Pilot Debrief

Czech Sport Aircraft AS Piper Sport near Spring Hill, FL — 2011-05-07

Final reportERA11FA287
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Date
2011-05-07
Location
Spring Hill, FL, USA
Aircraft
Czech Sport Aircraft AS Piper Sport
Registration
N420PS
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Cruise

Probable cause

The pilot's inadvertent application of control inputs that resulted in rapid, right-rolling, negative g-forces during night cruise flight and his subsequent ejection from the airplane. Contributing to the accident was the pilot's decision to fly at night in an airplane not approved for night flight, his unbuckling of the seat belt portion of the restraint harness, and the inadvertent opening of the airplane’s canopy.

Contributing factors

Contributing to the accident was the pilot's decision to fly at night in an airplane not approved for night flight, his unbuckling of the seat belt portion of the restraint harness, and the inadvertent opening of the airplane’s canopy.

NTSB narrative

The pilot, who had previously provided flight instruction in the light sport airplane to its two principal owners, was flying it at night from Florida to Illinois. The pilot had flown commercially from Illinois to Florida earlier that day and had been offered lodging by the owners on several occasions but declined. The airplane was not approved for night operations due, in part, to a lack of interior lighting. For over an hour after takeoff, on a clear, dark night, the airplane was headed northbound in straight and level flight at 6,500 feet. The pilot, who had been in contact with an air traffic control facility, had been told to switch to a new radio frequency; afterward radar contact was lost and there were no distress calls from the pilot. The airplane impacted wooded terrain and was mostly consumed by post-impact fire. All flight control surfaces were accounted for at the scene and no preexisting mechanical anomalies were found. There was no evidence of an in-flight fire and no evidence of the pilot attempting to use the whole-airplane ballistic parachute system. The pilot was found about 1/3 mile away from the wreckage, about 600 feet to the right of the airplane's radar track. Numerous personal items were also located to the right of the airplane's radar track, with heavier items generally closer to the track than the lighter items. Shards of bubble-canopy glass and the canopy frame were found at the airplane's impact site, but no shards were noted in the vicinity of where the pilot or the personal items were found, indicating that the canopy was likely unlatched and open when the pilot and the other items exited the airplane. Each seat of the two-seat airplane was equipped with a four-point restraint harness, with each harness having four identical belt adjusting mechanisms: two for the risers and two for the seatbelt portion of the harness. Except for a number of small pieces, both harnesses were almost entirely burned. One surviving piece, for adjusting either a riser or a seat belt portion of the harness, had distorted metal and pulled material, consistent with sudden, forceful loading. The top of the pilot's shoulders also exhibited bruising, indicative of a sudden loading while the harness risers were loosely in place. There were no marks on the pilot's frontal area to indicate that the seat belt portion of the harness was buckled at the time of the loading. Ground testing revealed that access to the back shelf behind the seats would have been difficult to reach if the pilot had not unbuckled the seat belt portion of his restraint harness and loosened the risers. Thus, it is likely that the pilot tried to reach something on the back shelf. Then, at some point afterward, the canopy T-handle likely became unlatched, possibly having been caught by a loose right harness riser or a looped headset wire that plugged in next to the canopy handle. With a dark, noisy cockpit, the pilot likely then inadvertently applied rapid control inputs that resulted right-rolling, negative g-forces of sufficient intensity to eject him and the other personal items.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should have ensured the canopy was securely latched before flight.

NTSB coding

Evidence available

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

Docket documents23

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