ERA13LA229

NTSB accident investigation · Schweizer SGS 2-33A · Erwinna, PA · May 4, 2013

Accident · Serious injuriesLimited investigationFinal report
Date
May 4, 2013, 10:50 local (14:50 UTC)
Place
Erwinna, PA
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2045TSchweizer SGS 2-33A
Defining event
Initial climb: Flight control sys malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report April 23, 2014
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20130504007869A
Case key
86821

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

The pilot’s loss of glider control due to improper rigging of the rudder control cables, the mechanic’s inadequate flight control checks following the glider’s most recent annual inspection, and the pilot’s failure to perform a thorough preflight inspection.

Findings · 5

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelSchweizer SGS 2-33A: 1 caseAll aircraft: 371 casesProbable cause
Flight control system: rudder control systemAircraft › Aircraft systems · Incorrect service/maintenanceSchweizer SGS 2-33A: 1 caseAll aircraft: 93 casesProbable cause
Inspection: preflight inspectionPersonnel issues › Task performance · PilotSchweizer SGS 2-33A: 1 caseAll aircraft: 551 casesProbable cause
Inspection: scheduled/routine inspectionPersonnel issues › Task performance · Maintenance personnelSchweizer SGS 2-33A: 1 caseAll aircraft: 167 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleSchweizer SGS 2-33A: 2 casesAll aircraft: 1,269 casesProbable cause

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

The glider pilot intended to practice stalls after being towed to an altitude of 3,000 feet mean sea level. Shortly after takeoff, the tow pilot observed the glider yaw left, then right, and then left again. He added that, for most of the tow, the glider appeared to be above the normal tow position with its nose pointed 45 degrees right. About 400 feet above ground level, the glider pilot released the tow line, and the glider turned about 180 degrees left; its right wing then impacted trees, and the glider pitched down and impacted terrain. Postaccident examination of the wreckage revealed that the rudder control cables were rigged backward. The accident flight was the first flight following the glider's most recent annual inspection. Before the annual inspection, the rudder had been removed for repair then re-installed. The mechanic who conducted a flight control check after the annual inspection with assistance from another pilot seated in the cockpit stated that he confirmed movement of the rudder while at the rear of the glider; however, he did not see which pedal the pilot was pushing and did not verbally confirm the corresponding position of the rudder pedals. If the pilot had conducted a thorough preflight inspection, he should have been able to detect that the rudder control cables were rigged backward.

Factual narrative

On May 4, 2013, about 1050 eastern daylight time, a Schweizer SGS 2-33A glider, N2045T, registered to and operated by the Civil Air Patrol (CAP), was substantially damaged when it impacted trees and terrain, near Erwinna, Pennsylvania. The commercial pilot was seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed. The maintenance test flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight originated from Vansant Airport (9N1), Erwinna, Pennsylvania about 1045. The pilot was critically injured and was unable to provide any information about the accident. According to the tow plane pilot, the glider pilot intended to practice stalls after being towed to an altitude of 3,000 feet mean sea level. After takeoff from runway 07, the tow plane pilot observed the glider yaw to the left, then right, and left again. For most of the flight, the glider appeared to be above the normal tow position with its nose pointed 45 degrees to the right. Approximately 400 feet above ground level, the glider pilot released the tow line and made a left turn. The tow plane pilot observed the glider turn about 180 degrees, where it impacted trees with its right wing, pitched down, and impacted terrain. Postaccident examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the rudder controls were rigged backwards. According to FAA records, the pilot held a commercial pilot and flight instructor certificates, with ratings for airplane single-engine land, instrument airplane, and glider. His most recent FAA second class medical certificate was issued on August 30, 2011. As of April 15, 2013, the pilot reported 13,290 total hours of flight experience; of which, 8,960 of those hours were in gliders. The two-seat glider was manufactured in 1977. Review of the glider's logbooks revealed that its most recent annual inspection was completed on May 1, 2013. At the time of inspection, the glider had accumulated 13,626 total hours. According to the mechanic, who performed the annual inspection, the glider was scheduled for a total restoration in the fall of 2012. Due to lack of funding the restoration never took place and the disassembled glider sat on a trailer through the winter. During the spring of 2013, the glider was reassembled and an annual inspection was performed. The rudder had been removed at an earlier date due to previous damage, repaired, and re-installed prior to the annual inspection. The flight was the first flight following the most recent annual inspection. A mechanic performed a flight control check after the annual inspection. According to the mechanic, he stood at the rear of the glider and held the rudder while another pilot sat in the cockpit and moved the pedals. The mechanic could not see which pedal the pilot was pushing and did not verbally confirm the position of the pedals. The 2-33 Sailplane Flight-Erection-Maintenance manual preflightinspection checklist included inspecting the condition, operation, security of attachment and/or other signs of failure of the rudder and other components.

Aircraft

Registration
N2045T
Reported as
Schweizer SGS 2-33A
Category
Glider
Serial number
475
Built
1977
Airframe hours
13,624
Damage
Substantial damage
Flight
Flight test · Part 91
Operator
Civil Air Patrol
Registered owner
Civil Air Patrol
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 15, 2013 · 0 hours before
Departed
9N1 · Erwinna, PA
Destination
9N1 · Erwinna, PA
Flight plan
Company VFR
Airport
9N1 · Vansant Arpt, runway 07, 3,058 × 120 ft, grass/turf

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
76
Injuries
Serious
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
October 20, 2012
Seat
Front
Restraint
4-point
Flight hours
13,290 total

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 45 °F
Altimeter
30.28 inHg
Observed at
DYL, 10 nm away

Docket · 13

The files NTSB released with the investigation on March 5, 2014, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.1 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N2045T · 1

Matched to the same aircraft by N-number and date.