# NTSB BFO91LA023: Holmes Special S2C, N484MH, Ellendale, DE, January 15, 1991

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: January 15, 1991, 10:52 local (15:52 UTC)
- Place: Ellendale, DE
- Coordinates: 38.999187, -75.46096 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.9992&lon=-75.4610&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Highest injury: Serious injuries
- Injuries: 2 serious
- Status: Completed, report August 13, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 11654
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO91LA023
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/11654/pdf
- Page: https://openairdocs.org/ntsb/BFO91LA023

## Probable cause

THE PILOT'S FAILURE TO RECOVER FROM AN AEROBATIC MANUEVER IN TIME TO AVOID INFLIGHT COLLISION WITH THE GROUND.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of control - in flight, maneuvering
  - aerobatics - performed, pilot in command (contributing factor)
  - aircraft handling - inadequate, pilot in command (cause)
  - remedial action - inadequate, pilot in command (contributing factor)
- In flight collision with terrain/water, maneuvering

## Analysis

A WITNESS REPORTED THE AIRPLANE WAS DOING AEROBATIC MANUEVERS WHEN IT CRASHED. ACCORDING TO A WITNESS, THE AIRPLANE WAS ABOUT 2000 FEET MSL WHEN HE SAW THE AIRPLANE ROLL TWO AND ONE HALF TIMES, FINISHING IN AN INVERTED ATTITUDE.  THE AIRPLANE THEN ENTERED A FLAT SPIN BEFORE IT PITCHED DOWN AND DESCENDED.  THE WITNESS STATED THE AIRPLANE STOPPED SPINNING AND WAS BEGINNING TO LEVEL WHEN IT COLLIDED WITH THE GROUND. THE INVESTIGATION DID NOT REVEAL EVIDENCE OF AIRCRAFT MECHANICAL MALFUNCTION. THE PILOT AND PASSENGER WERE SERIOUSLY INJURED AND DID NOT RECALL THE DETAILS OF THE FLIGHT.

## Aircraft

- Registration: [N484MH](https://openairdocs.org/deregistered/N484MH-2017-05-15), registration cancelled 2017-05-15, S/N 001MH, built 1987 (OpenAirDocs)
- Reported make and model: HOLMES SPECIAL S2C (SPECIAL S2)
- Registry model: [Holmes Milton N HOLMES SPECIAL S2C](https://openairdocs.org/model/holmes-milton-n-holmes-special-s2c) (registry code 05612HN) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane, amateur-built
- Serial number: 001MH
- Engines: LYCOMING O-320-H2AD 160 horsepower reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Operator: Charles R. Bradley
- Registered owner: Milton N. Holmes
- Last inspection: Annual, January 2, 2000

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; private; airplane ratings: single-engine land; seat: center; flight hours: 400 total

## Weather

- Conditions: Visual (VMC), Day
- Wind: 190° at 6 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 48 °F, dew point 27 °F
- Altimeter: 30.00 inHg
- Observed at: SBY, 999 nm away

## FAA reports on this event (1)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 19910115063289A](https://openairdocs.org/incident/19910115063289A), Jan 15, 1991: Amtrhm SPECIALS2C, Ellendale, DE, Destroyed. Entered flat spin during snap rolls, recovered too late and impacted ground as nose came up.

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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