# NTSB DEN07FA136: Zlin Aviation s.r.o. Savage, N808GS, Mosquero, NM, August 15, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 15, 2007, 09:53 local (15:53 UTC) - Place: Mosquero, NM - Coordinates: 35.768054, -103.984169 - Nearby events: https://openairdocs.org/map.md?lat=35.7681&lon=-103.9842&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 30, 2008 - Report: Approved by Office Director - Parties: Rotax Flying & Safety Club, Savage Aircraft Sales, FAA Flight Standards District Office - NTSB case key (mKey): 66444 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=DEN07FA136 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/66444/pdf - Page: https://openairdocs.org/ntsb/DEN07FA136 ## Probable cause The pilot's failure to maintain airspeed while maneuvering, resulting in an aerodynamic stall. Contributing to the accident was the conflicting airspeed information provided by the manufacturer, the incorrect airspeed indicator markings, and the high density altitude. ## Analysis According to GPS data the airplane was making a 360 degree turn to the left at an altitude of 350 feet agl. GPS altitude data depicted an immediate descent at a rate of 2,200 to 3,300 feet per minute, at a ground speed of 59 miles per hour. Examination of the wreckage revealed impact damage signatures on the fuselage, engine cowling, and wings consistent with a stall. No evidence of preimpact mechanical anomalies was discovered. The investigation revealed discrepancies between the airspeed indicator and the airspeed guidance provided in the airplane flight manual. In addition, rate of climb data and the effects of nonstandard atmospheric pressure and nonstandard temperature on performance were not presented in the flight manual. This additional information is not specified by the current ASTM consensus standards. Density altitude, at the accident site, was between 7,450 and 8,360 feet. ## Factual narrative This report was modified on May, 13, 2008. HISTORY OF FLIGHT On August 15, 2007, at 0953 mountain daylight time, a Zlin Aviation s.r.o. Savage special light sport airplane (S-LSA), N808GS, owned and piloted by a private pilot, was substantially damaged when it impacted terrain 3 miles northwest of Mosquero, New Mexico. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91 without a flight plan. The private pilot and passenger were fatally injured. The local flight departed Bell Ranch Airport, Bell Ranch, New Mexico at 0930. According to Global Positioning System (GPS) data recovered from the airplane, the airplane departed Bell Ranch Airport at 0930:55 and flew northeast into rugged terrain located between Bell Ranch Airport and Mosquero. At 0935:20 the airplane executed two right-hand 360 degree turn maneuvers while flying between 5,700 to 6,050 feet GPS altitude. The airplane then flew approximately 2 miles to the northeast to a position adjacent to County Road J-1 and executed eight to nine alternating left and right hand 360 degree turns while flying between approximately 5,750 to 5,850 feet GPS altitude (about 200 to 500 feet agl). The airplane flew a short zigzag course to the west crossing two ridges before turning southwest and flying down a valley in the direction of Bell Ranch Airport. At approximately 0951, the airplane turned to the north and flew up a valley for approximately 2.7 miles. At approximately 0953, the airplane executed one left 360 degree turn while flying at approximately 350 feet agl. At 0953:23, the airplane began to descend rapidly - accelerating from negative 2,200 to negative 3,300 feet per minute based on GPS altitude data. The last GPS position location fix was recorded at 0953:28 and placed the airplane at 35 degrees 46.102 minutes north and 103 degrees 59.656 minutes west at a GPS altitude of 5,482 feet (about 137 feet agl). The last calculated groundspeed and course of the airplane was 59 mph and 353 degrees true. According to the Bell Ranch manager, the pilot and his passenger were surveying the ranch in order to find an ideal location for a new road. When the flight did not return to the ranch airport, a search was initiated. An aerial search located the airplane approximately 1800. PERSONNEL INFORMATION The pilot, age 57, held a private pilot certificate with an airplane single-engine land and instrument rating, last issued on March 10, 2006. He was issued a third class airman medical certificate on August 7, 2007. The certificate contained the limitation "must have available glasses for near vision." At the time of application, the pilot estimated his flight experience as 3,900 hours total time; 90 hours of which was logged in the previous 6 months. The family provided the National Transportation Safety Board (Safety Board) Investigator-In-Charge (IIC) excerpt copies of the pilot's flight logbook. A review of the logbook indicated that the pilot had logged 3,400 hours total time. He had logged no less than 5 hours in the Savage. According to the family, the pilot successfully completed the requirements of a flight review at Flight Safety International, in Texas, in December of 2006. According to the pilot's logbook, he had performed a checkout in the accident airplane on August 10, 2007. The flight check lasted for 1 hour and included 3 landings. According to the flight instructor who performed the checkout, the accident pilot was an excellent pilot. He stated that they spent time performing stalls and touch-and-go landings to a full stop. He stated that during the ground school they reviewed weight and balance and the flight manual. He was impressed with the pilot's knowledge of the flight manual materials. The flight instructor stated that upon completion of the checkout, he had no doubt in his mind that the accident pilot was a safe pilot. AIRCRAFT INFORMATION The accident airplane was a Zlin Aviation s.r.o. Savage S-LSA (serial number 0073) manufactured in 2005 in the Czech Republic. It was registered with the Federal Aviation Administration (FAA) on a special airworthiness certificate for light sport operations in November of 2005. A ROTAX 912 ULS engine, rated at 100 horsepower at 5,500 rpm, powered the airplane. The engine was equipped with a 2-blade, Tonini GT 130 wooden-composite propeller. On November 12, 2005, the FAA issued "Light-Sport Category Aircraft Operating Limitations" on the accident airplane. These limitations stated the following in part: "(13) Aircraft instruments and equipment installed and used under Part 91.205 must be inspected and maintained in accordance with the requirements of Part 91. Any maintenance or inspections of this equipment must be recorded in the aircraft maintenance records. (14) No person will operate this aircraft unless within the preceding 12 calendar months it has had a condition inspection performed in accordance with the manufacturer's maintenance and inspection procedures, and was found to be in a condition for safe operation. As part of the condition inspection, cockpit instruments must be appropriately marked and needed placards installed in accordance with Part 91.9. This inspection will be recorded in the aircraft maintenance records." The airplane was registered to a private individual and operated by the pilot. According to the pilot's family, he had just purchased the airplane on August 8, 2007. The family provided the Safety Board IIC with a copy of the maintenance records they had received with the airplane. The last maintenance performed on the airplane took place on July 10, 2007, at an airframe total time of 28.1 hours. The records indicated a heat shroud had been installed in accordance with the manufacturers' specifications. Aside from a brake installation in November of 2006 and the initial airplane assembly upon its arrival in the United States, there was no record of an annual condition inspection or 6 month, 12 month, or 18 month inspections as required by the manufacturer in the maintenance manual. The previous owner purchased the airplane new in November of 2005. He stated that one condition inspection was conducted while he owned the airplane. This inspection was conducted at Aero Engines of Winchester, Inc., in Winchester, Virginia. He stated that he had received a piece of paper documenting this inspection, but had not "attached" it to the maintenance manual. Aircraft Maintenance Each S-LSA is required to have a condition inspection each year in accordance with inspection procedures developed by the aircraft manufacturer, (FAR 91.327, (b), (2)). According to the American Society for Testing and Materials (ASTM) F 2483 - 05, 3.1.1 the aircraft manufacture must specify, in the airplane's required maintenance manual, the inspection procedures to be followed to perform a 100-hour inspection and an annual condition inspection. According to the "Savage ROTAX 912S" Maintenance Manual, Section 9, the "schedule of inspection periods" included the following: every 50 hours or 6 months; every 100 hours or 12 months; every 200 hours or 18 months; every 600 hours and every 1,200 hours. METEOROLOGICAL INFORMATION The closest official weather observation station was Tucumcari Municipal Airport (TCC), Tucumcari, New Mexico, located 46 nautical miles (nm) southeast of the accident site. The elevation of the weather observation station was 4,065 feet mean sea level (msl). The routine aviation weather report (METAR) for TCC, issued at 0953, reported winds, 220 degrees at 16 knots, gusting to 24 knots; visibility, 10 miles; sky condition, clear; temperature 31 degrees Celsius (C); dewpoint, 11 degrees C; altimeter, 30.07 inches. The routine aviation weather report (METAR) for Las Vegas Municipal Airport (LVS), Las Vegas, New Mexico, located 45 nm east of the accident s ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, maneuvering - airspeed(vs) - not maintained, pilot in command (cause) - stall - inadvertent, pilot in command (cause) - weather condition - high density altitude (contributing factor) - flight/nav instruments,airspeed indicator - incorrect (contributing factor) - flight manuals - conflicting, manufacturer (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Aircraft - Registration: [N808GS](https://openairdocs.org/deregistered/N808GS-2017-06-01), registration cancelled 2017-06-01, S/N 0073, built 2005 (OpenAirDocs) - Reported make and model: Zlin Aviation s.r.o. Savage - Registry model: [Zlin Aviation Sro SAVAGE](https://openairdocs.org/model/zlin-aviation-sro-savage) (registry code 0600003) (OpenAirDocs) - Registry engine: [Rotax SEE BOMBADIER](https://openairdocs.org/engine/rotax-see-bombadier) (registry code 55555, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 0073 - Airframe hours: 60.5 - Engines: Rotax 912 ULS 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Special light-sport (Special) - Last inspection: July 1, 2007, 32.4 hours before - Departed: PVT, Bell Ranch Apt, NM - Destination: PVT, Bell Ranch Apt, NM ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review December 1, 2006; seat: front; toxicology performed; flight hours: 3,400 total, 5 in this make and model, 50 in the last 90 days, 28 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 16 knots, gusting 24 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 88 °F, dew point 52 °F - Altimeter: 30.06 inHg - Observed at: TCC, 46 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 20070815023399A](https://openairdocs.org/incident/20070815023399A), Aug 15, 2007: Zlin SAVAGE, Mosquero, NM, Destroyed, 2 fatal. (-23) On August 15, 2007, at approximately 1000 local time, N808GS, Zlin model Savage single engine special light sport aircraft, serial number 0073 collided… 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.