Pilot Debrief

INIZIATIVE INDUSTRIALI ITALIAN SKY ARROW 600 near Malibu, CA — 2008-10-08

Final reportWPR09FA005
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Date
2008-10-08
Location
Malibu, CA, USA
Aircraft
INIZIATIVE INDUSTRIALI ITALIAN SKY ARROW 600
Registration
N454SA
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Maneuvering

Probable cause

The pilot's failure to maintain aircraft control during a low-altitude maneuver. Contributing to the accident was the pilot's decision to perform a maneuver at a low altitude that was insufficient to allow him to recover from the loss of control. Contributing to the occupants’ injuries was the inadequacy of the restraint system design by the manufacturer.

NTSB narrative

Witnesses observed the airplane fly at a low altitude over the water and, during a steep left turn, nose over and impact the water about 50 yards offshore. First responders rescued the pilots, a certified flight instructor (CFI) and a pilot who was receiving instruction, who told them that the airplane and engine had no mechanical failures or malfunctions during the flight. The CFI succumbed to his injuries 17 days later. Examination of the airframe and engine revealed no mechanical abnormalities that would have precluded normal operation. The airplane was equipped with a shoulder harness restraint that connected to the crotch strap; however, there was no lap belt installed. Examination of the restraint system webbing revealed no visual signs of distress or damage. During the impact sequence, the rear bulkhead separated from the fuselage allowing the rear seat and CFI to be pushed into the front seat. The investigation determined that the airplane had been designed without a lap belt restraint. The inadequacy of the restraint system likely exacerbated the CFI's injuries. The requirements under the American Society for Testing and Materials international standards stated that there must be a seat belt and harness for each occupant and adequate means to restrain the baggage.

Analysis

Primary failure mode
Loss of control
First missed decision gate
The decision to make a steep left turn over the water could have been reconsidered.

NTSB coding

Evidence available

  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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