Pilot Debrief

BEECH A45 near Deer Harbor, WA — 2024-06-07

Final reportWPR24FA184
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Date
2024-06-07
Location
Deer Harbor, WA, USA
Aircraft
BEECH A45
Registration
N268AF
Category
Airplane
Highest injury
Fatal
Fatalities
1

Probable cause

The pilot’s decision to perform an aerobatic maneuver at low level, and his misjudged entry altitude for the maneuver, which resulted in impact with water.

NTSB narrative

The pilot was performing a flight around an island archipelago where he used to live, with the intention of also performing a flyby of a friend’s home. He was familiar with the route of flight and had performed the same flyby multiple times before. The friend stated that, in the past, the pilot often rocked the airplane’s wings during his flybys, but had never performed aerobatics. She stated that, during the accident flight, the airplane was flying at a higher altitude than on previous occasions. The left wing then dropped, and she thought this was part of the pilot’s usual routine; however, the wing continued to drop as the airplane began to rapidly descend toward the water. The airplane began to pull out of the dive, but by the time it had recovered to an almost wings-level, upright attitude, the belly impacted the water. Video of the accident recorded by another witness in the vicinity showed the airplane inverted and diving, in what appeared to be the early stages of an aerobatic maneuver consistent with a split S. Video analysis indicated that the airplane began the maneuver about 1,800 ft above the water. Its flight path followed a constant radius arc which, at its lowest point, extended 30 feet below the water’s surface. Examination of the airframe and engine showed no evidence of pre accident malfunction. Video footage indicated that the engine was operating during the descent and appeared to be producing power at impact. Damage to the airplane’s altimeter precluded a determination of its operating status at the time of the accident; however, its Kollsman window was set correctly for local atmospheric conditions. The pilot had an extensive and distinguished career in human spaceflight and aviation, and according to family members exhibited a lifelong pattern of maintaining high standards and conservative flying habits. Evidence suggests, however, that as he aged the pilot became less rigid in maintaining those standards. As an example, he was not wearing a personal floatation device during the accident flight despite his self-imposed rule of doing so when flying over water. Additionally, although it was reported that he never performed aerobatics without wearing a parachute, the pilot did perform a barrel roll the week before the accident without wearing one. According to the pilot’s son, performing a split-S maneuver at such a low altitude and with such little margin for error would have been out of character for the pilot. The pilot’s decision to perform the flyby at a higher altitude than usual suggests that he likely intended to perform the maneuver, but misjudged the entry altitude. The pilot’s medical profile included conditions typical for a 90-year-old, and evidence suggested that behaviorally he demonstrated impatience with other aircraft in the traffic pattern and was struggling with the communications equipment in another similar airplane. About 10 years before the accident, he voluntarily stopped flying aerobatics at airshows and flying higher performance airplanes because he was concerned about damaging them. He shifted instead to simpler, seasonal flying in the accident airplane type—the airplane in which he originally learned to fly—and had recently stopped flying solo in congested airspace. Nevertheless, the pilot’s son stated that his flying skills were still excellent. Although regulations permit any authorized flight instructor to conduct a flight review, the pilot’s son served as the pilot’s exclusive reviewer and recurrent instructor. This resulted in a lack of independent oversight, and due to family dynamics and the power disparity associated with the pilot’s experience, this arrangement may have limited the candid identification of risk increasing behaviors or degrading skills. The pilot’s autopsy report indicated his cause of death was a result of multiple blunt force injuries. The examination identified moderate coronary artery disease, but did not identify other significant natural diseases. As a result of his heart disease, the pilot was at some increased risk of a sudden impairing or incapacitating cardiac event, such as chest pain, arrhythmia, or heart attack. However, such an event does not leave reliable autopsy evidence if it occurs immediately before death. The pilot also would have been experiencing the effects of elevated G-forces during the maneuver. Pilot tolerance to G-forces is affected by multiple factors, including magnitude and duration of the acceleration, the individual’s training and level of fitness, and other health factors. However, the coordinated manner in which the maneuver was performed indicated that the pilot was actively controlling the airplane throughout. Thus, it is unlikely that the effects of the pilot’s coronary artery disease or encounter with elevated G-forces contributed to the accident.

NTSB coding

Evidence available

  • Video
  • ADS-B / radar
  • 12 docket documents
View NTSB final reportView NTSB docket

Docket documents12

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