Pilot Debrief

MANISCALCO GREAT LAKES near Corona, CA — 2015-06-28

Final reportWPR15FA200
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Date
2015-06-28
Location
Corona, CA, USA
Aircraft
MANISCALCO GREAT LAKES
Registration
N7LM
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Maneuvering

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.

Contributing factors

Contributing to the accident was the pilot's improper fuel planning and his distraction by the loss of engine power due to fuel exhaustion.

NTSB narrative

The private pilot was taking his second passenger of the day on a sightseeing flight. Based on onboard video, after making several shallow turns, the airplane entered a steep left turn, the nose fell, and the airplane stalled; the pilot initiated a recovery. The passenger later stated that the airplane shook violently from side to side and that the pilot apologized to her over the microphone and stated that it would not happen again. The onboard video indicated that, less than 1 minute later and without gaining altitude, the pilot initiated a moderate turn. During the turn, the engine noise decreased, the airplane began to shake, and the airplane departed controlled flight. The video showed the pilot attempt to initiate a recovery. However, because of the airplane's low altitude, the pilot was not able to regain control, and the airplane struck the ground. On-site examination determined that the fuel tank was not breached. There was no fuel odor, no signs of leakage such as stains on the wing or ground, and the tank contained no fuel. Postaccident examination of the engine did not reveal any anomalies that would have precluded normal operation. Toxicology results for the pilot revealed that the sedating antihistamine diphenhydramine was detected in his urine but not in his blood. Thus, it would not have had any ongoing systemic effects. The pilot had coronary artery disease; however, it was unlikely that he had any symptoms that would have impaired his ability to safely operate the airplane, particularly given his reaction to the loss of control and his attempted recovery. It is likely that the pilot became distracted by the loss of engine power due to fuel exhaustion, and stalled the airplane, which entered a spin too low to the ground to allow recovery.

Analysis

Primary failure mode
Fuel management
First missed decision gate
Pilot did not check fuel levels before flight; fuel gauge was removed.

NTSB coding

Evidence available

  • Photos
  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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