# NTSB LAX93LA276: Curtis Rans S-12, N410ZE, Samoa, CA, July 4, 1993

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Limited investigation · Final report
- Date: July 4, 1993, 14:53 local (21:53 UTC)
- Place: Samoa, CA
- Coordinates: 40.789596, -124.199287 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=40.7896&lon=-124.1993&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed, report November 19, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 27982
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=LAX93LA276
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/27982/pdf
- Page: https://openairdocs.org/ntsb/LAX93LA276

## Probable cause

THE INADVERTENT STALL OF THE AIRPLANE.  FACTORS RELATED TO THIS ACCIDENT WERE: THE EMERGENCY PARACHUTE SYSTEM THAT WAS DEPLOYED BY THE PILOT, THE PARTIAL FAILURE OF THE PARACHUTE SURVIVAL EQUIPMENT TO DEPLOY PROPERLY, AND THE INSUFFICIENT INFORMATION PROVIDED BY THE AIRCRAFT PARACHUTE MANUFACTURER.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of control - in flight, cruise
  - weather condition - high wind
  - stall - inadvertent, pilot in command (cause)
  - emergency equipment - selected, pilot in command (contributing factor)
  - misc eqpt/furnishings,survival equipment - failure,partial (contributing factor)
  - procedures/directives - information insufficient, manufacturer (contributing factor)
- In flight collision with terrain/water, descent - uncontrolled

## Analysis

SEVERAL WITNESSES REPORTED THAT THE AIRPLANE, WHICH HAS A REAR MOUNTED ENGINE, SEEMED TO BE HAVING SOME DIFFICULTY WITH CONTROLLABILITY DUE TO THE HIGH WINDS IN THE AREA.  THE CONSENSUS WAS THAT THE AIRPLANE APPEARED TO ENTER A STALL, AND THEN IT SPUN SEVERAL TIMES BEFORE IMPACTING THE GROUND.  THE AIRCRAFT BALLISTIC PARACHUTE SYSTEM WAS MANUALLY DEPLOYED BY THE PILOT, BUT DID NOT INFLATE BEHIND THE AIRPLANE.  THE PARACHUTE WAS FOUND ENTANGLED IN THE CRANKSHAFT JUST FORWARD OF THE PROPELLER.  THE PARACHUTE OWNERS MANUAL STATES THE ENGINE SHOULD BE STOPPED PRIOR TO DEPLOYMENT OF THE PARACHUTE.  IT ALSO RECOMMENDS NOT DEPLOYING THE PARACHUTE IN 'STRONG WINDS OR CONVECTION', ALTHOUGH NO SPECIFIC GUIDELINES WERE FOUND FOR THE PILOT TO FOLLOW IN THE EVENT HE ENCOUNTERED SUCH PHENOMENA.  A SENIOR TECHNICIAN WHO WORKED AT THE PARACHUTE MANUFACTURER APPROVED THE INSTALLATION OF THE PARACHUTE PER PHOTO DOCUMENTATION, AS REQUIRED BY THE MANUFACTURER.  THE COMPANY COULD NOT PROVIDE A WRITTEN RECORD OF THE APPROVAL.  THE MANUAL DOES NOT ADDRESS A MINIMUM RECOMMENDED ALTITUDE OR A MINIMUM SPEED FOR THE DEPLOYMENT OF THE PARACHUTE.  POST CRASH INVESTIGATION FAILED TO FIND ANY PRE EXISTING FAILURE/MALFUNCTION OF THE PROPELLER OR POWERPLANT.

## Aircraft

- Registration: [N410ZE](https://openairdocs.org/deregistered/N410ZE-1996-05-29), registration cancelled 1996-05-29, S/N 0591083 (OpenAirDocs)
- Reported make and model: CURTIS RANS S-12
- Registry model: [Curtis Jerry G S-12](https://openairdocs.org/model/curtis-jerry-g-s-12) (registry code 05618Q2) (OpenAirDocs)
- Category: Airplane, amateur-built
- Serial number: 0591083
- Engines: ROTAX 582 65 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Bish, Gregory Keith
- Registered owner: Bish, Gregory Keith
- Airworthiness certificate: Special, Experimental (Special)
- Last inspection: Unknown, January 2, 2000
- Departed: 033, EUREKA, CA

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 39; private; airplane ratings: single-engine land; medical: class 3, valid medical--no waivers/lim.; seat: left; flight hours: 265 total, 187 in this make and model, 255 as pilot in command, 62 in the last 90 days, 14 in the last 30 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 330° at 20 knots, gusting 25
- Visibility: 30 statute miles
- Lowest ceiling: none
- Temperature: 66 °F, dew point 52 °F
- Altimeter: 29.00 inHg
- Observed at: ACV, 14 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 19930704021869A](https://openairdocs.org/incident/19930704021869A), Jul 4, 1993: Amtr RANSS12, Samoa, CA, Substantial damage, 1 fatal. Lost control in strong gusty wind. Stalled. Deployed ballistic chute. Lines wrapped around rear engine prop.

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.

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