Pilot Debrief

AVERY JACK H GLASTAR GS-1 near Grand Rapids, MN — 2013-06-25

Final reportCEN13LA376
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Date
2013-06-25
Location
Grand Rapids, MN, USA
Aircraft
AVERY JACK H GLASTAR GS-1
Registration
N103A
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Approach

Probable cause

The loss of directional control during landing because the autopilot engaged for undetermined reasons because water and recovery damage precluded detailed examination of system components.

NTSB narrative

Prior to takeoff from the airport pond, the pilot performed a few high-speed taxi and on-the-step maneuvers with no anomalies noted. After the flight and during the short flight to the intended landing area, the pilot heard two to three aural "autopilot disconnect" voice messages. Because the pilot believed he did not engage the autopilot during the flight, he was uncertain why he was hearing the autopilot disconnect messages and was not overly concerned. During the landing, after the floats contacted the water, the airplane's right wing immediately lifted up, and the left wing tip contacted the water. Subsequently, the airplane nosed over. The pilot reported the weather at the time of the accident as ideal for flying; sky clear and a steady 5-knot wind. Data extracted from the avionics units showed 9 autopilot engagements during the flight; however, the data did not show what caused the inadvertent engagements. It is likely the autopilot engaged during the attempted landing and caused the loss of directional control, but the reason for the autopilot engagement was not determined due to damage to the avionics system caused by water exposure and recovery damage.

Analysis

Primary failure mode
Automation / mode confusion
First missed decision gate
Pilot could have verified autopilot status before landing.

NTSB coding

Evidence available

  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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