Pilot Debrief

SCHLEICHER ASW-19B near JACKSONVILLE, FL — 2022-04-16

Final reportERA22FA189
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Date
2022-04-16
Location
JACKSONVILLE, FL, USA
Airport
HEG
Aircraft
SCHLEICHER ASW-19B
Registration
N19KW
Category
Glider
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot’s improper preflight assembly of the glider’s elevator control, which resulted in a loss of control on takeoff, and the pilot’s failure to complete a positive control check before the flight, which would have identified the disconnected elevator control.

NTSB narrative

Shortly after the tow airplane and the glider became airborne, the pilot of the glider released from the tow plane about 200 ft above ground level, then entered a left turn back toward the runway, during which the glider impacted terrain. Witnesses to the accident described the glider’s takeoff as “abnormal” and “erratic” and reported that the glider climbed above the tow plane twice before the glider pilot released from tow. Postaccident examination of the glider revealed that the elevator control was not connected as required by preflight assembly procedures, which would have resulted in the pilot’s inability to control the glider’s pitch attitude. According to the tow pilot, the glider pilot had assembled the glider by himself (as he had done many times before) on the morning of the accident. It is likely that, had the pilot completed a positive control check after assembly, he would have identified the disconnected elevator control. Toxicology testing identified two sedating drugs, cetirizine (Zyrtec) and trazodone (an antidepressant), in the pilot’s cavity blood and urine; however, the pilot’s use of these medications most likely did not contribute to the accident.

Analysis

Primary failure mode
Mechanical failure
First missed decision gate
Properly secure elevator control connection before flight.

NTSB coding

Evidence available

  • Photos
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10

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