CEN20LA227

NTSB accident investigation · Vans RV8 · Mandan, ND · June 13, 2020

Accident · FatalClass 2 · LimitedFinal report
Date
June 13, 2020, 14:00 local (19:00 UTC)
Place
Mandan, ND
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N836JCVans RV8
Defining event
Takeoff: Collision during takeoff/land
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 2
NTSB office
Central Region
Parties
Lycoming Engines, Federal Aviation Administration, Van's Aircraft
FAA report
20200613007679A
Case key
101430

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

On this page

Probable cause

The pilot's failure to remove the seat belt used as a flight control lock from the aft cockpit control stick before takeoff, which resulted in a loss of control during takeoff and collision with terrain.

Findings · 1

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.

Planning/preparationPersonnel issues › Task performance · PilotCooke John J RV8: 1 caseAll aircraft: 113 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

While the airplane was parked on the ramp before the flight, a witness noted that the aft cockpit seatbelt was wrapped around the control stick to secure the flight control surfaces; the conditions at the airport at the time were described by a second witness as "very windy." The first witness reminded the pilot to remove the belt before departure. Both witnesses noted that the airplane's elevator was up as the airplane taxied out for departure. The airplane's takeoff ground roll was short, and as the airplane became airborne, it entered a steep climb to about 50 ft above the ground, rolled left, then entered a vertical descent to ground contact. The witnesses noted that the airplane's elevator was in the full up position at the accident site and as the fire continued, the elevator slowly lowered. Postaccident examination of the wreckage did not reveal any preimpact anomalies that would have precluded normal operation of the airplane. The seat belt webbing was not identified in the charred cockpit. Given the available information, it is likely that the pilot, seated in the front cockpit of the tandem-configured airplane, failed to remove the seat belt from the aft control stick before departure, resulting in a loss of control during the initial climb and subsequent impact with terrain. The elevator likely lowered as the webbing material melted due to the fire.

Factual narrative

The airplane kit manufacturer had a stated policy in place for all its company pilots that only the pilot’s stick is to be wrapped around the control stick whenever an airplane's controls are secured by wrapping . The copilot/passenger stick is not to be used to secure the controls under any circumstances. The airplane was a low-wing, tailwheel-equipped airplane with a tandem seating configuration. Both forward and aft seating positions were equipped with seatbelts and flight controls. On June 13, 2020, about 1400 central daylight time, a Vans RV8 airplane, N836JC, was destroyed when it was involved in an accident near Mandan, North Dakota. The private pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. One witness had a meeting with the pilot and others just before the accident flight. The witness walked over to the airplane after the meeting and noticed that the aft cockpit seatbelt was strapped around the control stick. The pilot said that this was done to hold the airplane's flight controls while parked with windy conditions present. This witness reminded the pilot to remove the belt from around the rear seat controls before departure. The witness walked away from the parking area on the ramp and saw the pilot turn around while in the cockpit, but could not see what he was doing. The witness noticed that the airplane's elevator was up as the airplane departed. The airplane became airborne quickly, flew straight up, rolled left, and then went straight down before impacting the ground; a fire ensued. The witness observed that the elevator was in an up position at the accident site and slowly lowered as the fire continued. Another witness stated that it was very "windy," and he noticed that the wind swung the airplane around during its taxi for departure. The pilot continued a 360° turn on the ramp and then taxied the airplane to the runway for departure. The witness noticed that the airplane's elevator was up during this time and it stayed up throughout the takeoff. Upon lifting off the runway, the airplane "immediately" went straight up to about 50 ft above the ground, entered a left bank, then entered a nose-down, vertical descent to impact. The witness along with another witness tried to pull the pilot out, but the airplane was engulfed in flames. The North Dakota Department of Health State Forensic Examiner conducted an autopsy on the pilot and took toxicological samples. The cause of death was listed as blunt head and chest injuries with burning by fire. Toxicology testing performed at the FAA Forensic Sciences Laboratory was negative for carboxyhemoglobin, ethanol, and drugs of abuse. Federal Aviation Administration inspectors examined and documented the wreckage site. The inboard portions of both wings, the engine, and sections of the fuselage were thermally damaged consistent with a postimpact fire. A ground scar was present south of the wreckage. Linear gougeswere observed within the ground scar. The propeller blades exhibited leading edge nicks and chordwise abrasion. The trim tab on the left elevator was displaced downward, consistent with nose-up trim. The cockpit interior was discolored, deformed, and charred. The seatbelt webbing was not identified.

Aircraft

Registration
N836JC
Reported as
Vans RV8 (Undesignat)
Category
Airplane, amateur-built
Serial number
81012
Built
2002
Airframe hours
694.9
Engine
Lycoming IO-360-A1B6D, 200 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · November 21, 2019
Departed
Y19 · Mandan, ND
Destination
PVT · Stanton, ND
Airport
Y19 · Mandan Muni, runway 13, 4,399 × 75 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
57
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
April 23, 2020
Seat
Front
Restraint
4-point
Toxicology
Performed
Flight hours
1,022 total

Weather

Conditions
Visual (VMC) · Day
Wind
130° at 18 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 63 °F
Altimeter
30.00 inHg
Observed at
KY19

Docket · 12

The files NTSB released with the investigation on January 15, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 284 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.