Pilot Debrief

Vans RV-12 near Lady Lake, FL — 2019-09-06

Final reportERA19FA265
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Date
2019-09-06
Location
Lady Lake, FL, USA
Airport
97FL
Aircraft
Vans RV-12
Registration
N767FS
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot's loss of pitch control due to the in-flight opening of the canopy for reasons that could not be determined.

NTSB narrative

The pilot departed with the intent of remaining in the airport traffic pattern. Automatic Dependent Surveillance-Broadcast (ADS-B) data indicated that the airplane departed and climbed to an altitude of about 1,000 ft above ground level. Near the end of the downwind leg, the airplane entered a brief 50-ft climb, followed by a rapid descent to impact with the ground. Examination of the engine and airframe revealed no evidence of any preimpact mechanical malfunctions that would have precluded normal operation. Examination of the canopy roll bar and the tip-up canopy bow, which are connected in flight when the canopy is latched, indicated that they deformed in a dissimilar manner at impact. The roll bar and canopy bow were located about 12 ft apart at the accident site, and there was little damage to the handle and latch block, indicating that the canopy was likely not latched at the time of impact. Examination of the canopy and latch handle revealed that the handle and washers did not match any of the manufacturer’s drawings. The kit manufacturer issued a service letter about 3 years before the accident advising that, in the event of an inflight opening of a forward opening, tip-up canopy, the airplane would “most likely pitch down abruptly.” The pilot had recently modified the latch on the airplane’s tip-up canopy. The pilot had purchased a latch replacement kit from the airplane manufacturer; however, only the handle from the new latch kit was installed at the time of the accident, and additional washers that were not part of the kit had been added, likely to compensate for the longer dimensions of the new handle assembly. Whether full engagement of the latching mechanism could be achieved in this configuration could not be determined. Additionally, it could not be determined whether the pilot departed with the canopy unlatched or it became unlatched in flight, but it is likely that when the pilot reduced engine power to begin a descent for landing, the canopy opened enough to affect the airplane’s pitch control, resulting in a subsequent abrupt descent and impact with terrain.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot should have ensured canopy was properly latched before takeoff.

NTSB coding

Evidence available

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

Docket documents21

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