# NTSB ERA19LA214: Pipistrel Sinus, N269PW, Haverhill, MA, July 4, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: July 3, 2019, 20:00 local (Jul 4, 2019, 00:00 UTC) - Place: Haverhill, MA - Coordinates: 42.740833, -71.095001 - Nearby events: https://openairdocs.org/map.md?lat=42.7408&lon=-71.0950&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 99793 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA214 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99793/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99793 - Page: https://openairdocs.org/ntsb/ERA19LA214 ## Probable cause The pilot's failure to utilize the proper procedure and unfeather the motorized glider’s propeller prior to an in-flight engine restart, resulting in a lack of thrust and subsequent forced landing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Propeller system: propeller controlling system](https://openairdocs.org/ntsb-findings/01046120): Aircraft › Aircraft propeller/rotor · Incorrect use/operation (probable cause); cases with it: [Pipistrel Lsa SINUS, 1 case](https://openairdocs.org/ntsb-findings/01046120/cases.md?model=0600083), [All aircraft, 25 cases](https://openairdocs.org/ntsb-findings/01046120/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Pipistrel Lsa SINUS, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=0600083), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Pipistrel Lsa SINUS, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=0600083), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Pipistrel Lsa SINUS, 2 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=0600083), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Pipistrel Lsa SINUS, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=0600083), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot departed in his motorized glider, climbed to 3,500 ft, then turned off the engine and feathered the two-bladed propeller once he reached the area where he wanted to soar. Since weather conditions were not conducive to soaring, he attempted to return to the airport. In preparation to land he said he restarted the engine without using the glider's documented procedures. The engine started but was not producing the expected power. The pilot thought he had a fuel problem and was not aware that the propeller was still in a feathered condition. Although the engine was operating normally, the feathered propeller was unable to produce the thrust needed to maintain altitude. The pilot subsequently made a forced landing and the airplane impacted a fence about 1.5 miles short of the runway. The glider sustained substantial damage. Postaccident examination of the glider revealed that both propeller blades and the propeller control knob were in the feathered position. Examination of the engine and airplane revealed no mechanical deficiencies that would have precluded normal operation at the time of impact. ## Factual narrative On July 3, 2019, about 2000 eastern daylight time, a Pipistrel Sinus motorized glider, N269PW, was substantially damaged when it was involved in an accident near Lawrence Municipal Airport (LWM) Lawrence, Massachusetts. The pilot was not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. The pilot reported that he flew about 16 miles to the coast after departure from LWM at an altitude of 3,500 ft mean sea level (msl). As he got over the spot where he normally conducts his soaring, he turned off the engine power, feathered the propeller, and soared for a few minutes as he looked for thermals. Finding none, and with little westerly wind, he elected to restart the engine and return to LWM as his altitude descended through 2,500 ft msl. During his attempted engine restart, the engine started but it seemed "sluggish" and he was not getting the normal performance out of the engine. In addition, he stated that his fuel flow was higher than normal. The pilot attempted to troubleshoot the problem but was unable to achieve normal power. He thought he may have had contaminated fuel or excessive air in the tanks or fuel line. He switched fuel tanks, but the problem continued. Because he was approaching from the east, he lined up for runway 23; however, he was unable to maintain altitude. About 1-1/2 miles from the approach end of the runway, the glider struck a fence on a hilltop at an elevation of about 300 ft and skidded to a stop next to the LMW VOR. A postaccident examination of the glider revealed substantial damage to the landing gear structure, the lower portion of the fuselage, and the left wing. The aircraft came to rest on a magnetic heading of about 200°. About 8 gallons of fuel was drained from the fuel tanks. Both composite propeller blades sheared off about 8 inches from the hub from impact and were in a feathered position. In addition, the propeller control knob in the center console of the cockpit indicated the propeller was feathered. Examination of the engine and fuel system revealed no discrepancies that would have precluded normal operation at the time of impact. Following the accident, an FAA inspector interviewed the pilot, and the pilot stated that he did not use the documented engine restart procedure. A review of the glider's Flight Manual and Maintenance Manual under the Normal Procedures Section, page 39 stated; Restarting the engine in flight This procedure applies only for restarting the engine following an intentional unpowered flight. Reduce speed to 90 km/h (50 kts) and set propeller to minimum pitch setting Master switch ON (key in full right position) Magnetos ON WARNING! Before you activate the starter make sure the propeller is not feathered any more but at minimum pitch setting (propeller pitch knob full forward and screwed left fully) In addition, a description of the procedures to increase/decrease pitch and feathering were found on pages 62 and 63 of theFlight Manual and Maintenance Manual described the procedures. The propeller is controlled by a knob in the middle of the instrument panel. If the knob is turned counterclockwise (left), the pitch decreases. Turning the knob clockwise (right) the propeller pitch increases. WARNING! Feather propeller only after the engine has stopped and at minimum pitch. To feather the propeller, first reduce airspeed to 90 km/h, then pull the propeller pitch knob's metal base backwards fully and then rotate it 20° clockwise. A propeller pitch of approximately 70° is reached by doing so. To feather the propeller fully (90°), rotate the knob clockwise a couple of times until it stops. Propeller unfeathering To unfeather the propeller, first reduce airspeed to 90 km/h. Now pull the propeller pitch knob's metal base slightly, then rotate it counterclockwise and gently push it all the way to the instrument panel. ## Aircraft - Registration: [N269PW](https://openairdocs.org/deregistered/N269PW-2020-09-18), registration cancelled 2020-09-18, S/N 503 SN 912 LSA, built 2013 (OpenAirDocs) - Reported make and model: Pipistrel SINUS - Registry model: [Pipistrel Lsa SINUS](https://openairdocs.org/model/pipistrel-lsa-sinus) (registry code 0600083) (OpenAirDocs) - Registry engine: [Rotax 912UL2](https://openairdocs.org/engine/rotax-912ul2) (registry code 55574, 4 cycle) (OpenAirDocs) - Category: Glider - Serial number: 503 SN 912 LSA - Year built: 2013 - Airframe hours: 217 - Engines: Rotax 912-UL2 80 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Special light-sport (Special) - Last inspection: 100 hour, June 28, 2019 - Departed: LWM, Haverhill, MA - Destination: LWM, Haverhill, MA - Airport: LWM, Lawrence Muni, runway 23, 5,001 × 100 ft, asphalt - Equipment: Airframe parachute, Electronic multifunction display, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 82; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: basicmed, with waivers/limitations; last flight review November 19, 2017; seat: left; restraint: 4-point; flight hours: 1,600 total, 215 in this make and model ## Weather - Conditions: Visual (VMC), Dusk - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 63 °F - Altimeter: 29.88 inHg - Observed at: LWM, 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 20190703009059A](https://openairdocs.org/incident/20190703009059A), Jul 3, 2019: Pipistrel Lsa Srl SINUS, Haverhill, MA, Substantial damage. The pilot departed N269PW, a Pipistrel Sinus LSA motor glider, from lawrence municipal airport (lwm) under visual flight rule (VFR) at approximately 19:00 LCL… ## Docket (10 files) The files NTSB released with the investigation on March 3, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99793. 14.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 10 pages, 10.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9038170&FileExtension=pdf&FileName=Pilots%206120%20Accident%20Report_Redacted-Rel.pdf - FAA inspector's statement (item 2, PDF, 2 pages, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9039078&FileExtension=pdf&FileName=FAA%20Accident%20Report_Redacted-Rel.pdf - Pilot logbook excerpt (item 3, PDF, 3 pages, 555 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9045692&FileExtension=pdf&FileName=Pilot%20Logbook%20Pages_Excerpt_Redacted-Rel.pdf - Record of conversation-faa (item 4, PDF, 1 page, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9039899&FileExtension=pdf&FileName=Record%20of%20Conversation-FAA-Rel.pdf - Propeller manual excerpt_pitch setting (item 5, PDF, 3 pages, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9039757&FileExtension=pdf&FileName=Propeller%20Manual%20Excerpt-Rel.pdf - Flight and maintenance manual excerpt_propeller (item 6, PDF, 2 pages, 293 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9045543&FileExtension=pdf&FileName=Sinus%20Flight%20Manual%20Excerpt-Rel.pdf - Maintenance records excerpts (item 7, PDF, 12 pages, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9045552&FileExtension=pdf&FileName=Maintenance%20Records%20Excerpts_Redacted-Rel.pdf - Photo array-accident site and damage (item 8, PDF, 4 pages, 516 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9039620&FileExtension=pdf&FileName=Accident%20Site%20and%20Damage%20Photographs-Rel.pdf - Record of weather (item 9, PDF, 1 page, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9038587&FileExtension=pdf&FileName=Record%20of%20Weather-Rel.pdf - Location of accident (item 10, PDF, 2 pages, 409 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9039471&FileExtension=pdf&FileName=Location%20of%20Accident-Rel.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.