Aerodynamic stall/spin: Piper PA-28R-180 Cherokee Arrow, N3757T, fatal accident occurred on September 8, 2024, at Basin Harbor Airport (B06), Vergennes, Vermont

• Location: Vergennes, Vermont
• Accident Number: ERA24FA371
• Date & Time: September 8, 2024, 12:25 Local
• Registration: N3757T
• Aircraft: Piper PA28R
• Aircraft Damage: Substantial
• Defining Event: Aerodynamic stall/spin
• Injuries: 4 Fatal
• Flight Conducted Under: Part 91: General aviation - Instructional

https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/195076/pdf

https://data.ntsb.gov/Docket?ProjectID=195076

On September 8, 2024, at 1225 eastern daylight time, a Piper PA-28R-180 airplane, N3757T, was substantially damaged when it was involved in an accident near Vergennes, Vermont. The non-certificated student pilot, flight instructor, and two passengers were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight.

The flight instructor and owner of the airplane had been providing flight instruction to the noncertificated student pilot, who was not yet old enough to obtain a student pilot certificate. Earlier on the day of the accident, the airplane was flown from its home airport to an airport with a grass runway that was about 155 nautical miles away. About 2 hours after the airplane arrived at that airport, a witness observed the airplane as it was departing and recorded a video of its initial takeoff roll from the grass runway. Neither the witness nor the video observed the airplane’s liftoff or the accident. The airplane was later found at the accident site, which was located in a wooded area adjacent to the runway.

The airplane was equipped with brake controls only in the left front seat position, where the non-certificated student pilot was seated, so it is likely that the non-certificated student pilot controlled the airplane during at least some portion of the taxi, as it would have been difficult to maneuver the airplane on the ground without differential braking. Because the flight instructor’s logbook indicated that he had been providing instruction to the non-certificated student pilot, it is possible that she also manipulated the flight controls during the accident takeoff. Regardless, the flight instructor was the only certificated pilot aboard the airplane with access to the flight controls, and was responsible for ensuring the airplane remained under positive control. He was also responsible for intervening as necessary to maintain the safe operation of the airplane. Since the airplane was not equipped with brake controls for the front right seat occupant, if an emergency arose during takeoff that required the takeoff to be aborted, the flight instructor would not have the ability to stop the airplane using conventional braking. The only braking option for the flight instructor would be the use of the parking brake. However, there was no evidence that the accident sequence involved an attempted rejected takeoff.

Postaccident examination of the accident site and wreckage revealed that the airplane impacted terrain in a left-wing-low, nose-low attitude, consistent with an aerodynamic stall at low altitude. The main landing gear remained extended, and the landing gear control switch was in the extended position, consistent with the accident occurring shortly after takeoff. Examination of the engine revealed that the fuel injector servo throttle stop was missing the plastic material that surrounded the stop pin, which allowed the throttle to move slightly past the normal full throttle stop. The fuel injector servo was tested on a production test bench at an overhaul facility and the servo operated normally. The slight movement of the throttle past the normal full throttle stop likely did not result in a loss of power. Overall, no evidence of any mechanical malfunctions or failures of the engine were found that would have precluded normal operation.

A sound spectrum analysis of the witness video indicated that, at the beginning of the takeoff roll, the propeller was rotating at approximately 2,500 rpm. The airplane was equipped with a constant-speed propeller with a maximum governed speed of 2,700 rpm. The observed propeller speed, approximately 200 rpm below the maximum governed speed, could have been consistent with several possibilities, including the propeller governor setting, reduced engine power, or an improperly positioned propeller control. However, since the video ended early in the takeoff roll, it could not be determined whether the engine’s rpm increased further along the takeoff roll. The airplane’s tachometer was impact damaged; therefore, its accuracy could not be verified. The airplane was equipped with a digital engine monitor that recorded limited engine parameters such as the exhaust gas temperatures (EGT) and cylinder head temperatures (CHT). The last recording revealed that, at the time when recording stopped, the EGTs were at levels consistent with high engine power; though, the engine rpm and manifold pressure could not be precisely calculated. The EGTs were compared to the previous flight that day, and were comparable to those recorded during that flight. Although the available evidence did not allow the engine rpm to be determined throughout the takeoff roll, the engine monitor data provided no evidence of a loss of engine power or other mechanical malfunction that would have precluded normal engine operation.

Postaccident examination of the airframe revealed that the alternate air door was in the open position. The alternate air door was intended for use when the air filter or inlet was suspected of being clogged with debris or ice. The airplane’s alternate air door was installed in a location that would bring in unfiltered, warm air from inside the engine cowling, which typically resulted in a slight reduction in engine performance because of the lower density of the warmer air. Because the air filter was not found obstructed during the postaccident examination of the airplane, and icing conditions were not present, it is possible that the flight instructor inadvertently left the alternate air on following an operational check. According to the airplane’s Owner’s Handbook, the alternate air door should be closed for takeoff. Further examination of the airplane’s configuration revealed that the flaps were in the retracted position, which was confirmed by the witness video. The airplane’s Owner’s Handbook recommended a flap setting of 25° for takeoffs from soft fields (like the grass runway the airplane was departing from) to improve takeoff performance. Additionally, the elevator trim was found set for a slightly nose-down attitude, despite the handbook’s recommendation to trim for takeoff so that only very light back pressure on the wheel was required to lift the airplane. 

Two weight-and-balance calculations were performed. One assumed the airplane departed the home airport with full fuel, and the other assumed it departed fueled to an intermediate position. The calculation for full fuel at the home airport revealed that the airplane was within the maximum weight limitations; however, the center of gravity (CG) was forward of the forward-most CG limit. The calculation for the airplane being filled to the intermediate position revealed that it was still within the maximum weight limitations and was just within the forward CG limit. A forward CG can increase the back-elevator pressure and elevator control forces required to control an airplane’s pitch, and can result in a higher stall speed. 

The airplane’s configuration, including the alternate air in the open position, the flaps retracted rather than being in the 25° setting recommended for takeoffs from a soft surface, and a slight nose-down trim setting, was not consistent with the Owner’s Handbook recommendations for optimizing takeoff performance. Collectively, these configuration discrepancies likely reduced the airplane’s takeoff performance and indicate that the flight instructor had not ensured that the airplane was properly configured before takeoff. Additionally, the airplane’s likely forwardbiased CG would have resulted in a higher stall speed, and increased the risk of an aerodynamic stall. Coupled with the reduced takeoff performance as a result of the airplane’s mis-configuration, it is likely that the flight instructor lost control of the airplane during the initial climb after the airplane encountered an aerodynamic stall, resulting in an uncontrolled descent at an altitude too low to recover. 

- Probable Cause: The flight instructor’s failure to maintain control of the airplane, which resulted in the airplane exceeding its critical angle of attack and entering an aerodynamic stall. Contributing to the accident was the flight instructor's failure to properly configure the airplane for takeoff from a soft surface, which reduced the airplane’s takeoff performance.

Collision during takeoff/land: Aero Commander 200D, N2912T, fatal accident occurred on August 31, 2024, at Gnoss Field Airport (DVO/KDVO), Novato, California

• Location: Novato, California 
• Accident Number: WPR24FA290 
• Date & Time: August 31, 2024, 15:50 Local 
• Registration: N2912T 
• Aircraft: Aero Commander 200D 
• Aircraft Damage: Substantial 
• Defining Event: Collision during takeoff/land
• Injuries: 1 Fatal 
• Flight Conducted Under: Part 91: General aviation - Personal

https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/195033/pdf

https://data.ntsb.gov/Docket?ProjectID=195033

On August 31, 2024, about 1550 Pacific daylight time, an Aero Commander 200D airplane, N2912T, was substantially damaged when it was involved in an accident at the Gnoss Field Airport (DVO), Novato, California. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

Multiple witnesses described the airplane crossing over into the runway safety area shortly after the pilot’s takeoff roll on a personal flight in his single-engine airplane. The airplane crossed over a taxiway and into another runway safety area before crossing the ramp in a nose-high pitch attitude. The airplane was unable to outclimb the nearby hangars as it approached them, subsequently impacting the end hangar. A postaccident fire ensued. 

About 15 minutes before the pilot departed, the wind conditions for the departure runway were reported as variable between 190° to 270° with gusts to 14 knots, with the prevailing wind from 240° at 7 knots. About 5 minutes after the accident, the reported wind conditions were from 220° at 9 knots. Additionally, other pilots at the airport at the time of the accident reported gusting and variable wind conditions.

A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. 

Given the left-turning tendency due to engine torque and P-factor, combined with the left crosswind and gusts during the time of the accident, exacerbated the runway excursion. The pilot was likely unable to maintain directional control during takeoff due to these combined factors, resulting in the airplane departing the runway and entering the runway safety area. The takeoff was not aborted for unknown reasons.

In the setting of a post-crash fire and smoke inhalation, the pilot’s elevated carboxyhemoglobin level does not constitute evidence that the pilot was impaired by carbon monoxide during the flight. The pilot’s cardiovascular disease, including severe coronary artery disease, placed him at substantially increased risk of an impairing or incapacitating cardiovascular event, such as chest pain, arrhythmia, or heart attack. There is no autopsy evidence that such an event occurred; however, such an event does not leave reliable autopsy evidence if it occurs just before death. Notably, even severe coronary artery disease may not cause major symptoms. 

- Probable Cause: The pilot’s failure to abort takeoff or compensate for gusty crosswind conditions during takeoff, which resulted in a loss of control and subsequent runway excursion. 

Medical event: Beechcraft C90A King Air, N6077X, fatal *accident* occurred on October 4, 2024, near Bakersfield, California

• Location: Bakersfield, California 
• Accident Number: WPR25LA003 
• Date & Time: October 4, 2024, 13:40 Local 
• Registration: N6077X 
• Aircraft: RAYTHEON AIRCRAFT COMPANY C90A 
• Aircraft Damage: None 
• Defining Event: Medical event 
• Injuries: 1 Fatal, 1 None 
• Flight Conducted Under: Part 91: General aviation - Personal

https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/195260/pdf

https://data.ntsb.gov/Docket?ProjectID=195260

On October 4, 2024, about 1340 Pacific daylight time, a Raytheon Aircraft Company C90A airplane, N6077X, was not damaged when it was involved in an accident near Bakersfield, California. The pilot was fatally injured, and the passenger was not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

While enroute at cruise altitude during a personal cross-country flight, the pilot lost consciousness. The passenger contacted air traffic control, who provided assistance with navigation and airplane operation, and successfully landed the airplane at a nearby airport.

According to the pilot’s autopsy report, his cause of death was hypertensive and atherosclerotic cardiovascular disease, and his manner of death was natural. The autopsy identified an enlarged heart. All four chambers of the heart were described as severely dilated. Moderate coronary artery disease was present. There was old scar tissue of the left cardiac ventricle, consistent with a past heart attack. The only identified traumatic injuries were sternum and rib fractures following emergency life-saving cardiopulmonary resuscitation (CPR) efforts. Based upon circumstances of the event and the pilot’s significant heart disease identified during the autopsy, it is likely that the pilot suffered an in-flight cardiac event, which resulted in his incapacitation and subsequent cardiac arrest. 

- Probable Cause: The pilot’s incapacitation by an in-flight cardiac event that led to cardiac arrest.

Loss of control in flight: Fantasy Air Allegro, N969RC, fatal accident occurred on July 7, 2024, near Eureka, Utah

• Location: Eureka, Utah 
• Accident Number: WPR24FA227 
• Date & Time: July 7, 2024, 05:44 Local 
• Registration: N969RC 
• Aircraft: FANTASY AIR SRO ALLEGRO 2007 
• Aircraft Damage: Substantial 
• Defining Event: Loss of control in flight 
• Injuries: 1 Fatal 
• Flight Conducted Under: Part 91: General aviation - Personal

https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/194620/pdf

https://data.ntsb.gov/Docket?ProjectID=194620

On July 7, 2024, at approximately 0544 mountain daylight time, a Fantasy Air SRO Allegro 2007 airplane, N969RC, was substantially damaged when it was involved in an accident near Eureka, Utah. The pilot sustained fatal injuries. The airplane was being operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 as a personal flight.

The pilot departed from a local airport and proceeded to land on a road where, according to acquaintances, the pilot frequently landed to hike in the surrounding area. Flight track data show that the airplane departed from the road a little over an hour after landing and subsequently impacted terrain about a minute later. The wreckage was later located in a field adjacent to the road.

A nearby landowner stated that airplanes occasionally land on the road, though he did not observe the airplane on the day of the accident, and noted that dust devils were a common occurrence in the area. The investigation could not determine whether the pilot obtained a weather briefing before the flight.

Postaccident examination of the airframe and engine revealed no evidence of a preexisting mechanical malfunction or failure that would have precluded normal operation. However, a flight control locking device was found about 22 ft from the airplane's right wing, raising the possibility that the airplane departed with the control lock installed. The airplane’s co-owner reported that the accident pilot had a history of sometimes omitting the preflight inspection. It is possible that the pilot omitted a departure preflight inspection and left the flight control locking device in place. 

The pilot had severe cardiovascular disease that placed him at increased risk for an impairing or incapacitating cardiac event, including chest pain, arrhythmia, or myocardial infarction. Although the autopsy found no evidence of such an event, cardiac arrhythmias and other acute cardiac conditions may not leave definitive postmortem findings when they occur immediately before death. While a pacemaker may record arrhythmias, the autopsy report did not indicate that the pilot's pacemaker was interrogated to evaluate device function or detect arrhythmias. 

The autopsy and toxicology findings also suggested a likely history of heart failure, a condition commonly associated with fatigue; however, heart failure was not specifically documented in the available medical records. 

Toxicology testing detected citalopram, an antidepressant medication, in the pilot's system. Based on the available evidence, it could not be determined whether the pilot was experiencing impairment from an underlying condition, such as depression, or adverse effects associated with his unreported citalopram use. 

The presence of frequent localized wind events, commonly referred to as dust devils, may have influenced the pilot to expedite his departure during a perceived lull between wind events. In doing so, the pilot likely inadvertently omitted the removal of the airplane's flight control locking device. During the departure, any wind-induced displacement of the wing from a level attitude would have left the pilot with limited ability to correct roll deviations as the aircraft ascended. Compounding the situation was the pilot's underlying medical condition and associated propensity for a cardiac event, which may have further degraded his ability to respond effectively to the developing emergency.

- Probable Cause: The pilot’s failure to maintain airplane control during initial climb, which resulted in an in-flight upset and impact with terrain.

Controlled flight into terr/obj (CFIT): Cessna 150F, N8110S, fatal accident occurred on October 31, 2024, near Wilder, Tennessee

• Location: Wilder, Tennessee 
• Accident Number: ERA25FA037 
• Date & Time: October 31, 2024, 18:37 Local 
• Registration: N8110S 
• Aircraft: Cessna 150F 
• Aircraft Damage: Destroyed 
• Defining Event: Controlled flight into terr/obj (CFIT) 
• Injuries: 1 Fatal 
• Flight Conducted Under: Part 91: General aviation - Personal 

https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/195426/pdf

https://data.ntsb.gov/Docket?ProjectID=195426

On October 31, 2024, at about 1837 central daylight time, a Cessna 150F airplane, N8110S, was destroyed when it was involved in an accident near Wilder, Tennessee. The student pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

 The student pilot was on the second leg of a long visual flight rules cross-country flight. The pilot departed shortly after the end of civil twilight and on a night where no lunar illumination was present. The pilot had not filed a flight plan and there was no evidence that he had obtained an official weather briefing from a source that would have logged that contact. After departure, the pilot flew over a town that contained significant cultural lighting and highway, flying parallel to a road for about 1 mile. He then turned away from the town and roughly toward the destination airport, over a sparsely populated area covered with dense forest and rising terrain.

The dark night, in addition to the generally cloudy conditions and limited ground lighting along the flight path, would have made it difficult for the pilot to visually recognize the rising terrain. As the pilot continued toward this area of diminished visual reference, he encountered a band of light rain showers, which in addition to further restricting visibility, had the potential for updrafts and associated turbulence. Given these conditions, it is likely that the pilot was flying in instrument meteorological conditions (IMC) for the last 4 minutes of the flight. Postaccident examination of the wreckage at the accident site revealed no evidence of any preimpact mechanical malfunctions or failures of the airframe or engine. The relatively straight flight path for the final portion of the flight that was observed via ADS-B, the length of the wreckage path at the accident site, and the damage observed to trees along that wreckage path, were all consistent with controlled flight into terrain.

The results of postaccident toxicological testing indicated that the pilot had used the prescription medication lamotrigine. While it is possible that his cognitive and psychomotor performance might have been impaired by the effects of the medication, no more-specific conclusion about pilot impairment can be drawn from the reviewed medical evidence alone. Based on the available information, the student pilot’s decision to continue the long crosscountry flight at night, without obtaining a preflight weather briefing or having an apparent awareness of approaching precipitation, and without filing a flight plan, was indicative of poor judgement. 

- Probable Cause: The student pilot’s decision to continue the visual flight rules flight into instrument meteorological conditions at night, which resulted in controlled flight into terrain.