What happened
The FAA’s narrative, in sentence case. The FAA writes it in capitals and removes private details.
Coyote hunting flight for usda made low level turn. Wing hit ground. A1 cartwheeled. Fatal for front seated pilot. (From .4) in furtherance of the U.S. Department of agriculture's animal plant health inspection service (aphis) wildlife services aviation program, the rear seat instructor-gunner and the front seat trainee-pilot commenced aerial hunting operations which required the trainee-pilot to maneauver at slow airspeed and low altitude while the instructor-gunner shot coyotes. The instructor was also required to be observant of the recently hired trainee's flying skill and provide any needed instruction. On previous flights, the instructor had observed the trainee experiencing difficulty maintaining altitude during turns. He also opined that the trainee was not strong enough to fully extend the wing flaps. The trainee used two seat cushions behind her back to reposition her closer to the flight controls (and the instrument panel). The instructor did not report his observations to management. During the accident flight following a coyote shoot, the trainee entered a low altitude, slow airspeed, medium bank turn to reverse course. During the turn, the instructor's attent ion was diverted to search the cabin floor for an ejected live shotgun shell. The instructor looked outside the airplane just as the left wing impacted the level terrain in a nose low attitude. The usda operated the public-use airplane and directed the instructor to have it maintained by contract mechanics in accordance with FAA regulations. Contrary to the airplane manufacturer's FAA type certificate, the usda had erroneously connected the front seat shoulder harness, with its associated inertial reel, to the back of the front seat instead of using the prescribed factory mandated location at an overhead airframe hardpoint. Additionally, the shoulder harness webbing was routed beneath seatback material. An engineering analysis revealed that due to the anchoring of the harness to the seat structure rather than the prescribed airframe hardpoint, and the nose low ground impact trajectory, the inertial crash loads to the seat increased thus exceeding its designed strength. The improper harness attachment combined with the compressive fuselage buckling resulted in the seat yielding in a forward bending direction. The trainee's head impacted the instrument panel resulting in fatal injuries. The airplane had undergone four 100-hour and an annual inspection with the harness incorrectly attached. (-23) pilot executed a low altitude turn (most coyote control work is accomplished below 50'). Left wing struck level ground causing a low speed. Cartwheel of aircraft. Front seat pilot was fatally injured.
As the FAA filed it
COYOTE HUNTING FLIGHT FOR USDA MADE LOW LEVEL TURN. WING HIT GROUND. A1 CARTWHEELED. FATAL FOR FRONT SEATED PILOT. (FROM .4) IN FURTHERANCE OF THE U.S. DEPARTMENT OF AGRICULTURE'S ANIMAL PLANT HEALTH INSPECTION SERVICE (APHIS) WILDLIFE SERVICES AVIATION PROGRAM, THE REAR SEAT INSTRUCTOR-GUNNER AND THE FRONT SEAT TRAINEE-PILOT COMMENCED AERIAL HUNTING OPERATIONS WHICH REQUIRED THE TRAINEE-PILOT TO MANEAUVER AT SLOW AIRSPEED AND LOW ALTITUDE WHILE THE INSTRUCTOR-GUNNER SHOT COYOTES. THE INSTRUCTOR WAS ALSO REQUIRED TO BE OBSERVANT OF THE RECENTLY HIRED TRAINEE'S FLYING SKILL AND PROVIDE ANY NEEDED INSTRUCTION. ON PREVIOUS FLIGHTS, THE INSTRUCTOR HAD OBSERVED THE TRAINEE EXPERIENCING DIFFICULTY MAINTAINING ALTITUDE DURING TURNS. HE ALSO OPINED THAT THE TRAINEE WAS NOT STRONG ENOUGH TO FULLY EXTEND THE WING FLAPS. THE TRAINEE USED TWO SEAT CUSHIONS BEHIND HER BACK TO REPOSITION HER CLOSER TO THE FLIGHT CONTROLS (AND THE INSTRUMENT PANEL). THE INSTRUCTOR DID NOT REPORT HIS OBSERVATIONS TO MANAGEMENT. DURING THE ACCIDENT FLIGHT FOLLOWING A COYOTE SHOOT, THE TRAINEE ENTERED A LOW ALTITUDE, SLOW AIRSPEED, MEDIUM BANK TURN TO REVERSE COURSE. DURING THE TURN, THE INSTRUCTOR'S ATTENT ION WAS DIVERTED TO SEARCH THE CABIN FLOOR FOR AN EJECTED LIVE SHOTGUN SHELL. THE INSTRUCTOR LOOKED OUTSIDE THE AIRPLANE JUST AS THE LEFT WING IMPACTED THE LEVEL TERRAIN IN A NOSE LOW ATTITUDE. THE USDA OPERATED THE PUBLIC-USE AIRPLANE AND DIRECTED THE INSTRUCTOR TO HAVE IT MAINTAINED BY CONTRACT MECHANICS IN ACCORDANCE WITH FAA REGULATIONS. CONTRARY TO THE AIRPLANE MANUFACTURER'S FAA TYPE CERTIFICATE, THE USDA HAD ERRONEOUSLY CONNECTED THE FRONT SEAT SHOULDER HARNESS, WITH ITS ASSOCIATED INERTIAL REEL, TO THE BACK OF THE FRONT SEAT INSTEAD OF USING THE PRESCRIBED FACTORY MANDATED LOCATION AT AN OVERHEAD AIRFRAME HARDPOINT. ADDITIONALLY, THE SHOULDER HARNESS WEBBING WAS ROUTED BENEATH SEATBACK MATERIAL. AN ENGINEERING ANALYSIS REVEALED THAT DUE TO THE ANCHORING OF THE HARNESS TO THE SEAT STRUCTURE RATHER THAN THE PRESCRIBED AIRFRAME HARDPOINT, AND THE NOSE LOW GROUND IMPACT TRAJECTORY, THE INERTIAL CRASH LOADS TO THE SEAT INCREASED THUS EXCEEDING ITS DESIGNED STRENGTH. THE IMPROPER HARNESS ATTACHMENT COMBINED WITH THE COMPRESSIVE FUSELAGE BUCKLING RESULTED IN THE SEAT YIELDING IN A FORWARD BENDING DIRECTION. THE TRAINEE'S HEAD IMPACTED THE INSTRUMENT PANEL RESULTING IN FATAL INJURIES. THE AIRPLANE HAD UNDERGONE FOUR 100-HOUR AND AN ANNUAL INSPECTION WITH THE HARNESS INCORRECTLY ATTACHED. (-23) PILOT EXECUTED A LOW ALTITUDE TURN (MOST COYOTE CONTROL WORK IS ACCOMPLISHED BELOW 50'). LEFT WING STRUCK LEVEL GROUND CAUSING A LOW SPEED. CARTWHEEL OF AIRCRAFT. FRONT SEAT PILOT WAS FATALLY INJURED.
NTSB investigation
The NTSB’s investigation of this event, with its probable cause and findings. Matched to this report by N-number and date.
Other reports on N9615G · 1
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