WPR22LA192

NTSB accident investigation · Maule MX-7-180C · Willits, CA · May 30, 2022

Accident · FatalClass 3 · LimitedFinal report
Date
May 30, 2022, 08:40 local (15:40 UTC)
Place
Willits, CA
Injuries
1 fatal, 1 serious
Damage
Destroyed
Phase of flight
Approach
Aircraft
N1043BMaule MX-7-180C
Defining event
Approach-VFR go-around: Unknown or undetermined
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Maule Air Inc., Lycoming Engines, Federal Aviation Administration
FAA report
20220530009169A
Case key
105165

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

An uncommanded descent during a go-around maneuver for undetermined reasons.

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: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not specifiedMaule MX-7-180C: 1 caseAll aircraft: 809 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedMaule MX-7-180C: 1 caseAll aircraft: 2,247 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 pilot and passenger were landing at the 1,600-ft-long private dirt runway at the conclusion of a cross-country flight. The pilot told the passenger as they approached the runway that he may need to perform a go-around. The airplane landed hard about halfway down the runway and bounced, and the pilot added engine power to abort the landing. The airplane lifted off the ground near the end of the runway and transitioned into a climb. As the airplane crossed trees and continued toward rising terrain past the end of the runway, the passenger observed the pilot curse while pulling or rotating a knob which she identified as the throttle control. The airplane subsequently entered a left turn and began to descend nose-down. The passenger thought that the airplane may have leveled out, possibly in a left-wing-low attitude, before impact. Postaccident examination of the airplane and engine revealed no preimpact mechanical anomalies or malfunctions that could have precluded normal operation. Evidence revealed during the investigation suggests that the airplane’s uncommanded descent to the ground was either the result of an aerodynamic stall or excessive drag as the examination discovered that the flaps may have been in a fully deployed position at the time of the accident. However, there was no performance information on the airplane available or parametric data to determine if the airplane’s flight profile was consistent with an aerodynamic stall or whether the flap deployment contributed to the uncommanded descent. Based on these findings, the accident was result of an uncommanded descent during a go-around maneuver for undetermined reasons due to a lack of available evidence. Damage to the airplane was consistent with impact in an approximately level attitude. The wing flaps were found fully extended (48°), consistent with a landing position. Although the pilot had about 8,000 hours of helicopter flight experience, he had received his airplane single-engine land rating about two weeks before the accident and his flight experience in the accident airplane make and model was unknown. The circumstances of the accident suggest that the pilot likely failed to retract the flaps from the landing position during the attempted aborted landing, which resulted in a reduced climb performance. The pilot’s toxicology was positive for midazolam in his hospital blood and hydromorphone and fentanyl in his urine, which were likely administered after the accident. Thus, the medications detected in the pilot’s toxicology testing were not a factor.

Factual narrative

Stall Characteristics According to the airplane flight manual (AFM), the airplane was equipped with a red light that illuminates to indicate a stall, which occurs 5 to 10 mph above stall speed. The manual further stated that stalls are preceded by a mild buffet, which can be felt through the rudder pedals. The AFM stated that the airplane may lose as much as 300 ft of altitude during stall recovery. The passenger reported that she did not hear an aural alarm or observe any annunciator warnings, nor did she feel any buffeting during the accident flight. A representative of the airplane manufacturer reported that a flap deployment of 48° is meant to produce drag over lift for approaching runways during a steep approach. He added that the accident airplane make and model, “would struggle to climb with the flaps” in this position. Takeoff and Climb The “Normal Procedures” section of the AFM stated that there were five flap positions: -7°, 0°, 24°, 40° and 48°. The AFM recommended that only notch 1 or 2 (0° or 24°) be used for takeoff and climb. Performance Aircraft performance computations could not be completed as the AFM did not contain any performance charts nor was it required to as the airplane was certified under CAR 3. Flaps The airplane was equipped with plain flaps. According to the FAA Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25B), “The plain flap is the simplest of the four types [of flaps]. It increases the airfoil camber, resulting in a significant increase in the coefficient of lift at a given AOA. At the same time, it greatly increases drag and moves the center of pressure aft of the airfoil…” The dirt runway was 1,600 ft long and was oriented on an east/west heading along the Eel River. The elevation of the runway was about 1,367 ft mean sea level (msl), and the elevation increased rapidly to the east, terminating in a peak elevation of about 2,300 ft msl about 1 nautical mile from the east end of the runway. The accident site was located about 900 ft northeast of the east end of the runway at an approximate elevation of about 1,424 ft msl. On May 30, 2022, about 0840 Pacific daylight time, a Maule MX-7-180C airplane, N1043B, was destroyed when it was involved in an accident near Willits, California. The pilot was fatally injured and the passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The passenger stated that they departed Sonoma, California, about 0730 and flew directly to the destination, a private dirt airstrip. After an uneventful flight, while approaching the runway from the southwest, the pilot informed her that he may need to perform a go-around. While landing to the east, the airplane contacted the runway hard and bounced about midfield and the pilot immediately added power to abort the landing. The airplane lifted off the ground near the end of the runway and transitioned into a climb. As the airplane crested a group of 60 to100-ft-tall trees on either side of them, the passenger observed the pilot curse while pulling or rotating a knob on the instrument panel, which she identified as the throttle control. The airplane then abruptly turned left and descended in a nose-down attitude. The passenger thought that the airplane may have leveled out, possibly in a left-wing-low attitude, before impact. The airplane was subsequently consumed by a postcrash fire.Photograph 1: Accident site An NTSB medical review revealed that the pilot’s antemortem hospital blood was positive for midazolam, a short-acting sedative-amnestic typically administered intravenously for surgical procedures. Toxicology testing of his hospital urine detected the pain medications hydromorphone, fentanyl, and its metabolite norfentanyl; these substances were not detected in his blood. The generally non-impairing medications albuterol and famotidine were detected in his urine. The passenger reported that she did not observe any unusual behavior from the pilot prior to the accident. The pilot held a commercial pilot certificate with a rating for rotorcraft-helicopter and private privileges for airplane single-engine land. The pilot received his airplane single-engine land rating on May 13, 2022. His logbook was not recovered. The airplane came to rest at the base of a tree about 1,000 ft northeast of the runway. The airplane was mostly consumed by postrcrash fire with the exception of the right wing, which remained attached to the fuselage frame. Both propeller blades were attached to the propeller hub, which had separated from the engine at the crankshaft. The empennage frame was intact, but the vertical stabilizer, rudder, and elevator fabric were consumed by postcrash fire. Postaccident examination of the airframe and engine revealed no evidence of preimpact mechanical failures or malfunctions that would have precluded normal operation. The flap handle position was consistent with a full flap extension (48°). According to the passenger, the pilot “filled the tanks to the top” before they departed on the accident flight.

Aircraft

Registration
N1043B
Reported as
Maule MX-7-180C
Category
Airplane
Serial number
28003C
Built
1997
Airframe hours
1,486
Engine
Lycoming Engines O-360-C1F, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 14, 2022
Departed
0Q9 · Sonoma, CA
Destination
Same as departure
Airport
none · Priv, runway 09/27, 1,600 × 50 ft, dirt
Equipment
ADS-B, Data recorder, Electronic multifunction display

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
33
Injuries
Fatal
Certificates
Commercial, Private
Airplane ratings
Single-engine land
Medical
Class 2, Without waivers/limitations
Last flight review
May 13, 2022
Seat
Left
Restraint
4-point
Toxicology
Performed
Flight hours
8,100 total · 7,980 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Visibility
10 statute miles
Lowest ceiling
None
Temperature
57 °F, dew point 37 °F
Altimeter
30.00 inHg
Observed at
KUKI, 22 nm away
METAR
KUKI 301556Z AUTO VRB04KT 10SM CLR 14/03 A3000 RMK AO2 SLP154 T01440028

Docket · 11

The files NTSB released with the investigation on April 10, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.7 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.