Pilot Debrief

FORTUNA DAVE SONEX near Dunnellon, FL — 2014-04-05

Final reportERA14FA464
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Date
2014-04-05
Location
Dunnellon, FL, USA
Airport
X35
Aircraft
FORTUNA DAVE SONEX
Registration
N229P
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The in-flight collision with a tree in a heavily wooded area during controlled flight while the pilot was attempting a forced landing for reasons that could not be determined based on the available evidence. Contributing to the delay in locating the wreckage were the nonactivation of the emergency locator transmitter and delayed coordination between the Civil Air Patrol and multiple local and state agencies.

Contributing factors

Contributing to the delay in locating the wreckage were the nonactivation of the emergency locator transmitter and delayed coordination between the Civil Air Patrol and multiple local and state agencies.

NTSB narrative

The private pilot was conducting a personal cross-country flight. Witnesses at the airport reported that they observed the airplane depart and climb out and that everything appeared to be normal. The airplane proceeded west of the departure end of the runway, made a left climbing turn, and then proceeded in a southerly direction. GPS data showed that the airplane then climbed to about 817 ft mean sea level, which was below the floor of available radar coverage. The airplane then continued in a southerly heading while descending with the ground speed increasing until about 2 minutes 30 seconds after takeoff, at which point the airplane made a right 270-degree turn for unknown reasons. The airplane continued to descend during controlled flight. The airplane subsequently impacted trees and the ground and then came to rest inverted about 1.7 nautical miles and 187 degrees from the departure end of the departure runway. No distress call was received from the pilot. About 2 days later, an employee of the intended arrival airport called the departure airport and reported the airplane overdue. Subsequently that same day, the Civil Air Patrol, multiple local and state agencies, the pilot's son, and several privately operated aircraft began search operations; however, despite several weeks of ongoing search efforts, the airplane was not located. About 6 months later, the inverted wreckage was spotted by an individual in a heavily wooded area. No emergency locator transmitter (ELT) signal was ever received, and the ELT switch was found in the "off" position. The investigation determined that miscommunications, which led to delayed coordination, occurred between the Civil Air Patrol and the multiple local and state agencies during the initial search efforts. The delayed coordination between the response agencies, the nonactivation of the ELT, and the airplane's flight below radar coverage hampered the search efforts. However, the accident was not survivable; therefore, these issues did not contribute to the pilot's death. Examination of the airframe revealed no evidence of fire. The engine, which had separated during the impact sequence, exhibited heat damage, which precluded testing of its operability. However, the No. 3 cylinder was found to have low compression, which likely existed when the flight departed. Full flight control continuity was confirmed, but the flap extension could not be determined. Although a hole was noted in a fuel supply line immediately adjacent to an engine control cable, extensive corrosion precluded a determination of whether the hole was preexisting or occurred postimpact. Witnesses reported that the canopy opened while the pilot was taxiing to begin the flight, and it was found unlatched. However, the pilot was able to relatch it for taxi. Given that the fuel shutoff was found in the "off" position, it is likely that the pilot was preparing for a forced landing and unlatched the canopy at that time rather than it inadvertently becoming unlatched in flight. Based on the available evidence, the reason for the forced landing could not be determined.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Pilot should have ensured canopy was properly secured before takeoff.

NTSB coding

Evidence available

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

Docket documents15

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