NTSB Factual Report

HISTORY OF FLIGHT

On June 28, 2015, about 1204 Pacific daylight time (PDT), an experimental amateur-built Great Lakes 2T1A-E, N7LM, collided with terrain near Corona, California. The owner, who lent the airplane to the pilot, was operating the airplane under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. The private pilot sustained fatal injuries, and one passenger sustained serious injuries. The airplane was destroyed during the accident sequence. The local personal flight departed Corona about 1150. Visual meteorological conditions prevailed, and no flight plan had been filed.

A resident of a nearby house heard a thud, and went to investigate. She saw that the airplane had crashed inside a fenced in area surrounding a cell phone tower and its associated equipment. The passenger was on the ground outside the airplane, and asking for assistance. The resident contacted first responders who transported the passenger to the hospital.

The passenger stated that the takeoff was uneventful, and the pilot flew over the local area for sightseeing. As the pilot made a turn, the passenger thought they were returning to the departure airport. The airplane then shook violently from side to side; the pilot said that he was sorry, and it would not happen again. About 1 minute later, it happened again; the engine stopped, and she heard no sound from it. She thought that the propeller stopped moving, and they went nose down straight into the ground.

A relative of the passenger had been at the departure airport, and stated that the pilot had just previously taken another relative up for a 25 minute flight. He took videos of both takeoffs. The pilot spent some time working on a Go-Pro camera that had stopped intermittently during the first flight. The relative also reported that the airplane's fuel gauge, which usually hung from the upper wing, had been removed at some time before these flights. He did not observe the pilot perform any preflight activities.

PERSONNEL INFORMATION

A review of Federal Aviation Administration (FAA) airman records revealed that the 55-year-old pilot held a private pilot certificate with a rating for airplane single-engine land. The pilot held a third-class medical certificate issued on June 13, 2014, with no limitations or waivers.

No personal flight records were located for the pilot. The National Transportation Safety Board (NTSB) investigator-in-charge (IIC) obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. The pilot reported on his medical application that he had a total time of 478 hours with 15 hours logged in the previous 6 months.

AIRCRAFT INFORMATION

The airplane was an experimental amateur-built single-engine biplane built in 1979. A review of the airplane's logbooks revealed that it had a total airframe time of 106.39 hours at the most recent condition inspection dated March 27, 2015. The tachometer read 109.99 at the accident scene. The engine was a Fairchild Range 6-440-C5, and time since major overhaul was 106.39 hours at the last condition inspection.

FAA records indicated that the airplane was registered to the current owner in 2012, and that the propeller was an Aeromatic 220.

WRECKAGE AND IMPACT INFORMATION

Investigators from the NTSB and FAA examined the wreckage at the accident scene on June 28, 2015. A complete report is included in the public docket for this accident.

The first identified point of contact (FIPC) was a tree with broken limbs, which contained the separated left aileron. The tree was next to a chain link fence that surrounded a small compound containing a small building, electrical boxes along the fence's internal perimeter, and a cell phone tower disguised as a tree. The airplane was in the middle of the compound with the nose on the ground, and the tail up vertically against the cell tower.

The airplane's wings were severely crushed and distorted around the cabin. One of the two wooden propeller blades separated near the hub with the wood splintered.

The center wing top section, which contained the fuel tank, came to rest almost vertically over the airplane's engine. The tank did not appear to be breached; the fuel filler cap remained in place, there was no fuel odor, and there were no signs of leakage such as stains on the wing or ground. A stick was utilized to probe the tank through the filler neck, and no fuel was present.

MEDICAL AND PATHOLOGICAL INFORMATION

The Riverside County Sheriff-Coroner Division completed an autopsy, and determined that the cause of death was blunt impact injuries to the head. The autopsy report noted 50 percent narrowing of two coronary arteries, but no focal lesions were identified in the heart muscle.

The FAA Forensic Toxicology Research Team, Oklahoma City, Oklahoma, performed toxicological testing of specimens of the pilot. Analysis of the specimens for the pilot contained no findings for carbon monoxide or volatiles. They did not perform tests for cyanide.

The report contained the following findings for tested drugs: diphenhydramine not detected in blood (heart), diphenhydramine detected in urine. Diphenhydramine is a sedating antihistamine used to treat allergy symptoms and as a sleep aid, and is available over the counter under the trade names Benadryl and Unisom. It carries a Federal Drug Administration warning that it may impair mental and/or physical ability required for the performance of potentially hazardous tasks such as driving or operating heavy machinery.

TESTS AND RESEARCH

The NTSB IIC examined the wreckage at the facilities of Air Transport, Phoenix, Arizona, on July 14, 2015. A full report is contained within the public docket for this accident.

The examination revealed no anomalies that would have precluded normal operation of the airframe or engine.

ADDITIONAL INFORMATION

Video Review

A GoPro Hero 4 camera with a wrist remote was recovered, and sent to NTSB Office of Research and Engineering for data extraction. The extracted video data revealed the entire flight, and a report on the findings is in the public docket for this accident.

The camera appeared to have been mounted to a wing strut, and provided a rearward view of both the front seat passenger and the rear seat pilot. The field of view also included the left aileron, rudder, and the elevator, and occasionally the pilot's hands on the control stick through an access hole between the front and rear cockpits.

The report noted that two recording files contained portions of the accident flight. The first file was 3 minutes and 3 seconds in length, and began at 11:50:23 with the pilot activating the camera using a device on his wrist. The airplane appeared to be taxiing in the vicinity of a hold short line next to a runway with the engine at a low power setting. The video continued as the airplane took off and maneuvered; the file ended with the airplane in near level flight with the departure airport visible off the airplane's left wing.

The second video began at 11:58:09, and it recorded various turns including steep right and left turns as the pilot maneuvered the airplane. Six minutes into the video, a noticeable decrease in engine power was audible. The airplane was in a steep left turn at this time; one second after the power decrease, the nose fell sharply, and the airplane appeared to drop and depart controlled flight. The pilot reacted immediately, and the control positions were up elevator, right rudder, and left roll aileron.

The pilot continued to manipulate all control surfaces; in 5 seconds, the airplane had become level, and was pulling out of the descent. At no time during the recovery was elevator seen in a position other than a nose up command. After recovery was complete, all control surfaces returned to neutral positions. Five seconds later, the engine sound changed slightly, and it appeared to regain power. The rear pilot spoke into the headset boom microphone, and the front seat passenger laughed.

The airplane had lost an unquantifiable amount of altitude, and did not appear to significantly gain any back as it began the next maneuver, which was a moderately banked left turn. Throughout the left turn, the elevator position became increasingly more up elevator. Ten seconds after the engine sound had increased slightly, a decrease was heard. Two seconds later, the airplane continued in the moderate left bank, and the camera began shaking in a manner consistent with airframe buffet. One second after the onset of buffet, the airplane began to depart controlled flight. The elevator commanded a pitch up attitude, and the airplane began rolling sharply to the left. Within seconds, the bank angle was almost 90° to the horizon, and the engine sound was not nominal. The airplane began a quick descent toward the ground while rolling to the left and back to the right. The roll condition repeated until ground impact. The camera broke free, and rolled in the debris; it came to rest at 12:04:40.

NTSB Probable Cause

The pilot's failure to maintain adequate airspeed and his exceedance of the airplane's critical angle-of-attack while maneuvering, which resulted in a stall/spin at too low an altitude to allow recovery. Contributing to the accident was the pilot's improper fuel planning and his distraction by the loss of engine power due to fuel exhaustion.