Pilot Debrief

VANS AIRCRAFT INC RV-12 near Fishers, IN — 2017-08-31

Final reportCEN17FA334
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Date
2017-08-31
Location
Fishers, IN, USA
Airport
UMP
Aircraft
VANS AIRCRAFT INC RV-12
Registration
N212ZF
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot's failure to latch the canopy before takeoff, and his failure to maintain pitch control following the in-flight opening of the canopy during the initial climb resulting in a subsequent impact with terrain and ground fire.

NTSB narrative

A private pilot departed on a local flight in his experimental, amateur-built airplane equipped with a tip-up (forward-opening) canopy. A witness saw the airplane during its initial climb after takeoff and stated that it descended "straight down and burst into a ball of flames" upon impact. Examination of the accident site revealed that items from the cabin were found on the ground near the runway threshold and before the impact site. There were no preimpact anomalies of the airframe or engine and kit manufacturer fuel tank Service Bulletins were compiled with. The airplane's before takeoff checklist stated, "Canopy – CHECK Latched." However, the metal canopy latching mechanisms on the roll bar frame exhibited soot-colored discoloration and its polyethylene latch block was not present, and the latch handle on the canopy was intact, not deformed, and not discolored, consistent with the latch being unsecured at the time of impact. Additionally, the presence of items from the cockpit before the impact site is consistent with the canopy opening in flight. About 9 months before the accident, the kit manufacturer published a service letter regarding the in-flight opening of tip-up canopies. The letter stated that, based on previous events, the aircraft will most likely pitch nose down abruptly if the canopy opens in flight. The severity of the pitching moment can depend on speed, attitude, and weight and balance. The letter further stated that most instances of in-flight canopy openings were the result of the pilot forgetting to latch the canopy properly before takeoff, and cautioned pilots to ensure that the latching mechanism fully engaged as designed. Based on the available evidence, it is likely that the accident pilot failed to properly latch the canopy before takeoff, did not maintain airplane control following the canopy opening, and the airplane subsequently impacted terrain to the extent that the incorporated service bulletins remedies did not keep the fuel tank from breaching, causing the ground fire.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot failed to secure the canopy latch before takeoff, leading to loss of control.

NTSB coding

Evidence available

  • FDR / data
  • Photos
  • 19 docket documents
View NTSB final reportView NTSB docket

Docket documents19

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