive result for a low amount of glucose detected in the urine, which was not significant. The pilot held a private pilot certificate with an airplane single-engine land rating. The pilot was issued a Federal Aviation Administration (FAA) third-class airman medical certificate on October 10, 2015, with the limitation “must wear lenses for distant, have glasses for near vision.” The pilot reported having logged 1,201 total flight hours and no flight hours in the last 6 months on the application for this airman medical certificate. The pilot’s logbook was not located during the investigation. However, an excerpt from the logbook indicated that the pilot’s last flight review was accomplished on June 4, 2019. The pilot’s medical certificate expired for all classes in 2017, but he had applied for BasicMed. His BasicMed course date was December 5, 2019, and his Comprehensive Medical Examination Checklist (CMEC) date was August 3, 2017. The flight instructor held a commercial pilot certificate with airplane single-engine land, single-engine sea, multi-engine land, and instrument ratings. Additionally, he held flight instructor ratings for single-engine airplane and instrument airplane. The instructor was issued an FAA second-class airman medical certificate on September 30, 2015, with the limitation “must have glasses for near vision.” The pilot reported having logged about 12,000 total flight hours and about 300 hours in the accident airplane type. The instructor’s medical certificate expired for all classes in 2017, but he had applied for BasicMed. His BasicMed course date and his CMEC date were June 15, 2021. The accident site was located about 500 ft short of the extended centerline of runway 06R in a grassy field. All major structural components of the airplane were observed at the site. There were ground scars consistent with the landing gear tracks that led to the main wreckage. Just before the main wreckage, a large ground disturbance was observed that was consistent with the nose gear digging into the ground and the airplane nosing over. The fuselage came to rest inverted on a heading of about 250° magnetic. Examination of the wreckage by theNational Transportation Safety Board investigator-in-charge found the speed brake was extended. The front cockpit area sustained substantial damage to the bottom portion. The ground could be seen through openings on the bottom of the front cockpit. The engine and engine accessories remained attached and were observed to be relatively intact. The two-bladed wooden propeller remained attached to the crankshaft. Both blades had splintered, and between 8 inches to 12 inches of each propellor blade remained attached to the hub. The propeller spinner was attached and intact. Subsequently, the airframe and engine were examined at a recovery facility. Flight control continuity was established. Examination of the engine revealed that the crankshaft could be rotated by hand, and rotational continuity was established throughout the engine and valve train to all cylinders. A borescope inspection of the cylinders revealed normal operating conditions. The examination of the airframe and engine revealed no evidence of pre-impact mechanical failures or malfunctions that would have precluded normal operation.

## Aircraft

- Registration: [N966EZ](https://openairdocs.org/deregistered/N966EZ-2022-12-03), registration cancelled 2022-12-03, S/N 966, built 1986 (OpenAirDocs)
- Reported make and model: Borom Long-EZ
- Registry model: [Borom Marcus P LONG-EZ](https://openairdocs.org/model/borom-marcus-p-long-ez) (registry code 0569077) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane, amateur-built
- Serial number: 966
- Year built: 1986
- Airframe hours: 1200
- Engines: Lycoming O-320-E2G reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Airworthiness certificate: Special, Experimental (Special)
- Departed: RYN, Tucson, AZ
- Destination: Same as departure
- Airport: RYN, Ryan Fld, runway 06R/24L, 5,500 × 75 ft, asphalt
- Equipment: Handheld GPS, ADS-B, Electronic primary flight display, Auto-pilot, Electronic flight bag or handheld device

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 87; injuries: fatal; private; airplane ratings: single-engine land; medical: basicmed, with waivers/limitations; last flight review June 4, 2019; seat: front; restraint: 4-point; toxicology performed; flight hours: 1,201 total, 1,201 in this make and model
- Flight instructor; age 88; injuries: serious; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: basicmed, with waivers/limitations; last flight review June 27, 2020; seat: rear; restraint: 4-point; flight hours: 12,000 total, 521 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: calm
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 79 °F, dew point 66 °F
- Altimeter: 30.09 inHg
- Observed at: KRYN, 1 nm away
- METAR: KRYN 271445Z 10SM SKC 26/19 A3009

## Other investigations on N966EZ (1)

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.

- [NTSB WPR18LA003](https://openairdocs.org/ntsb/WPR18LA003), Oct 7, 2017: Borom Marcus P Long EZ (N966EZ), Tucson, AZ, substantial damage. Probable cause: The failure of both pilots to see and avoid the other airplane while maneuvering in the traffic pattern, which resulted in a midair collision. Contributing to the accident was the controller's…

## Docket (14 files)

The files NTSB released with the investigation on February 27, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103562. 48.8 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 8 pages, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14895078&FileExtension=pdf&FileName=NTSB%206120_Redacted-Rel.pdf
- Accident site summary (item 2, PDF, 5 pages, 870 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14898408&FileExtension=pdf&FileName=WPR21FA288%20On%20Site%20Examination%202-Rel.pdf
- Airplane crash video (courtesy of tucson apt authority pd) (item 3, MP4, 40.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14902810&FileExtension=mp4&FileName=Crash%20Video%20Final%20(courtesy%20of%20Tucson%20Apt%20Authority%20PD)-Rel.mp4
- ADS-B data (item 4, CSV, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14899861&FileExtension=csv&FileName=20210727_AD72EC_460608972_ADSB-Rel.csv
- Record of conversation (item 5, PDF, 2 pages, 123 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14900251&FileExtension=pdf&FileName=WPR21FA288%20Record%20of%20Conversation-Rel.pdf
- Flight review excerpt (item 6, PDF, 1 page, 481 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14892573&FileExtension=pdf&FileName=Flight%20Review%20Doc_Redacted-Rel.pdf
- Airframe and engine summary report (item 7, PDF, 4 pages, 484 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14899590&FileExtension=pdf&FileName=WPR21FA288%20Airframe%20and%20Engine%20Examination%20Summary%20Final-Rel.pdf
- FAA legal interpretation letter (item 8, PDF, 2 pages, 579 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14892890&FileExtension=pdf&FileName=FAA%20Legal%20Interpretation_Redacted-Rel.pdf
- Toxicological report (item 9, PDF, 1 page, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14900472&FileExtension=pdf&FileName=2021_128_001%20Final_Redacted-Rel.pdf
- Party form (item 10, PDF, 1 page, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14900629&FileExtension=pdf&FileName=NTSB%20party%20form_Lycoming-WPR21FA288_Redacted-Rel.pdf
- Release of aircraft wreckage, NTSB form 6120.15 (item 11, PDF, 1 page, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14905715&FileExtension=pdf&FileName=2021%20Retention-Release-of-Wreckage-Form_Redacted-Rel.pdf
- 14 CFR 1-1 (item 12, PDF, 18 pages, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15006119&FileExtension=pdf&FileName=14%20CFR%201-1%20(up%20to%20date%20as%20of%2012-20-2022)-Rel-Rel.pdf
- 14 CFR 61-56 (item 13, PDF, 2 pages, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15006688&FileExtension=pdf&FileName=14%20CFR%2061-56%20(up%20to%20date%20as%20of%2012-15-2022)-Rel.pdf
- 14 CFR 91-109 (item 14, PDF, 2 pages, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15006162&FileExtension=pdf&FileName=14%20CFR%2091-109%20(up%20to%20date%20as%20of%2012-16-2022)-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.

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