Pilot Debrief

COSMOS PHASE II near El Mirage, CA — 2010-09-20

Final reportWPR10LA462
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Date
2010-09-20
Location
El Mirage, CA, USA
Airport
PVT
Aircraft
COSMOS PHASE II
Registration
N56078
Category
Trike
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot's improper preflight and starting procedures, which resulted in an inadvertent takeoff with the gust lock still installed.

NTSB narrative

A witness reported that the non-certificated pilot's normal procedure was to start the engine while seated in the weight-shift-control trike. Once started, he would then exit while the engine warmed up, and put on his helmet and glasses. On the day of the accident, the pilot was seated and unrestrained in the aircraft, with the gust lock installed, and appeared to be having difficulty starting the engine. He then moved the throttle to the full forward position and attempted a restart. This time the engine started, and immediately accelerated to high power. The aircraft then accelerated forward, rotated, and began a steep climb followed by a stall and uncontrolled descent to the ground. Throughout the maneuver the pilot appeared to be struggling to stay within the aircraft. The engine manufacturer's instructions specified that the throttle control should be set to the idle position during engine startup. Additionally, the manual stated that the operator should be able to operate the engine controls instinctively at startup, and be in a position to turn off the ignition switch instantly if necessary. No anomalies were noted with the throttle control, which was observed in the full open position. The pilot did not use wheel chocks to secure the trike prior to engine start.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have ensured throttle was at idle before attempting to start the engine.

NTSB coding

Evidence available

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

Docket documents12

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