LAX96FA075

NTSB accident investigation · Great Lakes 2T-1A-2 · Fillmore, CA · December 19, 1995

Accident · Serious injuriesField investigationFinal report
Date
December 19, 1995, 15:00 local (23:00 UTC)
Place
Fillmore, CA
Injuries
1 serious
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N3511LGreat Lakes 2T-1A-2
Weather
Visual (VMC) · Day
Status
Completed · report November 11, 1996
Report
Approved by Office Director
FAA report
19951219043339A
Case key
29244

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

failure of the pilot to take proper remedial action to recover from an intentional spin.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightManeuvering
Stall/spin - intentionalPilot in command
Trim setting - excessivePilot in command
Remedial action - not attainedPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

At completion of an aerobatic practice session, the pilot intentionally placed the aircraft in a spin from 3,000 feet agl before returning to the home airport for landing. He said the aircraft did not respond to recovery control input, and that it spun until impact with terrain. The pilot recalled that the controls felt mushy, and the spin seemed flat. He said that he had done hundreds of spins, and this one was different. During a postaccident examination of the airplane, the pitch trim was found in the full nose-up position.

Factual narrative

History of flight

On December 19, 1995, at 1500 hours Pacific standard time, a Great Lakes 2T-1A-2, N3511L, impacted the terrain near Fillmore, California. The aircraft was destroyed and the commercial pilot was seriously injured. The aircraft departed from Santa Paula, California, at 1350 for a local area personal flight. Visual meteorological conditions prevailed and no flight plan was filed.

In his report to the NTSB, the pilot reported that following several touch-and-go landings he proceeded to the aerobatic practice area northeast of the airport where he performed a series of aerobatic maneuvers. Prior to returning to Santa Paula for landing, he said he performed a spin from 3,500 feet msl (approximately 3,000 feet agl), which ultimately led to the accident. In a later conversation with the NTSB investigator, the pilot said that his recollection of the spin was that the control stick felt "mushy" in pitch and the spin seemed flat. He said that he had done hundreds of spins but this one was "different."

There were four witnesses to the accident. One witness reported observing the aircraft flying westbound at 300 feet agl and at a low air speed. He observed the aircraft begin spiraling to the ground in a 25-degree nose-low attitude. There was no engine sound as the aircraft spun to the impact. This witness helped extricate the pilot from the aircraft, and as reported in a local newspaper, said that the pilot was conscious but not coherent. When asked, the pilot could not tell him what day it was or how old he was.

The second witness reported hearing the airplane doing "stunts" as he worked. He heard the noise stop and looked up in time to watch the plane spiraling to the ground.

In the Ventura County Sheriff's report of the accident, the above witness and a third witness are reported to have observed the aircraft "flying unusually low to the ground." Then suddenly the aircraft's engine stopped and the plane began "a slow, wide, spin towards the ground."

The fourth witness telephoned the FAA Flight Standards District Office on December 22, 1996. He reported working on a hill 400 to 500 feet above the accident site and observing the aircraft doing "stunt" flying for about 1/2 hour. This witness reported that the aircraft had "good" altitude, the engine sounded good and that the aircraft was not doing "severe acrobatics." When the engine went quiet for 10 to 20 seconds he observed the aircraft at his elevation (400 to 500 feet above the accident site) and then heard some "weird" sounds for a few seconds before hearing the sound of impact. His view was partially obscured by trees. This witness reported that, upon arrival at the crash site, fuel was pouring out of the aircraft and that there was a "buzzing" sound that stopped when someone else turned off some switches in the cockpit.

Personnel information

The 52-year-old pilot reported a total flying time of 2,243 hours, of which 842 hours were in the Great Lakes aircraft. He reported 70 hours in the last 90 days and 20 hours in the last 30 days in the accident aircraft. The pilot completed a biennial flight review in the Great Lakes Aircraft 22 months before the accident, and had completed an advanced aerobatic maneuvers course (emergency maneuver training) approximately 3 years prior. Personnel at the Santa Paula airport told the NTSB investigator that the pilot usually flew the accident aircraft once or twice each week and performed some aerobatics on most flights.

Aircraft information

The accident aircraft was manufactured in 1978 and had accumulated a total flying time of 382 hours. The last major maintenance performed was an annual inspection on August 22, 1995, at 313 hours. The pilot purchased the aircraft in partnership approximately 4 months before the accident.

Wreckage and impact information

The aircraft wreckage was located in a level lemon orchard, 4 miles southwest of Fillmore at latitude 34 degrees, 23.7 minutes north and longitude 118 degrees, 59.0 minutes west. The location is 75 yards east of the northern terminus of Hall Road.

The fuselage of the aircraft was between two trees, headed south in a wings level, nose low attitude. The left and right wings were each resting on an adjacent lemon tree to the left and right of the fuselage and the lower wings were bent upward. Branches of a tree protruded through the upper left wing. The entire aircraft was present at the accident site and control continuity was verified. Ground scars and damage to surrounding vegetation was limited to the area within 10 feet of the aircraft. The pitch trim actuator jackscrew and the horizontal stabilizer were found in the full nose-up position.

The forward fuselage in the area of the propeller spinner, the accessories underneath the engine, the firewall, the forward cockpit floor, and the main landing gear exhibited crushing damage in the vertical and aft direction. A line connecting these damaged areas corresponds to approximately a 30-degree nose low, wings level attitude. The left and right main landing gear were collapsed outward and aft, and were in the dirt under the lower wings. The fuel header tank in the forward cockpit was broken from its mounting brackets in the downward direction.

One blade of the propeller exhibited an S-bend along its length, but no torsional twisting. The leading edge of this blade had chordwise scratches back to about the 20 percent chord line. The remaining blade of the propeller was undamaged.

Tests and research

The separated weld cluster which attaches the aft cockpit control stick to the fuselage was sent to the NTSB laboratory for evaluation. The metallurgist's factual report is attached.

Additional information

A flight school owner who operates and teaches aerobatics in two Great Lakes aircraft told the NTSB investigator that in his experience the aircraft will recover from all spin attitudes if: power is off; the control stick is released; and full opposite rudder is applied. However, if the pilot doesn't input and hold full opposite rudder for 1 1/2 seconds there is an "accelerated" spin mode wherein the airplane continues to spin but spins faster and feels like it is resisting recovery. He said many experienced aerobatic pilots don't know this unless they have had formal aerobatic instruction which includes emergency spin recovery training. While the full nose up trim is unusual, he didn't think that it would prevent recovery.

Another person experienced in the manufacture and operation of the Great Lakes aircraft told the NTSB investigator that he has never heard of an unrecoverable spin in the aircraft. This person thought that the full nose up trim was relevant because it is not normal and suggested to him that the pilot was "experimenting."

The NTSB did not take custody of the aircraft wreckage; however, the aircraft was inspected at Ray's Aviation, Santa Paula, California, on December 22, 1996. The on-scene examination of the wreckage was performed by inspectors from the Federal Aviation Administration, Flight Standards District Office, Van Nuys, California, and assisted by an investigator from Textron Lycoming Company.

Aircraft

Registration
N3511L
Reported as
Great Lakes 2T-1A-2
Category
Airplane
Serial number
0793
Airframe hours
382
Engine
Lycoming AEIO-360-B1G6, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Southern Cross, Inc.
Airworthiness certificate
Standard, Aerobatic
Last inspection
Annual · July 3, 1995 · 76 hours before
Departed
SZP · Santa Paula, CA

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
52
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Rear
Flight hours
2,243 total · 842 in this make and model · 2,003 as pilot in command · 70 in the last 90 days · 20 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 13 knots, gusting 17
Visibility
40 statute miles
Lowest ceiling
None
Temperature
61 °F, dew point 46 °F
Altimeter
30.00 inHg
Observed at
CAM, 16 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.