Pilot Debrief

BRM Aero Bristell S-LSA near Lakeland, FL — 2018-12-22

Final reportERA19LA078
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Date
2018-12-22
Location
Lakeland, FL, USA
Airport
LAL
Aircraft
BRM Aero Bristell S-LSA
Registration
N587BL
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The student pilot's exceedance of the airplane's critical angle of attack during the initial climb, resulting in an aerodynamic stall from which the pilot did not recover.

NTSB narrative

The solo student pilot had completed two touch-and-go landings at his home airport in crosswind conditions. During the approach for the third touch-and-go landing, the air traffic controller instructed the pilot to fly a right closed traffic pattern, rather than a standard left traffic pattern (which was performed during the two previous touch-and-go landings), to avoid a potential conflict with another airplane. The pilot acknowledged the instruction. Surveillance video showed that, after the third touch-and-go landing, the airplane began a steep climb along the runway heading, gained altitude rapidly, entered a rapidly descending left turn, and impacted terrain in a near-vertical pitch-down attitude. Although a postcrash explosion and fire consumed most of the airplane, examination of the remaining airplane wreckage found no evidence of a preimpact mechanical malfunction or failure that would have precluded normal operation. The airplane's increased angle of attack and high rate of climb likely led to an exceedance of the critical angle of attack, causing an aerodynamic stall at low altitude from which the student pilot was unable to recover. The investigation could not determine, based on the available evidence, why the pilot did not mitigate the airplane's rapidly increasing angle of attack and climb rate shortly after takeoff given that the airplane was equipped with an angle-of-attack audio and visual stall warning indicator. The autopsy of the pilot found that he had early coronary artery disease. As a result, the pilot might have been at increased risk of a sudden cardiac event that could have caused symptoms such as palpitations, shortness of breath, chest pain, or fainting, but there was no evidence that such an event occurred. Therefore, it is unlikely that the pilot's heart disease contributed to this accident. Toxicology testing detected ethanol in one tissue at a very low level; no ethanol was found in the pilot's brain. The identified ethanol was most likely from postmortem production and therefore did not contribute to the accident circumstances. Although cetirizine, which is sedating and can affect decision-making and performance, was identified in the pilot's liver and muscle specimens, the amount of cetirizine in the pilot's blood, and thus the effects of the pilot's use of this drug, could not be determined.

Analysis

Primary failure mode
Human factors
First missed decision gate
Instructor was not informed of solo flight, leading to lack of oversight.

NTSB coding

Evidence available

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  • 10 docket documents
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Docket documents10

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