Pilot Debrief

GRAVES SH-2F near Montague, CA — 2013-06-12

Final reportWPR13FA269
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Date
2013-06-12
Location
Montague, CA, USA
Airport
1O5
Aircraft
GRAVES SH-2F
Registration
N15GG
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Maneuvering

Probable cause

The pilot’s failure to maintain airplane control while maneuvering for reasons that could not be determined during postaccident testing and examination, which resulted in a stall and subsequent spin.

NTSB narrative

The two pilots departed for a personal flight so that the right-seat pilot could become familiar with the airplane, which was owned by the left-seat pilot. The airplane was equipped with dual flight controls; however, it could not be determined which pilot was manipulating the controls at the time of the accident. Witnesses located adjacent to the accident site reported that they heard the sound of an airplane maneuvering with its engine operating at a high power setting followed by the sound of impact. Postaccident examination of the engine and airframe revealed that the flap handle interconnect was disconnected from the flap torque tubes with no corresponding bolt or nut located within the wreckage. Although the flaps in the disconnected configuration would have prevented the pilot from selecting a flap setting, airflow during flight would have kept the flaps in a retracted position. No evidence of any additional preexisting mechanical anomalies that would have precluded normal operation was found. Wreckage and impact signatures were consistent with an inverted flat-spin impact with terrain. Postmortem toxicology tests for the right-seat pilot, who had a valid Federal Aviation Administration (FAA) medical certificate, was positive for metoprolol (a beta-adrenergic receptor antagonist), which he was taking due to a valve replacement and aortic repair. Nothing from the autopsy suggested impairment or incapacitation from a medical condition or medication. Postmortem toxicology tests for the left-seat pilot, who did not have a current FAA medical certificate, were positive for norfluoxetine (an atypical antidepressant), fluoxetine (an antidepressant), olanzapine (commonly used for treatment of schizophrenia), and Warfarin (an anticoagulant medication). It is likely that the underlying psychiatric condition and/or medication being used to treat the conditions could have been impairing to some degree; however, the right-seat pilot should have been able to successfully fly the airplane even if some impairment was present in the left-seat pilot. No evidence suggests that pilot impairment or incapacitation contributed to the accident.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot could have avoided maneuvering that led to loss of control.

NTSB coding

Evidence available

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

Docket documents15

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