# NTSB CEN22FA416: Pipistrel Italia S R L Sinus 912 LSA, N397R, Waller, TX, September 12, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: September 12, 2022, 14:18 local (19:18 UTC) - Place: Waller, TX - Coordinates: 30.19326, -95.96079 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.1933&lon=-95.9608&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern base: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO, ICAO Notification - NTSB case key (mKey): 105916 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22FA416 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105916/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105916 - Page: https://openairdocs.org/ntsb/CEN22FA416 ## Probable cause The pilot’s failure to maintain aircraft control, which led to an aerodynamic stall at an altitude where recovery was not possible. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Pipistrel Italia S R L SINUS 912 LSA, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=06001B6), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Pipistrel Italia S R L SINUS 912 LSA, 2 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=06001B6), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Pipistrel Italia S R L SINUS 912 LSA, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=06001B6), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern base: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Pipistrel Italia S R L SINUS 912 LSA, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=06001B6), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis After an uneventful flight, the powered glider approached the grass airstrip to land. The passenger stated that the altitude seemed to be low during the approach. He stated that as the pilot started to turn the glider, the passenger felt that they were not going to land safely, and yelled to the pilot, “we are not going to make this.” The powered glider dropped down and seemed to stall. The passenger heard the engine rev up, and the powered glider collided with the ground. Examination of the accident site showed evidence of a low-energy impact, consistent with a low-altitude stall. Examination of the airframe and flight controls did not reveal any mechanical anomalies that would have precluded normal operations. Physical examination of the engine and downloaded engine data were consistent with normal engine operation. Cannabis was detected in the toxicology testing of the pilot; however, since no THC or active THC metabolite was detected, it is unlikely that the pilot’s use of cannabis was recent enough to have contributed to the accident. The autopsy on the pilot revealed moderate to severe atherosclerosis of the pilot’s cerebral arteries, coronary arteries, and aorta, as well as chronic kidney and lung conditions. It could not be determined whether these conditions contributed to the accident. The passenger did not report any indications that the pilot was impaired or incapacitated. Based on all available evidence, it is likely that the pilot attempted to extend the glide to the runway during the base turn to final, which resulted in an aerodynamic stall. ## Factual narrative The powered glider was an all-composite, high-wing monoplane with cantilevered wings, T-tail empennage, and fixed tricycle landing gear configuration. The nose landing gear was integrated into the engine mount and was steerable, connected to the pedals, and incorporated an oil-spring shock-absorber element. The load bearing structure of the glider was made of carbon fiber composite material. The cabin seating configuration was side by side and the aircraft could be flown as a glider or powered glider. A Dynon Skyview SV-HDX1100 display unit was removed from the wreckage. The display appeared to be undamaged and intact. The unit was sent to the National Transportation Safety Board laboratory for engine data evaluation. The downloaded data was consistent with normal engine operation. The data also was consistent with the surviving passenger’s statement of the the engine revving just before impact. On September 12, 2022, about 1418 central daylight time, a Pipistrel Sinus 912 LSA powered glider, N397R, sustained substantial damage when it was involved in an accident near Waller, Texas. The pilot sustained fatal injuries and the passenger sustained serious injuries. The glider was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the surviving passenger, the flight originated from David Wayne Hooks Airport (DWH), about 1356, with an intent to return to its home base at the Soaring Club of Houston (SCOH) glider port (89TA), Waller, Texas. The en route portion of the flight from DWH to 89TA was uneventful. He stated that they approached 89TA from the east at a perpendicular angle and the approach seemed inconsistent with what he had expected based on previous flights. He stated that the altitude seemed to be low, considering the trees at the approach end of the airstrip. As the pilot started to turn, the passenger felt that they were not going to land safely and yelled, “we are not going to make this.” The glider dropped down and seemed to stall. The passenger heard the engine rev up, and the powered glider collided with the ground. A resident of SCOH was standing outside and saw the glider approach from the east. She stated that the position of the glider was consistent with flying the right downwind leg to land on runway 35. She stated that the glider “looked and sounded normal,” but she did not see the accident. An autopsy of the pilot was conducted at the Harris County Institute of Forensic Sciences, Houston, Texas. According to the report, the pilot’s cause of death was blunt force injuries. The autopsy also revealed moderate to severe atherosclerosis of the pilot’s cerebral arteries, coronary arteries (including small branches into the heart), and aorta, as well as chronic kidney and lung conditions. Toxicological testing of the pilot was performed at the Federal Aviation Administration Forensic Sciences Laboratory. Oklahoma City, Oklahoma. The testing detected citalopram in liver tissue and at 1,040 ng/mLin heart blood. The citalopram metabolite n-desmethylcitalopram was detected in liver tissue and at 148 ng/mL in heart blood. Carboxy-delta-9-THC was detected at 1.8 ng/mL in heart blood and 4 ng/mL in lung tissue. Pilot logbooks were not available for review. The pilot’s estimated flight time was provided verbally by a family member. Examination of the wreckage at the accident site showed the glider impacted the ground in a left-wing-down, nose-low attitude. The wreckage debris was scattered about 75 ft from the initial impact point. The front portion of the fuselage was mostly destroyed from impact forces. The empennage was partially broken away from the main body, but still attached by sheet metal and flight control cables. The cabin section was mostly destroyed from impact forces. All the flight control cables and rods had continuity from the cockpit to their respective flight control surfaces. All interruptions in the flight controls were consistent with damage by impact forces. The flight controls had several bends and fractures (overload) throughout the system. All connections were accounted for and secure. All hardware securing the cockpit engine controls to the engine were found secure. The cockpit throttle control was in the full power position. The throttle valve on the fuel control unit on the engine was found in the full throttle position. Fuel was found in the fuel distribution lines. The engine was rotated by hand and continuity from the propeller flange to the rear on the engine was established. No preimpact engine anomalies were found. The propeller flange was broken and exhibited torsional twisting No preimpact anomalies were found with the flight controls, airframe, or engine during the on-scene examinations. ## Aircraft - Registration: [N397R](https://openairdocs.org/aircraft/N397R), registered now, S/N 1057 SFNM 912 LSA, built 2021 (OpenAirDocs) - Reported make and model: PIPISTREL ITALIA S R L SINUS 912 LSA - Registry model: [Pipistrel Italia S R L SINUS 912 LSA](https://openairdocs.org/model/pipistrel-italia-s-r-l-sinus-912-lsa) (registry code 06001B6) (OpenAirDocs) - Registry engine: [Rotax 912UL2](https://openairdocs.org/engine/rotax-912ul2) (registry code 55574, 4 cycle) (OpenAirDocs) - Category: Glider - Serial number: 1057 SFNM 912 LSA - Year built: 2021 - Airframe hours: 54 - Engines: Rotax 912-UL2-1 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental light sport (Special) - Last inspection: Continuous airworthiness, April 28, 2022, 50 hours before - Departed: DWH, Houston, TX - Destination: Same as departure - Flight plan: VFR - Airport: 89TA, Soaring Club of Houston Gliderport - Equipment: ADS-B, Airframe parachute, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: fatal; commercial; airplane ratings: single-engine land; seat: left; restraint: 4-point; toxicology performed; flight hours: 200 total, 50 in this make and model, 15 in the last 90 days, 5 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 350° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 63 °F - Altimeter: 30.02 inHg - Observed at: K11R, 21 nm away - METAR: K11R 121915Z AUTO 35008KT 10SM CLR 32/17 A3002 RMK AO2 T03150168 ## 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 20220912016729A](https://openairdocs.org/incident/20220912016729A), Sep 12, 2022: Pipistrel Italia S R L SINUS 912 LSA, Waller, TX, Destroyed, 1 fatal. On 9/12/2022, at around 2:17PM CST acft [privacy data omitted] while inbound to the Soaring Club of Houston glideport (89TA) crashed about 1/4 mile due east… ## Docket (12 files) The files NTSB released with the investigation on August 21, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105916. 36.4 MB in all. - Surviving passenger statement CEN22FA416 (item 1, PDF, 1 page, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17288251&FileExtension=pdf&FileName=Surviving%20Passenger%20Statement%20CEN22FA416_Redacted-Rel.pdf - Surviving passenger drawing of accident site CEN22FA416 (item 2, PDF, 1 page, 18.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17287796&FileExtension=pdf&FileName=Surviving%20Passenger%20Drawing%20of%20Accident%20Site%20CEN22FA416_Redacted-Rel.pdf - Witness statement CEN22FA416 (item 3, PDF, 1 page, 5.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17288003&FileExtension=pdf&FileName=Witness%20Statement%20CEN22FA416_Redacted-Rel.pdf - Memorandum for the record accident site and aircraft exam CEN22FA416 (item 4, PDF, 2 pages, 549 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17288232&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Accident%20Site%20and%20Aircraft%20Exam%20CEN22FA416-Rel.pdf - Approximate flight track CEN22FA416 (item 5, PDF, 1 page, 583 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17287766&FileExtension=pdf&FileName=Approximate%20Flight%20Track%20CEN22FA416-Rel.pdf - N397R csv data table CEN22FA416 (item 6, XLSX, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17287955&FileExtension=xlsx&FileName=N397R%20CSV%20Data%20Table%20CEN22FA416-Rel.xlsx - Dynon cockpit display factual report CEN22FA416 (item 7, PDF, 14 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17287965&FileExtension=pdf&FileName=Dynon%20Cockpit%20Display%20Factual%20Report%20CEN22FA416-Rel.pdf - Cockpit display factual report attachment 1 data table CEN22FA416 (item 8, CSV, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17287901&FileExtension=csv&FileName=Cockpit%20Display%20Factual%20Report%20Attachment%201%20Data%20Table%20CEN22FA416-Rel.csv - Medical factual memorandum for record (item 9, PDF, 5 pages, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16619425&FileExtension=pdf&FileName=CEN22FA416shortformmedicalfactualmemo-Rel.pdf - Pilot toxicology report CEN22FA416 (item 10, PDF, 1 page, 613 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17288396&FileExtension=pdf&FileName=Pilot%20Toxicology%20Report%20CEN22FA416_Redacted-Rel.pdf - Memorandum for the record pilot flight time information CEN22FA416 (item 11, PDF, 1 page, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17469333&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Pilot%20Flight%20Time%20Information%20CEN22FA416_Redacted-Rel.pdf - Investigative photos CEN22FA416 (item 12, PDF, 3 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17524320&FileExtension=pdf&FileName=Investigative%20Photos%20CEN22FA416-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.