Pilot Debrief

URBAN AIR SRO SAMBA XXL near Carson City, NV — 2013-08-16

Final reportWPR13FA376
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Date
2013-08-16
Location
Carson City, NV, USA
Airport
CXP
Aircraft
URBAN AIR SRO SAMBA XXL
Registration
N19UA
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Cruise

Probable cause

The pilot's failure to maintain adequate airspeed while maneuvering, which led to the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall/spin. Contributing to the accident was the improper location of the parachute activation handle and the pilot's failure to remove the handle's locking pin before flight.

Contributing factors

Contributing to the accident was the improper location of the parachute activation handle and the pilot's failure to remove the handle's locking pin before flight.

NTSB narrative

During the local area personal flight, the sport pilot/owner was seated in the right seat, and a student-pilot-rated passenger was seated in the left seat. Data downloaded from a GPS unit on board the airplane showed that the airplane departed from the airport and climbed to an altitude of about 3,000 ft above ground level while maneuvering. The airplane then made a 180-degree turn followed by a rapid, near-vertical descent to ground impact. The wreckage was located on flat open terrain. The airplane was intact, lying flat on its belly with the landing gear collapsed underneath the fuselage, consistent with impact in a flat spin. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunction or failure that would have precluded normal operation. Based on the GPS tracking data and the condition of the wreckage, the pilot likely failed to maintain adequate airspeed, which led to the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall that developed into a flat spin, which the pilot was unable to recover from before ground impact. The airplane was equipped with a ballistic recovery system parachute that was not deployed before impact. The parachute system manual states the following: 1) position the activation handle such that it is reachable by the occupants of both seats; 2) remove the handle's locking pin before flight; and 3) inform all passengers of the operation of the system. Postaccident examination found that the locking pin, which was equipped with a red warning flag, was secured in the parachute activation handle. The handle was located on the lower left side of the instrument panel (beneath the flight instruments) and was only readily accessible to the left seat occupant. It is unknown if the passenger in the left seat was aware of the parachute system and its operation. Had the parachute been activated, the accident may have been survivable. The pilot's autopsy revealed that he had a low-grade malignant lymphoma and a brain tumor. He also had a history of depression, which had been well controlled with medication. After a review of the pilot's medical history, autopsy, and toxicology findings, the investigation was unable to determine if medical impairment contributed to the loss of airplane control.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have activated the ballistic recovery system before losing control.

NTSB coding

Evidence available

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

Docket documents14

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