DCA15MA019

NTSB accident investigation · Scaled Composites 339 · Koehn Dry Lake, CA · October 31, 2014

Accident · FatalClass 1 · MajorFinal report
Date
October 31, 2014, 10:07 local (17:07 UTC)
Place
Koehn Dry Lake, CA
Injuries
1 fatal, 1 serious
Damage
Destroyed
Phase of flight
Other
Aircraft
N339SSScaled Composites 339
Defining event
Other: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report August 5, 2015
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
Scaled Composites, Virgin Galactic, Butler Parchute Systems, FAA AVP-100
Safety recommendations
Yes
Case key
90344

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

Scaled Composites' failure to consider and protect against the possibility that a single human error could result in a catastrophic hazard to the SpaceShipTwo vehicle. This failure set the stage for the copilot's premature unlocking of the feather system as a result of time pressure and vibration and loads that he had not recently experienced, which led to uncommanded feather extension and the subsequent aerodynamic overload and in-flight breakup of the vehicle.

Findings · 7

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.

Design: equipment designOrganizational issues › Development · ManufacturerScaled Composites 339: 1 caseAll aircraft: 35 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · CopilotScaled Composites 339: 1 caseAll aircraft: 397 casesProbable cause
Pressures/demands: time/schedule pressureEnvironmental issues › Task environment · Effect on personnelScaled Composites 339: 1 caseAll aircraft: 10 casesProbable cause
Oversight: oversight of reg complianceOrganizational issues › Support/oversight/monitoring · FAA/RegulatorScaled Composites 339: 1 caseAll aircraft: 14 cases
Training: training with equipmentPersonnel issues › Experience/knowledge · Flight crewScaled Composites 339: 1 caseAll aircraft: 32 cases
ResourcesOrganizational issues › Management · ManufacturerScaled Composites 339: 1 caseAll aircraft: 1 case
ResourcesOrganizational issues › Management · Emergency servicesScaled Composites 339: 1 caseAll aircraft: 1 case

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

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aerospace accident report. The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aerospace Accident Report number is NTSB/AAR-15/02. On October 31, 2014, at 1007:32 Pacific daylight time, the SpaceShipTwo (SS2) reusable suborbital rocket, N339SS, operated by Scaled Composites LLC (Scaled), broke up into multiple pieces during a rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. The pilot received serious injuries, and the copilot received fatal injuries. SS2 was destroyed, and no one on the ground was injured as a result of the falling debris. SS2 had been released from its launch vehicle, WhiteKnightTwo (WK2), N348MS, about 13 seconds before the structural breakup. Scaled was operating SS2 under an experimental permit issued by the Federal Aviation Administration's (FAA) Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations (CFR) Part 437.

Factual narrative

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aerospace accident report. The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aerospace Accident Report number is NTSB/AAR-15/02. On October 31, 2014, at 1007:32 Pacific daylight time, the SpaceShipTwo (SS2) reusable suborbital rocket, N339SS, operated by Scaled Composites LLC (Scaled), broke up into multiple pieces during a rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. The pilot received serious injuries, and the copilot received fatal injuries. SS2 was destroyed, and no one on the ground was injured as a result of the falling debris. SS2 had been released from its launch vehicle, WhiteKnightTwo (WK2), N348MS, about 13 seconds before the structural breakup. Scaled was operating SS2 under an experimental permit issued by the Federal Aviation Administration's (FAA) Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations (CFR) Part 437.

Aircraft

Registration
N339SS
Reported as
Scaled Composites 339
Category
Rocket
Serial number
01
Built
2010
Airframe hours
6.07
Engine
Scaled Composites RM2-20A001, 60,000 lbs thrust, hybrid rocket
Damage
Destroyed
Flight
Part 437
Operator
Scaled Composites LLC
Registered owner
Scaled Composites LLC
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · October 1, 2014
Departed
MHV · Mojave, CA
Destination
MHV · Mojave, CA
Flight plan
Company VFR
Equipment
Video recording device, Electronic primary flight display, Electronic multifunction display

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
43
Injuries
Serious
Certificates
Flight instructor, Private, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Seat
Left
Restraint
5-point
Toxicology
Performed
Flight hours
2,980 total · 48 in this make and model · 2,550 as pilot in command · 44 in the last 90 days · 3 in the last 30 days · 0 in the last 24 hours
Role
Co-pilot
Age
39
Injuries
Fatal
Certificates
Airline transport, Commercial, Flight instructor, Private
Airplane ratings
Multi-engine land, Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Right
Restraint
5-point
Toxicology
Performed
Flight hours
2,154 total · 30 in this make and model · 1,964 as pilot in command · 42 in the last 90 days · 20 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm

Docket · 103

The files NTSB released with the investigation on July 28, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 231 MB in all.

Export Control Review of SpaceShip Two Investigation DocumentsItem 1 · .PDF · 264 KBPilot/Operator Aircraft Accident Report, NTSB Form 6120.1Item 2 · .PDF · 2.7 MBStructures Group Chairman Factual ReportItem 3 · .PDF · 864 KBStructures Factual - Attachment 1 - Hinge DrawingItem 4 · .PDF · 40 KBStructures Factual - Attachment 2 - 7050 SpecsItem 5 · .PDF · 309 KBStructures Factual - Appendix A - FiguresItem 6 · .PDF · 9 photos · 4.0 MBMeteorology Group Chairman Factual ReportItem 7 · .PDF · 12.5 MBEdwards Air force Weather EmailItem 8 · .PDF · 36 KBMeteorology - Attachment 1 - SS2 PF04 Flight Weather ForecastItem 9 · .PDF · 227 KBMeteorology - Attachment 2 - Interview of Weather Forecaster for Accident FlightItem 10 · .PDF · 44 KBMeteorology - Attachment 3 - Space Weather Forecast and AnalysisItem 11 · .PDF · 949 KBMeteorology - Attachment 4 - Edwards AFB Range Complex Mission Ex Forecast (MEM)Item 12 · .PDF · 200 KBMeteorology - Attachment 5 - Weather Information Gathered Post Accident by Edwards AFBItem 13 · .PDF · 1.4 MBMeteorology - Attachment 6 - 0200 PDT KEDW Upper Air Sounding Data SetItem 14 · .PDF · 44 KBMeteorology - Attachment 7 - 0500 PDT KEDW Upper Air Sounding Data SetItem 15 · .PDF · 36 KBMeteorology - Attachment 8 - RUC Usage Tool Instructions ManualItem 16 · .PDF · 129 KBVehicle Recovery Group Factual ReportItem 17 · .PDF · 19.1 MBPropulsion Factual ReportItem 18 · .PDF · 15 photos · 3.8 MBExternal Imagery Factual ReportItem 19 · .PDF · 85 photos · 27.0 MBSystems Group Chairman Factual ReportItem 20 · .PDF · 32 photos · 19.3 MBSystems - Attachment 1 - MFD Playback Video Still ImagesItem 21 · .PDF · 3.3 MBComputed Tomography Specialist's Factual ReportItem 22 · .PDF · 6.1 MBSystem Safety Factual ReportItem 23 · .PDF · 492 KBSystem Safety - Attachment 1 - Scaled Composites January 23, 2012 LetterItem 24 · .PDF · 166 KBSystem Safety - Attachment 2 - FAA Letter February 7, 2012Item 25 · .PDF · 838 KBSystem Safety - Attachment 3 - FAA Letter May 23, 2012Item 26 · .PDF · 892 KBSystem Safety - Attachment 4 - Clarification of Hazard AnalysesItem 27 · .PDF · 140 KBSystem Safety - Attachment 5 - Information About HazardsItem 28 · .PDF · 161 KBSystem Safety - Attachment 6 - FAA Letter April 23, 2013Item 29 · .PDF · 162 KBSystem Safety - Attachment 7 - FAA Letter May 22, 2013 and EP12_007R1Item 30 · .PDF · 316 KBSystem Safety - Attachment 8 - FAA Letter to Scaled March 28, 2014Item 31 · .PDF · 175 KBSystem Safety - Attachment 9 - FAA Letter to Scaled May 21, 2014Item 32 · .PDF · 545 KBSystem Safety - Attachment 10 - EP 12-007Item 33 · .PDF · 1.2 MBSystem Safety - Attachment 11 - FAA Letter to Scaled October 14, 2014Item 34 · .PDF · 137 KBSystem Safety - Attachment 12 - Experimental Permit RuleItem 35 · .PDF · 179 KBSystem Safety - Attachment 13 - Experimental Permit ImplementationItem 36 · .PDF · 218 KBSystem Safety - Attachment 14 - Advisory Circular 413-1Item 37 · .PDF · 50 KBSystem Safety - Attachment 15 - Advisory Circular 437.55-1Item 38 · .PDF · 1.0 MBSystem Safety - Attachment 16 - Advisory Circular 23.1309-1DItem 39 · .PDF · 392 KBSystem Safety - Attachment 17 - Human Error Examples in FTAItem 40 · .PDF · 155 KBSystem Safety - Attachment 18 - MethodologyItem 41 · .PDF · 129 KBSystem Safety - Attachment 19 - FHAItem 42 · .PDF · 113 KBSystem Safety - Attachment 20 - FTA 13.02Item 43 · .PDF · 116 KBSystem Safety - Attachment 21 - FTA 13.03Item 44 · .PDF · 102 KBSystem Safety - Attachment 22 - FTA 13.01Item 45 · .PDF · 106 KBSystem Safety - Attachment 23 - WaiverItem 46 · .PDF · 128 KBSystem Safety - Attachment 24 - Scaled Write-up on WaiverItem 47 · .PDF · 189 KBSystem Safety - Attachment 25 - Interview SummariesItem 48 · .PDF · 490 KBSystem Safety - Attachment 26 - AST Response to NTSB Waiver QuestionsItem 49 · .PDF · 483 KBOperations Factual ReportItem 50 · .PDF · 4 photos · 1.7 MBOperations Group Chairman Factual Report Addendum 1 - Proposed SS2 TrainingItem 51 · .PDF · 740 KBOperations Group Chairman Factual Report Addendum 2 - FAA Compliance LettersItem 52 · .PDF · 456 KBOperations Factual - Attachment 1 Interview SummariesItem 53 · .PDF · 1.4 MBOperations Factual - Attachment 2 Interview TranscriptsItem 54 · .PDF · 1.6 MBOperations Factual - Attachment 3 Party FormsItem 55 · .PDF · 3.1 MBOperations Factual - Attachment 4 Control Room StatementsItem 56 · .PDF · 23.6 MBOperations Factual - Attachment 5 IFE Witness StatementsItem 57 · .PDF · 1.1 MBOperations Factual - Attachment 6 Witness StatementsItem 58 · .PDF · 17.8 MBOperations Factual - Attachment 7 Ground Training SyllabusItem 59 · .PDF · 691 KBOperations Factual - Attachment 8 WK2 Training SyllabusItem 60 · .PDF · 3.9 MB
All 103 files on NTSB’s docket