Pilot Debrief

MAGNUS AIRCRAFT LLC FUSION 212 near Conifer, CO — 2021-04-03

Final reportCEN21FA177
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Date
2021-04-03
Location
Conifer, CO, USA
Aircraft
MAGNUS AIRCRAFT LLC FUSION 212
Registration
N434MA
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Maneuvering

Probable cause

The pilot’s decision to fly at low altitude toward a mountainous canyon, and his exceedance of the airplane’s critical angle of attack while maneuvering to avoid rising terrain, which resulted in an aerodynamic stall and loss of airplane control.

NTSB narrative

The pilot flew the light sport airplane toward a mountainous canyon while at low altitude. When the pilot attempted to turn away from rising terrain in the canyon, the airplane decelerated toward stall speed and impacted the ground in a nose-low attitude that was consistent with a stalled condition. The airplane sustained substantial damage to both wings, empennage, and fuselage. Density altitude at the accident site was 11,365 ft. Post-accident examination of the airplane, as well as downloaded flight data, showed no evidence of pre-impact mechanical malfunctions. The pilot started flying about 3 years before the accident and was involved in 2 previous accidents and 4 pilot deviations that involved poor decision making and/or situational awareness. Toxicology testing detected the stimulant amphetamine, the antidepressants bupropion and citalopram, and the chronic nerve pain medication gabapentin. Although these medications can negatively affect psychomotor performance, based on the pilot’s flying history and the circumstances of the accident, it is unlikely they were factors in the accident. The circumstances of the accident are consistent with the pilot’s decision to fly toward a canyon at low altitude in high density altitude conditions, and his exceedance of the airplane’s critical angle of attack while maneuvering to avoid terrain, which resulted in an aerodynamic stall and loss of airplane control.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have avoided entering the canyon at low altitude.

NTSB coding

Evidence available

  • ADS-B / radar
  • Photos
  • 17 docket documents
View NTSB final reportView NTSB docket

Docket documents17

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