Pilot Debrief

BOEING A75N1(PT17) near Madras, OR — 2016-08-27

Final reportWPR16FA169
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Date
2016-08-27
Location
Madras, OR, USA
Airport
S33
Aircraft
BOEING A75N1(PT17)
Registration
N999PP
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Maneuvering

Probable cause

The pilot's failure to maintain clearance from the runway during a low-level aerobatic maneuver. Contributing to the accident was a high density altitude and the pilot's failure to plan/adequately compensate for high density altitude conditions.

Contributing factors

Contributing to the accident was a high density altitude and the pilot's failure to plan/adequately compensate for high density altitude conditions.

NTSB narrative

As part of an air show, the commercial pilot was attempting to perform an inside loop immediately after takeoff. He had successfully accomplished the maneuver the previous day, as well as at many previous air shows. Witnesses observed the airplane lift off the runway and remain in a level attitude just above the runway surface before it climbed to perform the loop. Witnesses reported that the airplane descended from the top of the loop to a point in which its pitch attitude was between 10° and 20° nose-down until it impacted the runway. Video footage of the accident indicated that the pilot was in control of the airplane throughout the maneuver, and postaccident examination revealed no evidence of a preimpact mechanical malfunction or failure that would have precluded normal operation. Another performer at the airshow reported that, during the evening practice the day before the accident, he observed the pilot perform the same maneuver, and described it as "sketchy" because of the low altitude at which the pilot completed the loop. He added that he previously asked the pilot how to perform this maneuver and the pilot said that it was a "complete crapshoot"; at the top of the loop, the pilot would decide whether he would "pull through and continue the loop or rollout into a half-Cuban or an Immelmann," both of which are recovery aerobatic maneuvers. Prior to takeoff, the Air Boss reported to the pilot a density altitude (DA) of 4,600 ft. Postaccident calculations revealed that the DA at the time of the accident was about 5,221 ft, both of which are well above a standard day. The high density altitude conditions would have degraded the airplane's overall performance, resulting in decreased engine power available and reduced rate of climb. It is likely that the pilot failed to adequately compensate for the changes in airplane performance due to the high density altitude conditions, which resulted in a collision with terrain.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen not to perform the inside loop at high density altitude.

NTSB coding

Evidence available

  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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