WPR23FA110

NTSB accident investigation · Willman Loren LOREN'S Aircam · Grass Valley, CA · February 19, 2023

Accident · FatalClass 3 · FieldFinal report
Date
February 19, 2023, 13:35 local (21:35 UTC)
Place
Grass Valley, CA · open field/orchard
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N420PFWillman Loren LOREN'S Aircam
Defining event
Maneuvering-low-alt flying: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Rotech Flight Safety Inc., Federal Aviation Administration, Lockwood Aircraft Corporation
FAA report
20230219001959A
Case key
106746

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 failure to maintain adequate airspeed and his exceedance of the airplane’s critical angle of attack, which resulted in an aerodynamic stall/spin at an altitude too low for recovery.

Findings · 4

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.

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 departed the airport to conduct a local flight. ADS-B data revealed that the flight was conducted at a low altitude that overflew areas of interest. The airplane was flying near the passenger’s property, at an altitude that witnesses estimated as about 100 ft or less above ground level (agl), and an airspeed estimated to be around 50 mph, but likely closer to the airplane’s published stall speed of 39 mph. The airplane exhibited a “wobble” and then entered an aerodynamic stall/spin and impacted open terrain in a nose-low attitude. Postaccident examination of the airframe and engines revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The airframe damage, wreckage distribution and near-vertical impact were consistent with a stall/spin while still under engine power. According to a witness, the pilot had a history of conducting low altitude flights in the accident airplane. Before the accident, the accident pilot told a fellow pilot that he did not fly above 500 ft agl. During the first months of ownership, the local airport manager received complaints about the pilot’s low-altitude flying. The airplane’s Pilot’s Operating Handbook (POH) states that the airplane did not come equipped with a stall warning device and that stall indications were not easily recognizable. The POH also advised operators to not operate at low altitudes at airspeeds less than 50 knots and advised operators to stay at least 500 ft away from people and property. Toxicology testing of the pilot indicated the presence of THC (tetrahydrocannabinol), the active compound in marijuana. There is no known relationship between tissue levels and impairment; therefore, whether the pilot's use of a potentially impairing substance contributed to the accident could not be determined.

Factual narrative

The airframe, serial number 001, was owned by the pilot. According to the manufacturer, the serial number did not match any serial numbers created by the company. The pilot filed an affidavit of ownership for amateur built and other non-type certificated aircraft form on June 27, 2022. A review of maintenance records revealed the airframe was designated as a new build on September 8, 2022, with 0-hour tachometer time and 0-hour total time. A writeup dated September 22, 2022, stated that an amateur-built experimental airworthiness certificate and operating limitations was issued for the airplane and signed by a representative of the local FAA Flight Standards District Office. A copy of the airplane’s weight and balance was not recovered. A calculated weight and balance was computed using an exemplar Air-Cam’s empty weight, full fuel, and estimated pilot and passenger weights, and found to be with in the manufacturers guidance. The POH for the Air-Cam stated, in part, “First and foremost, the Air-Cam does not come with any type of stall warning indicator and there is very little buffeting to warn of an approaching stall.” “Flying low and slow in the Air-Cam is a lot of fun but please remember the following. #3 Don’t let your airspeed get too low. Remember, the Air-Cam is rock solid right down to the stall which means you can accidentally fly much closer than intended to the stall. 50 mph is a good min. IAS [minimum indicated airspeed].” #5 FAA regs [regulations]. Avoid densely populated areas and stay at least 500 ft away from people and property (like boats, cars, horses, and buildings) in sparsely populated areas.” According to the Air Cam POH, the stall speed for the airplane was 39 mph. According to the manufacturer, if the control stick is held aft and the airplane is stalled while power is still applied by the engines, and if the control stick is then pushed forward, the airplane will develop an extremely nose-low attitude. The airport manager for OOG provided two quart-size containers of 100 low lead fuel taken from the airport’s fuel delivery system. The samples appeared blue, clear, and bright with no visible contaminants. A test with a water detection gel revealed no evidence of water in the fuel samples. On February 19, 2023, about 1335 Pacific standard time, an experimental, amateur-built amphibious Lockwood Air-Cam, N420PF, was substantially damaged when it was involved in an accident near Grass Valley, California. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulation Part 91 personal flight. According to the pilot’s brother-in-law, before the accident, the pilot took him on a local flight and stayed within five miles of the Nevada County Airport (GOO), Grass Valley, California. He estimated that the lowest altitude that they flew at was about 800 ft agl. ADS-B data showed this flight originated about 1219 and terminated about 1237. Most of the flight was calculated to havebeen about 250 to 500 ft agl. A Google Earth image with ADS-B data showing the flight with the brother-in-law is shown in Figure 1. The ADS-B track showed multiple areas of lost coverage. Figure 1. Google Earth image showing the ADS-B track of the flight with the pilot’s brother-in-law as a passenger. According to the brother-in-law, after the flight ended, the pilot taxied to his personal hangar that was located on his property, adjacent to the airport. The brother-in-law exited the airplane. A female friend of the family then got into the airplane, and the pilot and female passenger taxied away. A witness, who was located at the GOO fuel island, reported that the pilot, with a female passenger, taxied to the fuel island. The witness reported that the pilot topped the airplane off with 100 low lead aviation fuel. During a conversation, the pilot told the witness that he didn’t fly above 500 ft agl. The witness cautioned to the pilot about hazards of flying at that altitude. ADS-B data for the accident flight showed that the airplane departed GOO on runway 25 about 1309 and proceeded to the south. The recorded airplane altitudes and the intermittent ADS-B reception were consistent with low-altitude, maneuvering flight. About 3 minutes after takeoff, the airplane circled a large field near private property while about 200 to 300 ft agl. The airplane then proceeded southward to the north end of Rollins Reservoir. ADS-B data was lost temporarily about 1315 and regained about 1318 when the airplane was past the south end of the reservoir, above a dam. The flight continued along a river where ADS-B data was again lost about 1319. ADS-B data was regained about 1322 and showed that the airplane travelled about 1.7 miles southwest of the dam. About 1323 the airplane began a right 180° turn and crossed over a ridgeline. About this time, multiple witnesses reported observing the airplane operating at a low altitude, described as about 50 to 100 ft above the trees to about 200 ft and at an estimate speed of about 45 to 50 miles per hour. ADS-B data stopped at the completion of the 180° turn. The last data point recorded the airplane about 2,400 ft above mean sea level, or about 178 ft agl, about 2005 ft southeast of the accident site. A witness reported seeing the airplane as it traveled in a straight line, over her house, about 100 ft from the ground and about 50 mph. She saw the airplane’s wing tilt to the right, then the airplane “nosed-dived straight down.” Another witness said that it was going really slow and had a wobble, followed by a descent he described as, “nose first and the tail was straight up.” Figure 2. Google Earth image showing ADS-B data for the entire accident flight. The dashed lines highlight the lake and the river. Another witness provided a photograph of the accident airplane that was taken on the day of the accident (Figure 3). A section of a house roof was visible in the frame. One witness stated that the female passenger lived ina house very close to the accident site. Figure 3. Photo taken of the accident airplane on the day of the accident. (Source: witness) In interviews with people familiar with the pilot, one person mentioned that the pilot’s low-altitude airport pattern work was common. He mentioned that the pilot always left the landing gear down. The airport manager reported that around November 2022, he received complaints of the pilot flying about 100 to 200 ft agl near the community of Morgan Ranch housing development. He sent an email to the pilot advising him of the complaints. An autopsy of the pilot was conducted by the Office of the Sheriff-Coroner, Nevada County, Nevada City, California. The cause of death was multiple blunt injuries. The FAA Forensic Sciences Laboratory performed toxicology testing of postmortem specimens from the pilot. Delta-9-THC was detected at a low level in femoral blood. Delta-9-THC was also detected in lung tissue, at 2 ng/g. 11-hydroxy-THC was detected in femoral blood at 1.7 ng/mL and in lung tissue at 2 ng/g. Carboxy-delta-9-THC was detected in femoral blood at 16.3 ng/mL and in lung tissue at 18.2 ng/g. Delta-9-THC is the primary psychoactive chemical in cannabis, including marijuana and hashish. Delta-9-THC may be inhaled or ingested recreationally by users seeking mind-altering effects. It may also be used medicinally by users seeking to treat illness-associated nausea, chronic pain, and other symptoms of some chronic diseases. Pharmacologically pure delta-9-THC is available as a prescription medication, often used to treat involuntary weight loss secondary to chronic disease and nausea associated with chemotherapy. The specific psychoactive effects of delta-9-THC vary depending on the user, user history of use, dose consumed, and route of consumption. Effects of delta-9-THC consumption may impair motor coordination, worsen reaction time, impair decision making and problem solving, distort perceptions of reality, and decrease vigilance. 11-hydroxy-THC is the primary active metabolite of delta-9-THC. Carboxy-delta-9-THC is a non-psychoactive metabolite of delta-9-THC. Research shows inconsistent correlation between the presence and magnitude of impairment and THC concentrations in blood in living persons. Delta-9-THC is a federally controlled substance, and the FAA considers it unsuitable for flying, regardless of individual state cannabis laws. The pilot reported a total of 1451 flight hours on his last medical examination dated December 14, 2021. A review of the pilot’s logbook revealed that the pilot accumulated about 1,408.0 hours. According to the pilot’s wife, he accumulated about 50 hours flight experience in the accident airplane. The airplane impacted terrain in an open field surrounded by pine trees of about 70 to 80 ft tall. The first point of probable impact was 3 gouges in the terrain about 10 ft west of the main wreckage. The gouges were consistent with the impacts made by the nose of the airplane and thetips of the two floats. The debris field was contained to an area of no more than 50 ft around the wreckage, with one propeller blade found beyond that area. The floats remained attached to the undercarriage and the retractable wheels were found extended. The tips of the floats were crushed aft, and the damage extended to the front strut of the landing gear. The nose of the fuselage and the cabin were extensively crushed aft, with the damage extending back to the front strut of the landing gear. Examination of the airframe verified flight control continuity throughout the airframe from the cockpit controls to all primary flight control surfaces. Postaccident examinations of the engines were performed at a secure facility. The left engine exhibited minor damage, and a test run verified normal operations. The engine started easily and ran normally at idle without effort. The right engine exhibited damage that precluded a test run. A teardown examination was conducted that revealed no mechanical anomalies. Postaccident examination of the airframe and engines revealed no evidence of preaccident mechanical malfunctions or failures that would have precluded normal operation.

Aircraft

Registration
N420PF
Reported as
Willman Loren LOREN'S Aircam
Category
Airplane, amateur-built
Serial number
001
Built
2022
Airframe hours
0
Engines
Rotax 912UL SERIES, 80 horsepower, reciprocatingRotax 912UL SERIES, 80 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Annual · September 8, 2022 · 0 hours before
Departed
GOO · Grass Valley, CA
Equipment
ADS-B

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
63
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Front
Restraint
4-point
Toxicology
Performed
Flight hours
1,451 total · 500 in this make and model · 500 as pilot in command · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 27 °F
Altimeter
30.05 inHg
Turbulence
Severe
Observed at
KGOO, 8 nm away
METAR
KGOO 192115Z AUTO 30007KT 10SM CLR 16/M03 A3005 RMK A01

Docket · 15

The files NTSB released with the investigation on March 5, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 268 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.