ANC18LA042

NTSB accident investigation · Gippsaero PTY GA10 · Mojave, CA · June 4, 2018

Accident · Minor injuriesLimited investigationFinal report
Date
June 4, 2018, 11:52 local (18:52 UTC)
Place
Mojave, CA
Injuries
2 minor
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
VH-XMHGippsaero PTY GA10
Defining event
Maneuvering: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report April 20, 2020
Report
Approved by Office Director
NTSB office
Alaska Regional Office
Case key
97404

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The flight crew's inappropriate decision, without authorization or consultation from the manufacturer's chief design engineer, to introduce flaps in the landing configuration into the entry spin testing, which resulted in an unrecoverable spin and impact with the ground. Contributing to the accident was the failure of the anti-spin parachute.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Info processing/decision: decision making/judgmentPersonnel issues › Action/decision · Flight crewAll aircraft: 3,098 casesProbable cause
AircraftAircraft › Aircraft systems · FailureAll aircraft: 63 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane manufacturer was conducting spin flight testing for the installation of a cargo pod when the airplane exhibited aberrant behavior and the testing was halted. The chief design engineer (CDE) was consulted, and, to provide a margin of safety for further flights, a forward center of gravity position was authorized for flaps up and flaps takeoff entries to gain more insight into the airplane's behavior on the previous flight. At the final briefing, before the next flight, the flight crew added spins with flaps in the landing configuration (flaps landing) into the test plan without the CDE's consultation or authorization. According to the pilot flying, after two wings-level, power on, flaps landing spins with left rudder and right aileron, a third spin entry was flown in the same configuration except that the entry was from a 30° left-bank turn. The airplane entered a normal spin, and, at one turn, flight controls were inputted for a normal recovery; however, the airplane settled into a fully developed spin. When recovery attempts failed, the decision was made to deploy the anti-spin parachute. After repeated unsuccessful attempts to deploy the anti-spin parachute, and when the airplane's altitude reached about 500 ft above the briefed minimum bailout altitude, both pilots called for and executed a bailout. The airplane impacted the ground and was destroyed. A postaccident examination of the anti-spin parachute system revealed that half of the connector hook had opened, which allowed the activation pin lanyard for the anti-spin parachute to become disengaged. Based on the airplane's previous aberrant behavior and the conservative parameters that the CDE had previously set, it is not likely that the CDE would have authorized abused spin entries without a prior testing buildup to those entries. Thus, the flight crew made an inappropriate decision to introduce flaps landing entry spin testing, and the failure of the anti-spin parachute contributed to the accident.

Factual narrative

On June 4, 2018, about 1152 Pacific daylight time, an Australian registered GIPPSAERO PTY LTD, GA10 airplane, VH-XMH, was destroyed after it impacted terrain following an unrecoverable spin, and the unsuccessful deployment of the anti-spin parachute near Mojave, California. The airplane was registered to GIPPSAERO PTY LTD and operated by GIPPSAERO PTY LTD in conjunction with the National Test Pilot School (NTPS) as a visual flight rules test flight under the provisions of 14 Code of Federal Regulations Part 91.715 Special Flight Authorization when the accident occurred. The Australian certificated commercial pilot and the United States certificated airline transport pilot sustained minor injuries. Visual meteorological conditions prevailed, and company flight following procedures were in effect. According to the airplane manufacturer, the purpose of the flight was to conduct spin trials with the GA-10 airplane fitted with a cargo pod installation. Initial spin trials with the cargo pod were completed in Australia with company pilots, and the aircraft configured well away from the critical flight conditions identified during the original airplane certification spin testing. Due to scheduling and personnel constraints, it was decided to send the airplane and company personnel to NTPS to conduct the more critical spin tests. The flight tests commenced and proceeded until May 31, 2018, when the airplane exhibited some aberrant behavior, and the manufacturer's Chief Design Engineer (CDE) was consulted. To provide a margin of safety for further flights, a forward CG position was authorized for flaps up and flaps takeoff entries, in an effort, to gain more information into the airplane's aberrant behavior on the previous flight. At the final briefing, prior to the next flight, spins with landing flaps were added by the flight crew without consultation or authorization from the CDE. According to the pilot flying, the flight departed about 1105 PDT and a stall series consisting of stalls with flaps up, flaps takeoff and flaps landing was completed prior to any spin entries, with stall characteristics normal and benign. The first spin entry was a wings level, power on, flaps landing spin with left rudder and right aileron. He said that the recovery took longer than expected, and the decision was made to repeat the test point. A repeat of the same entry resulted in a very similar spin with the recovery at one additional turn. The second test point (third spin entry) was flown in the same configuration as the first two, except that the entry was from a 30° left-bank turn. The airplane entered a normal spin and at one turn, flight controls were inputted for a normal recovery; however, the airplane settled into a fully developed spin. After 3 turns, the pilots in the chase aircraft called "three turns". The control yoke was held full forward with full opposite rudder, and right aileron was inputted, in an attempt, to affect yaw rate, to no avail, so thecontrol yoke was returned to neutral, full forward and full right rudder. Around 10,000 ft, the pilots in the chase aircraft called "chute, chute, chute". The anti-spin parachute lever was pulled aft; however, the anti-spin parachute did not deploy even after repeated attempts. At about 8,500 ft msl, 500 ft above the briefed minimum bailout altitude, both pilots called for and executed a bailout. A postaccident examination of the anti-spin parachute system revealed that one half the connector hook had opened allowing the activation pin lanyard for the anti-spin parachute to become disengaged. The closest weather reporting facility was Mojave Air and Space Port (KMHV), Mojave, California, about 9 miles north of the accident site. At 1200, a METAR from KMHV was reporting, in part: wind from 300° at 15 knots, gusting 20 knots; visibility, 10 statute miles; clouds and sky condition, clear; temperature, 93° F; dew point 39° F; altimeter, 29.91 inches of mercury.

Aircraft

Registration
VH-XMH
Reported as
Gippsaero PTY GA10 (NO SERIES)
Category
Airplane
Serial number
GA10-TP450-16-1
Built
2016
Airframe hours
113.1
Engine
Rolls Royce M250-B17F/2, 450 horsepower, turbo prop
Damage
Destroyed
Flight
Flight test · Part 91
Operator
Gippsaero Pty Ltd
Registered owner
Gippsaero Pty Ltd
Airworthiness certificate
Certificate of authorization or waiver (COA)
Last inspection
100 hour · September 17, 2017
Departed
Mojave, CA
Destination
Mojave, CA
Flight plan
Company VFR
Equipment
Electronic primary flight display, Electronic multifunction display, Data recorder, Stall warning system, Video recording device

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
70
Injuries
Minor
Certificates
Flight instructor, Airline transport
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
November 9, 2017
Seat
Left
Restraint
4-point
Flight hours
9,767 total · 46 in this make and model · 8,315 as pilot in command · 53 in the last 90 days · 22 in the last 30 days · 1 in the last 24 hours
Role
Pilot
Age
61
Injuries
Minor
Certificates
Flight instructor, Foreign, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
April 15, 2018
Seat
Right
Restraint
4-point
Flight hours
10,980 total · 287 in this make and model · 10,780 as pilot in command · 22 in the last 90 days · 14 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
300° at 15 knots, gusting 20
Visibility
10 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 39 °F
Altimeter
29.90 inHg
Observed at
KMHV, 9 nm away

Docket · 5

The files NTSB released with the investigation on November 7, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.9 MB in all.