ERA23FA194
2023-04-15 · Andrews, North Carolina, United States · Fatal · 1 aircraft · Status: Completed
Airport RHP
Aircraft involved
Probable cause & findings
The pilot’s failure to engage the turbocharger for takeoff and his improper decision to continue the takeoff with partial power, rather than reject the takeoff.
Factual narrative
HISTORY OF FLIGHTOn April 15, 2023, about 1039 eastern daylight time, an experimental amateur-built Velocity, N2357, was destroyed when it was involved in an accident near Andrews, North Carolina. The commercial pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the current airplane owner, who was the fifth owner, the airplane suffered a landing accident in 2004 and was purchased by a salvage facility. That facility removed the engine and avionics, then sold it to the previous owner, who installed a newly overhauled engine equipped with a turbocharger. The current owner purchased the airplane and installed a new propeller and avionics. At the time of the accident, the engine had about 54 hours of operation since overhaul in 2012. Due to the modifications, a Federal Aviation Administration (FAA) designated airworthiness representative (DAR) inspected the airplane, issued an amended airworthiness certificate with revised operating limitations, and endorsed the airframe logbook on April 1, 2023. The accident flight was the first flight since that endorsement. The current owner added that he was a private pilot with about 90 hours of flight experience, of which about 10 hours were in the make and model airplane. Since he had little experience, he hired the accident pilot to fly the first flight since the modifications/DAR endorsement. The accident pilot inspected the airplane for about 1.5 hours before the accident takeoff. The owner saw the airplane take off on runway 26, a 5,500-ft-long runway, but subsequently lost sight of it behind buildings. Witnesses reported that the airplane took off and climbed about 300 ft above ground level while flying a left traffic pattern back to runway 26. Near the crosswind to downwind turn, the engine sounded loud, and the airplane descended into a wooded field and a postcrash fire ensued. The owner further stated that the engine was equipped with a fixed-pitch cruise propeller. With the turbocharger engaged, the engine would obtain 2,300 rpm; however, with the turbocharger bypassed, the engine would only obtain about 2,050 rpm. A spring switch in the cockpit controlled the turbocharger wastegate, to select whether the turbocharger was engaged or bypassed (or midrange). The owner added that, at 2,050 rpm, the airplane would not be able to fly with one pilot and full fuel, which it had for the accident takeoff. The owner provided a video that he recorded of a portion of the takeoff. Review of the video revealed that during the takeoff roll the airplane accelerated slower than normal, used more runway than normal, and lifted off the runway in a nose-high attitude. The airplane then descended back to the runway and bounced before lifting off nose-high again toward the end of the runway, where the video ended. PERSONNEL INFORMATIONThe pilot’s logbook was not recovered. On his most recent application for an FAA first class medical certificate, dated February 7, 2018, he reported a total flight experience of 450 hours. WRECKAGE AND IMPACT INFORMATIONThe wreckage came to rest inverted, oriented about a 075° magnetic heading. The left wing was separated and found against a tree inverted at the beginning of the debris path. The main wreckage was at the end of the 50-ft-long debris path and consumed by fire. No cockpit controls or instrumentation was identified. No seats or restraints were identified. The left aileron and left rudder separated and were recovered near the left wing. The right wing and canard remained with the main wreckage and were consumed by fire. The flight controls consisted of control rods and push-pull tubes. Flight control continuity and trim continuity could not be verified due to fire damage. The engine came to rest inverted and separated from the airframe. The two-blade propeller remained attached to the hub. One blade appeared undamaged while the other blade exhibited charring and tip separation. The top spark plugs were removed; their electrodes were intact and light gray in color (the Nos. 1 and 3 electrodes were oil soaked). Borescope examination of the cylinders did not reveal any anomalies. The crankshaft was rotated via an accessory gear drive. Crankshaft, camshaft, and valvetrain continuity were confirmed to the rear accessory section of the engine, and thumb compression was attained on all cylinders. Both magnetos had separated from the engine. One magneto was recovered, and it produced spark at all leads when rotated via electric drill. The other magneto was not located. Due to thermal damage, the fuel system could not be tested. The turbocharger wastegate was found in an open position. The turbocharger was further examined following wreckage recovery. It exhibited thermal damage, and the turbine would not initially rotate. WD-40 lubricant was applied to the turbine side and compressor side and the unit sat for several minutes. The turbine and its shaft then rotated freely by hand; however, the compressor was melted and did not turn along with the shaft. The compressor side was disassembled for further examination. No scoring was noted on the compressor housing and all compressor wheel blades were intact. The compressor nut was found about two threads loose. The internal housing of the compressor wheel and its corresponding position on the shaft were examined and no rotational scoring was noted. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy was performed on the pilot by the North Carolina Office of The Chief Medical Examiner, Raleigh, NC. The cause of death was reported as “multiple blunt force injures.” Toxicological testing was performed on specimens from the pilot by the FAA Office of Forensic Sciences, Oklahoma City, Oklahoma. The results were negative for drugs and alcohol. The owner recently purchased the experimental amateur-built, modified airplane. He did not have a lot of experience in the make and model airplane, so he hired the accident pilot to conduct the first flight since recent modifications. Witness statements and recorded video showed that during the takeoff roll from the 5,500-ft-long asphalt runway, the airplane accelerated slower than normal, used more runway than normal, and lifted off the runway in a nose-high attitude. The airplane then descended back to the runway and bounced before lifting off nose-high again toward the end of the runway. It climbed about 300 ft above ground level while flying a left traffic pattern back to the runway. Near the crosswind to downwind turn, the engine sounded loud, and the airplane descended into a wooded field and a postimpact fire ensued. The owner stated that the engine was equipped with a fixed-pitch cruise propeller. With the turbocharger engaged, the engine would produce 2,300 rpm; however, with the turbocharger bypassed, the engine would only produce about 2,050 rpm. A spring switch in the cockpit controlled the turbocharger wastegate, to select whether the turbocharger was engaged or bypassed (or midrange). The owner added that, at 2,050 rpm, the airplane would not be able to fly with one pilot and full fuel, which it had for the accident takeoff. The owner reported that he discussed the turbocharger operation with the pilot. Examination of the wreckage revealed that the turbocharger wastegate was found in an open position. No other anomalies were noted that would have precluded normal operation. It is likely that the pilot had inadvertently bypassed the turbocharger and then attempted to continue the takeoff with the with the engine only developing partial power. His decision to continue, rather than reject the takeoff, resulted in the airplane’s subsequent powered descent and collision with terrain. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
FAA avdata. C = Cause, F = Factor.
- — Personnel issues-Action/decision-Info processing/decision-Decision making/judgment-Pilot
- — Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot
- — Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Capability exceeded
- — Aircraft-Aircraft power plant-Turbocharging (recip only)-Turbocharger-Incorrect use/operation
Verbatim from NTSB's published report. Source file
NTSB_2023_ERA23FA194.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
Search this event elsewhere
External sources are reported, not agency: signal that something happened, not fact about what happened.
- TallyAero Live Wire Aviation press
- NTSB CAROL Agency ↗
- NTSB Docket Agency ↗
- Aviation Safety Network Aviation press ↗
- Kathryn's Report Aviation press ↗
- Aviation Herald Aviation press ↗
- AVweb Aviation press ↗
- Pilots of America Community ↗
- Reddit /r/flying Community ↗
- FlightAware Aviation press ↗
- AOPA accident database Aviation press ↗
- Google News News ↗
- DuckDuckGo News ↗
Related research
Matched on aircraft type or causal vocabulary (stall). All research papers
- arXiv 2026 · arXiv preprint Velocity-Free Horizontal Position Control of Quadrotor Aircraft via Nonlinear Negative Imaginary Systems Theory
This paper presents a velocity-free position control strategy for quadrotor unmanned aerial vehicles based on nonlinear negative imaginary (NNI) systems theory.
- arXiv 2026 · arXiv preprint Pitot-Aided Attitude and Air Velocity Estimation with Almost Global Asymptotic Stability Guarantees
This paper investigates the problem of attitude and air velocity estimation for fixed-wing unmanned aerial vehicles (UAVs) using IMU measurements and at least one Pitot tube measurement, with almost g…
- arXiv 2025 · arXiv preprint Obstacle Avoidance of UAV in Dynamic Environments Using Direction and Velocity-Adaptive Artificial Potential Field
The conventional Artificial Potential Field (APF) is fundamentally limited by the local minima issue and its inability to account for the kinematics of moving obstacles.
- arXiv 2025 · arXiv preprint A Nonlinear Observer for Air-Velocity and Attitude Estimation Using Pitot and Barometric Measurements
This paper addresses the problem of estimating air velocity and full attitude for unmanned aerial vehicles (UAVs) in GNSS-denied environments using minimal onboard sensing-an interesting and practical…
- arXiv 2024 · arXiv preprint Critical velocity for wake vortex generation behind a plate in a superflow
We study theoretically the critical velocity $U_c$ for quantum vortex generation by a thin plate-shaped obstacle moving through a uniform Bose-Einstein condensate.
- arXiv 2023 · arXiv preprint RRT and Velocity Obstacles-based motion planning for Unmanned Aircraft Systems Traffic Management (UTM)
In this paper, an algorithm for Unmanned Aircraft Systems Traffic Management (UTM) for a finite number of unmanned aerial vehicles (UAVs) is proposed.