# NTSB CEN20LA227: Vans RV8, N836JC, Mandan, ND, June 13, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 2 · Limited · Final report - Date: June 13, 2020, 14:00 local (19:00 UTC) - Place: Mandan, ND - Coordinates: 46.768054, -100.89444 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.7681&lon=-100.8944&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 2 - NTSB office: Central Region - Parties: Lycoming Engines, Federal Aviation Administration, Van's Aircraft - NTSB case key (mKey): 101430 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA227 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101430/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101430 - Page: https://openairdocs.org/ntsb/CEN20LA227 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation](https://openairdocs.org/ntsb-findings/02061000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cooke John J RV8, 1 case](https://openairdocs.org/ntsb-findings/02061000/cases.md?model=05612F8), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/02061000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Cooke John J RV8, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=05612F8), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Cooke John J RV8, 1 case](https://openairdocs.org/ntsb-events/490/sequence.md?model=05612F8), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## 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](https://openairdocs.org/deregistered/N836JC-2021-07-03), registration cancelled 2021-07-03, S/N 81012, built 2002 (OpenAirDocs) - Reported make and model: Vans RV8 (Undesignat) - Registry model: [Cooke John J RV8](https://openairdocs.org/model/cooke-john-j-rv8) (registry code 05612F8) (OpenAirDocs) - Registry engine: [Lycoming IO-360-A1B6D](https://openairdocs.org/engine/lycoming-io-360-a1b6d) (registry code 41593, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 81012 - Year built: 2002 - Airframe hours: 694.9 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; 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 ## 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 20200613007679A](https://openairdocs.org/incident/20200613007679A), Jun 13, 2020: Cooke John J RV8, Mandan, ND, Destroyed, 1 fatal. 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.… ## Docket (12 files) The files NTSB released with the investigation on January 15, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101430. 284 MB in all. - FAA inspector's statement (item 1, PDF, 2 pages, 748 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10067721&FileExtension=pdf&FileName=2020-7-8%20Inspector%20Statement%201%20_Redacted-Rel.pdf - Memorandum for record a�� FBO clerk at hze statement (item 2, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9840033&FileExtension=pdf&FileName=20Communication%20Summary227HZE_FBO-Rel.pdf - Memorandum for record a�� communication summary -- a martz vp claims (item 3, PDF, 1 page, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9846894&FileExtension=pdf&FileName=20Communication%20Summary227Insurance-Rel.pdf - Miscellaneous information - pilot logbook excerpts (item 4, PDF, 8 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10040489&FileExtension=pdf&FileName=N836JC_PilotLogbookExcerpts_Redacted-Rel.pdf - Miscellaneous information - pilot logbook excerpt spreadsheet (item 5, PDF, 1 page, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10077557&FileExtension=pdf&FileName=20pilotlog227-Rel.pdf - Maintenance records - airplane logbook excerpts (item 6, PDF, 3 pages, 512 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10038565&FileExtension=pdf&FileName=N836JCLogs_Redacted-Rel.pdf - Video file (item 7, MP4, 269 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10078223&FileExtension=mp4&FileName=replay-1-20200613133528-20200613135225-Rel.mp4 - Photos (item 8, PDF, 10 pages, 10 photos, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10077388&FileExtension=pdf&FileName=20photo227-Rel.pdf - Maps or charts of accident area (item 9, PDF, 1 page, 5.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10066637&FileExtension=pdf&FileName=N836JC%20Site-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9846578&FileExtension=pdf&FileName=N836JC%20NTSB%20Wreckage%20Release%20Completed%2006%2016%2020_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 11, PDF, 2 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11377468&FileExtension=pdf&FileName=20Party%20Forms227_Redacted-Rel.pdf - Toxicological report - cami 202000088001 (item 12, PDF, 1 page, 285 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10065852&FileExtension=pdf&FileName=2020_088_001%20_Redacted-Rel.pdf 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.