# NTSB ERA12LA455: Burkhart Grob G 103 Twin II, N5448G, Hilltown, PA, July 13, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: July 13, 2012, 15:30 local (19:30 UTC) - Place: Hilltown, PA - Coordinates: 40.328334, -75.241668 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.3283&lon=-75.2417&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Simulated/training event](https://openairdocs.org/ntsb-events/600) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report September 12, 2013 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 84330 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA455 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84330/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84330 - Page: https://openairdocs.org/ntsb/ERA12LA455 ## Probable cause The improper decision of the flight instructor receiving instruction to attempt a course reversal rather than land straight ahead following a simulated low-level rope break, and the inadequate remedial action of the flight instructor-in-command for allowing him to do so. ## 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: [Burkhart Grob G 103 TWIN II, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=1660203), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible; cases with it: [Burkhart Grob G 103 TWIN II, 2 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=1660203), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Burkhart Grob G 103 TWIN II, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=1660203), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Action: incomplete action](https://openairdocs.org/ntsb-findings/02041040): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Burkhart Grob G 103 TWIN II, 1 case](https://openairdocs.org/ntsb-findings/02041040/cases.md?model=1660203), [All aircraft, 105 cases](https://openairdocs.org/ntsb-findings/02041040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Glider tow event](https://openairdocs.org/ntsb-events/510); cases with it: [Burkhart Grob G 103 TWIN II, 2 cases](https://openairdocs.org/ntsb-events/510/sequence.md?model=1660203), [All aircraft, 45 cases](https://openairdocs.org/ntsb-events/510/sequence.md) - [Initial climb: Simulated/training event](https://openairdocs.org/ntsb-events/600) (defining event); cases with it: [Burkhart Grob G 103 TWIN II, 1 case](https://openairdocs.org/ntsb-events/600/sequence.md?model=1660203), [All aircraft, 173 cases](https://openairdocs.org/ntsb-events/600/sequence.md) - [Initial climb: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Burkhart Grob G 103 TWIN II, 1 case](https://openairdocs.org/ntsb-events/060/sequence.md?model=1660203), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Maneuvering: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120); cases with it: [Burkhart Grob G 103 TWIN II, 1 case](https://openairdocs.org/ntsb-events/120/sequence.md?model=1660203), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The flight instructor-in-command was in the rear seat, and the flight instructor receiving instruction was in the front seat for flight instructor winch-launch glider training. The two pilots had flown multiple launches earlier that day, with each flight preceded by a briefing. After practicing recoveries from simulated rope breaks at 400 feet and 10 feet above ground level (agl), the intent for the accident flight was to simulate a rope break at 200 feet agl, which the flight instructor-in-command expected would result in a straight-ahead landing. The ground roll, takeoff, and transition to climb were “normal,” and the flight instructor in command pulled the release lever about 150 feet agl. The flight instructor receiving instruction nosed the glider over, and established a wings-level airspeed of about 54 knots. However, instead of landing straight ahead, the flight instructor receiving instruction turned the glider to the right, then to the left, and attempted to land opposite the direction of takeoff. There was insufficient altitude to complete the maneuver, and the glider impacted trees. The flight instructor-in-command could not remember the latter part of the flight due to head trauma, but the flight instructor receiving instruction stated that the flight instructor in command did not take control of the glider at any time before impact. Neither pilot reported any preexisting mechanical anomalies that would have precluded the glider’s normal operation. ## Factual narrative On July 13, 2012, about 1530 eastern daylight time, a Burkhart Grob G 103 Twin II, N5448G, was substantially damaged when it impacted trees and terrain during a simulated low altitude launch failure after a launch from Philadelphia Gliderport (0PA0), Hilltown, Pennsylvania. The two flight instructors onboard were seriously injured. Visual meteorological conditions prevailed, and no flight plan had been filed for the local instructional flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the flight instructor in command (FIIC), the Philadelphia Glider Council was conducting winch launch training for its glider-rated flight instructors who did not have a ground launch endorsement, and for recently-endorsed instructors to gain additional ground winch teaching experience. Prior to beginning flight operations, a group briefing was conducted for participating personnel, including the launch crew and the flight instructors providing, as well as receiving instruction. The gliderport had multiple turf runways, including runway 7/25, which was 2,450 feet long and 300 feet wide. According to the FIIC, the glider was set up on east end of runway 25, and the winch was set up about 4,000 feet away, on the north side of the runway overrun. The FIIC and the flight instructor under instruction (FIUI) had flown multiple launches previously that day, with the FIUI noting that there were simulated rope breaks on his previous two launches at 400 feet above ground level (agl) and 10 feet agl. Both pilots concurred that the accident flight was briefed as a simulated rope break at 200 feet. According to the FIIC, the simulated rope break was expected to result in a landing straight ahead on the runway. The ground roll, takeoff and transition to full climb were “normal,” and about 150 feet, the FIIC pulled the release to simulate a launch failure. The FIUI executed a “normal” recovery from a full climb to straight and level flight at 100 feet and 52 knots. The glider subsequently turned to the left, which was all the FIIC could recall due to head trauma. According to the FIUI, after the FIIC pulled the release, he executed an “assertive round over” and established an airspeed of 54 knots. At that point, he felt that the glider was “considerably” lower than 200 feet agl. He initiated a right turn for a few seconds, then rolled wings level. He recalled that the FIIC said something to him “about having a plan,” and then, a few seconds later, he made the decision to make a 180-degree left turn to land on runway 7. The glider had insufficient altitude and impacted trees. The FIUI also recalled that the FIIC did not take control of the glider and that the FIUI was operating the flight controls when the glider hit the trees and the ground. Witnesses differed on specifics as to what occurred after the release, with one stating that after the glider achieved a 5-degree nose-down attitude, the dive brakes partially deployed,then retracted. The glider then made a slight right turn, followed by a turn to the left, “which appeared to be a low-level return to the field.” The witness was concerned that the glider was going to stall/spin at 100 feet, but it continued in a left turn, then rolled wings level before impacting trees. Another witness saw that after the glider was released, it continued in level flight for about 10 seconds, during which, it started a “gentle” right turn. It then rolled into a “medium bank turn” to the left, “attempting a 180-degree turn to return to the departure runway, this all occurring approx. 100 feet agl.” From the witness’s position, it was clear to him that the glider was not going to clear trees. During the last seconds, the dive brakes, which had been closed during the earlier part of the flight, opened and closed, and the glider disappeared behind the tree line. One of the witnesses also stated that when the simulated rope break occurred, the glider was low enough to open the dive brakes and land straight ahead. Neither flight instructor reported any preexisting mechanical anomalies that would have precluded the glider’s normal operation. ## Aircraft - Registration: [N5448G](https://openairdocs.org/deregistered/N5448G-2014-01-24), registration cancelled 2014-01-24, S/N 3868-K-109 (OpenAirDocs) - Reported make and model: BURKHART GROB G 103 TWIN II - Registry model: [Burkhart Grob G 103 TWIN II](https://openairdocs.org/model/burkhart-grob-g-103-twin-ii) (registry code 1660203) (OpenAirDocs) - Category: Glider - Serial number: 3868-K-109 - Airframe hours: 3222 - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Philadelphia Glider Council Inc - Registered owner: Philadelphia Glider Council Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 31, 2012, 147 hours before - Departed: 0PA0, Hilltown, PA - Destination: 0PA0, Hilltown, PA - Airport: 0PA0, Philadelphia Gliderport, runway 25, 2,450 × 300 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 65; injuries: serious; commercial, flight instructor; last flight review June 7, 2011; seat: rear; flight hours: 1,600 total, 249 in this make and model, 1,587 as pilot in command, 12 in the last 90 days, 4 in the last 30 days, 1 in the last 24 hours - Student pilot; age 67; injuries: serious; flight instructor, flight engineer, commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review October 13, 2012; seat: front; flight hours: 15,990 total, 390 in this make and model, 8,900 as pilot in command, 6 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 260° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 61 °F - Altimeter: 30.18 inHg - Observed at: DYL, 5 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 20120713018679A](https://openairdocs.org/incident/20120713018679A), Jul 13, 2012: Burkhart Grob G 103 TWIN II, Perkasie, PA, Destroyed. On 7/13/2012 (1530 local) a glider, grobe 103 (N5448G) crashed at Philadelphia Glider Council (0PA0) shortly after take off. This was a training flight. They… ## Other investigations on N5448G (1) 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. - [NTSB ATL98LA079](https://openairdocs.org/ntsb/ATL98LA079), May 24, 1998: Burkhart Grob G-103 (N5448G), Cordele, GA, substantial damage. Probable cause: The pilot's improper descent rate that led to a hard landing and porpoise, and his improper recovery from the ensuing bounced landing, resulting in the eventual separation of the empennage. A factor… ## Docket (3 files) The files NTSB released with the investigation on August 5, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84330. 1.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 - Submitted by Pilot A (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392381&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20-%20Submitted%20by%20Pilot%20A-Redacted.PDF - Pilot B Statement (item 2, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392382&FileExtension=.PDF&FileName=Pilot%20B%20Statement-Redacted.PDF - Witness Statements (item 3, .PDF, 163 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40392383&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.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.