# NTSB CHI96FA211: McDonnell Douglas F/A-18C, N16518, Bethalto, IL, June 19, 1996 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 19, 1996, 14:48 local (19:48 UTC) - Place: Bethalto, IL - Coordinates: 38.899635, -90.04039 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.8996&lon=-90.0404&mi=10 - Phase of flight: [Other](https://openairdocs.org/ntsb-phases/800) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 16, 1997 - Report: Approved by Office Director - NTSB case key (mKey): 10092 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI96FA211 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10092/pdf - Page: https://openairdocs.org/ntsb/CHI96FA211 ## Probable cause the pilot's failure to follow the preflight crew briefing and attain a proper altitude during an aerobatic maneuver. Factors in the accident were: the pilot's previous experience of flying similar airshow routines in a different airplane with substantially different performance characteristics, and the company's failure to have a formal training plan for pilots performing airshow demonstration flights. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, other - aerobatics - performed, pilot in command - crew/group briefing - not followed, pilot in command (cause) - proper altitude - not attained, pilot in command (cause) - qualification, pilot in command (contributing factor) - insufficient standards/requirements, company/operator mgmt (contributing factor) - bail-out/emergency ejection - not performed, pilot in command ## Analysis A McDonnell Douglas Aerospace (MDA) pilot was flying a leased Navy F/A-18C and conducting an airshow practice at St. Louis Regional Airport when the airplane impacted the ground at the bottom of a reverse one-half Cuban eight aerobatic maneuver. The briefed altitude at the top of the maneuver was to be 3,500 feet above ground level (agl), which gave the pilot a base line of 1,000 feet agl. Recorded data showed that the actual altitude at the top of the maneuver was 2,280 feet agl. Using a group of F/A-18 pilots in a F/A-18 simulator, the lowest altitude at the top of the reverse one-half Cuban eight required to successfully complete the maneuver was 2,500 feet agl. The pilot had been trained as a Naval Aviator, and was a graduate of the Navy's test pilot school. He joined MDA Flight Operations 3/4/96. The pilot had accrued 16 hours in the F/A-18 in the last year, of which 11 hours were in the last 90 days. MDA did not have a formal training plan for their pilots who perform airshow demonstration flights. The pilot had flown 5 civilian airshows within the last year; the most recent was 11 days prior to the accident. All the airshows were flown in a Pitts Special. ## Factual narrative HISTORY OF FLIGHT On June 19, 1996, at 1448 central daylight time (cdt), a Department of the Navy F/A-18C, Buno Number 165189, leased and operated by McDonnell Douglas Aerospace (MDA), was destroyed after it impacted the terrain while performing a reverse one-half Cuban eight maneuver during a practice airshow at the St. Louis Regional Airport, Alton, Illinois. The commercial pilot sustained fatal injuries. The local 14 CFR Part 91 flight was operating in visual meteorological conditions. No flight plan was on file. The practice airshow flight departed St. Louis Regional Airport, Alton, Illinois, at 1447 cdt. On the morning of the accident, the airplane preflight was initiated by the launching Quality Assurance (QA) inspector. Another QA inspector began to preflight the cockpit and the ejection seat. This inspector was called away to perform a final go/no-go inspection on another airplane that was ready to depart. This inspector stated that while at the other airplane, he received a call, from another McDonnell Douglas inspector, inquiring if he had finished his portion of the preflight. He replied that he still needed to run the seat up and inspect the cockpit lights. By the time this inspector returned to the airplane the pilot had already pulled the ejection seat and canopy pins. The pilot had given the pins to the ground crew to be stored in the 14L door for use upon landing at the St. Louis Regional Airport, if needed. The inspector stated this was not normal procedure and that the pilot should have waited for his return. This procedure is enclosed with the report under the Maintenance Group Chairman's item 14, Aircraft Flight and Inspection Release Form. The preflight was completed and the airplane was taxied to the runway where the go/no-go inspection was performed. The accident occurred during the second demonstration flight for the pilot on June 19, 1996. The first flight on June 19, 1996, was a functional check flight followed by a high altitude practice airshow sequence while en route from the McDonnell Douglas plant (Lambert International Airport, Bridgton, Missouri) to the St. Louis Regional Airport. The airplane departed Lambert Field at 1318 cdt and proceeded to a test area north of St. Louis where the pilot performed some routine inflight systems checks due to recently completed maintenance on the airplane. After performing a partial practice airshow sequence north of Alton, Illinois, the airplane arrived at the St. Louis Regional Airport. The tower cleared the airplane from 500 feet above ground level (agl) to 8,000 feet agl with a 3 mile radius around show center (approximately the center of the airport). The pilot then entered at 1,000 foot agl baseline into the practice airshow routine. The airshow routine, established by MDA in 1993, included the following sequence of events: Takeoff, gear down roll, slow loop, reverse one-half Cuban eight, high speed roll, inverted pass, roll over break, maximum g turn, immelmann, high AOA turn, high AOA pass, high AOA roll, minimum radius 180 degree turn, square loop, barrel roll, and landing. While nearing the top of a loop, the pilot broke off the maneuver because of a cloud that moved over the airport. After a few minutes, the remainder of the practice airshow routine was completed and the airplane landed at 1350 cdt. The airplane was refueled with 6,600 pounds of Jet A. The pilot had invited his family and some friends to watch his practice airshow demonstration and some were in attendance at St. Louis Regional Airport. The pilot met with family and friends both before and after his debrief/brief with the MDA Chief Test Pilot. The second practice flight departed the St. Louis Regional Airport at 1447 cdt. The routine began with a maximum afterburner takeoff, followed by a dirty roll (landing gear extended). After the aircraft completed the roll, the landing gear was retracted and a slow loop was executed. The slow loop was followed by entry to a reverse one-half Cuban eight. The airplane was observed to be low by the Chief Test Pilot who was acting as a safety observer on the St. Louis Regional Airport Air Traffic Control Tower catwalk. He called abort on a hand held radio to the pilot. The transmission of the abort was not acknowledged by the pilot. He did see that the airplane had a positive AOA before impact. Videotape of the accident indicates the airplane impacted the ground at the bottom of the reverse one-half Cuban eight. The time of the impact was approximately 1448 cdt. OTHER DAMAGE Multiple trees, one telephone pole, and a residential garage were damaged during impact sequence. PERSONNEL INFORMATION The pilot was born May 22, 1952. He was the holder of a commercial certificate with single/multi engine land and instrument ratings. The pilot also held a acrobatic competency certificate level two issued on May 20, 1996, with an altitude limitation to 250 feet agl. The acrobatic certificate included the following airplanes; Beech D17S, Beech BE-33C, and a Pitts Special. He held a second class medical issued on June 13, 1996. His most recent biennial flight review was on March 26, 1996. He had accumulated a total of 6,218 hours of flight time. The pilot was trained as a United States Naval Aviator and qualified in the F/A-18. During his military flying career he accumulated approximately 2,255 hours in the F/A-18 airplane prior to coming to MDA Flight Operations in March of 1996. The pilot was also a graduate of the Naval Test Pilot School, located at Naval Air Test Center, Patuxent River, Maryland. The pilot had the following 30/60/90 day flight hour totals in the F/A-18: 3.0/3.9/10.7 hours. The pilot had the following 30/60/90 day simulator hour totals in the F/A-18: 9/27/37 hours. AIRCRAFT INFORMATION The airplane was a McDonnell Douglas F/A-18C, serial number 165189. The airplane had accumulated 20.8 hours time in service at the time of the accident. The engines had 26 hours total hours in service. The most recent continuous inspection was conducted on June 19, 1996. FLIGHT RECORDERS The Deployable Flight Incident Recorder Set (DFIRS) was salvaged from the wreckage. The data was printed out and down loaded prior to NTSB involvement with the accident investigation. The data was loaded into the recovery analysis and presentation system (RAPS) program for visual display of the data collected. In addition, a visual 8MM tape of the right Digital Display Indicator (DDI) showed the Flight Control System (FCS) status display selected with no warnings displayed prior to impact with the terrain. The left 8MM tape was destroyed by the post-crash fire. The DFIRS data was broken down into the four parts of the reverse one-half Cuban eight; Pull-up 180 degree roll Top Bottom 1. Airspeed (knots) 236 176 180 144 2. Baro Alt (ft agl) 1212 1192 2008 472 3. Radar Alt (ft agl) 576 1408 invalid 0 4. AOA (degrees) 25.2 14 12.6 40.6 5. Pitch (degrees) 16.8 58.8 -7.0 22.4 6. Power Lever Angles Left/Right (degrees) 128.1/127.4 full after burner position though out the complete maneuver. The briefed target parameters were; Pull-up 180 degree roll Top Back side 1. Airspeed (knots) 260-280 280-200 200-230 250-270 2. Baro Alt (ft agl) 700-800 2700min 3500min 2000min 3. Radar Alt (ft agl) 700-800 Invalid Invalid Invalid 4. AOA (degrees) 25max 20 0-10 25max 5. Pitch (degrees) 50-55 50-55 0 -90 6. Power Lever Angles Left/right (degrees) 90-102/90-102 Military power position (maximum power needed without afterburner at low airplane weights) See four graphs enclosed with this report. At impact th ## Aircraft - Registration: N16518 (not matched to a registry record) - Reported make and model: McDonnell Douglas F/A-18C - Category: Airplane - Serial number: 165189 - Airframe hours: 21 - Engines: GE F404-GE-402 18000 lbs thrust turbo fan - Damage: Destroyed - Fire: On-Ground - Flight: Part 91 - Operator: Mcdonnell Douglas Aerospace - Registered owner: Department Of The Navy, Nasc - Last inspection: Continuous airworthiness, June 19, 1996, 21 hours before - Departed: ALN - Destination: ALN - Flight plan: Company VFR - Airport: ALN, St Louis Regional, runway 29, 8,101 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; military, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; seat: front; toxicology performed; flight hours: 6,218 total, 2,255 in this make and model, 6,218 as pilot in command, 60 in the last 90 days, 25 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 6 knots - Visibility: 15 statute miles - Lowest ceiling: 15,000 ft broken - Temperature: 90 °F, dew point 72 °F - Altimeter: 29.00 inHg - Observed at: ALN, 1 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 19960619019979A](https://openairdocs.org/incident/19960619019979A), Jun 19, 1996: Piper PA28235, Bethalto, IL, Destroyed, 1 fatal. (.19) Onjune 19, 1996, at 1448 central daylight time (CDT), a department of the navy F/A-18C, buno number 165189, leased back and operated by Mcdonnell… 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.