LAX99MA251

NTSB accident investigation · Schempp-Hirth Nimbus 4DM · Minden, NV · July 13, 1999

Accident · FatalClass 1 · MajorFinal report
Date
July 13, 1999, 13:10 local (20:10 UTC)
Place
Minden, NV
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N807BBSchempp-Hirth Nimbus 4DM
Weather
Visual (VMC) · Day
Status
Completed · report September 30, 2002
Report
Board-adopted at Board Meeting
Investigation class
Class 1
Parties
FEDERAL AVIATION ADMINISTRATION
FAA report
19990713008889A
Case key
46811

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

The pilot's excessive use of the elevator control during recovery from an inadvertently entered spin and/or spiral dive during which the glider exceeded the maximum permissible speed, which resulted in the overload failure of the wings at loadings beyond the structure's ultimate design loads.

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
Weather condition - thermal lift
Weather condition - turbulence,convection induced
Airspeed - not maintainedPilot in command
Stall/spin - inadvertentPilot in command
Airframe/component/system failure/malfunctionManeuvering
Wing - overloadCause
Airspeed(vne) - exceededPilot in commandCause
Pull-up - initiated
Elevator - improper use ofPilot in commandCause
Design stress limits of aircraft - exceededPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled

Analysis

The glider broke up in flight during the recovery phase after a departure from controlled flight while maneuvering in thermal lift conditions. Airborne witnesses in other gliders who saw the beginning of the sequence said the glider was in a tight turn, as if climbing in a thermal, when it entered a spiral or a spin. With a 45-degree nose down attitude, the speed quickly built up as the glider completed two full rotations. The rotation then stopped, the flight stabilized on a northeasterly heading, and the nose pitched further down to a near vertical attitude (this is consistent with the spin recovery technique specified in the Flight Manual). The glider was observed to be pulling out of the dive, with the wings bending upward and the wing tips coning higher, when the outboard wing tip panels departed from the glider, the wings disintegrated, and the fuselage dove into the ground. Several witnesses estimated the wing deflection reached 45-degrees or more before the wings failed. Examination of the wreckage disclosed that the left and right outboard wing sections failed symmetrically at 2 locations.

The glider is a high performance sailplane with an 87-foot wingspan and is constructed from fiber reinforced plastic (FRP) composites. The manufacturing process uses a hand lay-up of carbon and glass materials with applied epoxy resins. The glider is certificated in the normal category in Germany under the provisions of the European Joint Airworthiness Regulations.

Pilots with experience in the Nimbus 4 series gliders stated that the glider was particularly sensitive to over input of the rudder control during turns due to the 87-foot wingspan, with a resulting tendency for unwanted rolling moments. The manufacturer reported that to avoid undesired rolling moments once the bank is established the ailerons must be deflected against the bank.

Maneuvering speed (Va) is 180 km/h (97 kts) and the AFM notes that full control surface deflections may only be applied at this speed and below. Never exceed speed (Vne) is 285 km/h (154 kts) and control deflections are limited to one third of the full range at this speed and a bold print cautionary note reads, "Avoid especially sudden elevator control movements." The manufacturer reported that design dive speed (Vd) is 324 km/h (175 kts). The manufacturer also said that, assuming a 45-degree nose down attitude with airbrakes closed, the glider would accelerate from stall speed to Vne in 8.6 seconds, with an additional 1.8 seconds to accelerate from Vne to Vd. While no specific information on stick force per 'g' was available, certification flight test data showed that the elevator control stick forces were relatively light, with only 11.9 pounds of force (nose down) required to hold a fixed attitude at Vne versus the neutral stick force trim speed of 135 km/h (72.89 kts).

Detailed examination of witness marks and other evidence in the wreckage established that the pilot extended the airbrakes at some point in an attempt to slow the glider during the descent prior to the break-up. Concerning limitations on use of the airbrakes, the AFM notes that while airbrakes may be extended up to Vne they should only be used at such high speeds in emergency or if the maximum permitted speeds are being exceeded inadvertently. The manufacturer noted that the airbrakes function like spoilers and have the effect of shifting the aerodynamic loads outboard on the wings. The control linkages for the airbrakes and flaps are interconnected so that when full airbrake deployment is achieved, the flaps are extended to their full down limit.

The maximum maneuvering load factor limits (in units of gravity or g's) change with variations in glider speed and flap/airbrake configuration. From a "flaps up" configuration at Va to the condition of airbrakes and flaps extended at Vne, the maximum maneuvering load factor limits decrease from positive 5.3 to a positive 3.5.

The pertinent certification regulations require a minimum safety margin of 1.5 above the design limit load, which is defined as ultimate load. Review of the manufacturers data on safety margins in the wing spar disclosed that in the area of the primary wing failures, the structural design safety margin ranged between 1.55 and 1.75.

The manufacturer supplied data of the wing deflections under various load and aerodynamic conditions. At the design load limit (3.5g's) with airbrakes extended and at Vd, the wings were deflected to a 31-degree angle. At the ultimate load limit, the deflection was 46.5-degrees, similar to the witness observations of the wing deflection just prior to the break up.

An extensive series of scientific investigations were undertaken to establish: 1) if the structure as built conformed with the approved production drawings; 2) that the wing design met pertinent certification standards for strength safety margins; and 3) whether or not the failures occurred in overload beyond the ultimate load limits of the structure. While production control type discrepancies were found in the structure that differed from drawing specifications, none contributed to the failures. The testing established that the structure as built exceeded the minimum safety margin requirements. All the wing failures were overload in character and occurred at loadings well above the ultimate design load limits.

Factual narrative

The full report is available on the NTSB Web site. See http://www.ntsb.gov/publictn/publictn.htm for details.

Summary:

On July 13, 1999, at 1310 Pacific daylight time, a Schempp-Hirth Nimbus-4DM motorized glider, N807BB, experienced an in-flight breakup while maneuvering near Minden, Nevada. The commercial glider pilot and a passenger were fatally injured, and the glider was destroyed. The glider had departed from Minden-Tahoe airport at 1240 and was operated by the owner/pilot under the provisions of 14 Code of Federal Regulations (CFR) Part 91. No flight plan was filed for the local area soaring flight. The glider was certificated in the United States in the experimental category for exhibition and racing, and it was also certificated in Germany in the standard class, utility category.

Aircraft

Registration
N807BB
Reported as
Schempp-Hirth Nimbus 4DM
Category
Glider
Serial number
20
Airframe hours
201
Engine
Rotax 535C, 60 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
William S. Ivans
Registered owner
William S. Ivans Trustee
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Condition · May 18, 1999 · 19 hours before
Departed
MEV

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
79
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Single-engine land
Last flight review
October 20, 1998
Seat
Front
Toxicology
Performed
Flight hours
3,611 total · 103 in this make and model · 3,541 as pilot in command · 8 in the last 90 days · 8 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 6 knots
Visibility
30 statute miles
Lowest ceiling
None
Temperature
93 °F, dew point 46 °F
Altimeter
30.00 inHg
Observed at
MEV, 4 nm away

Docket · 60

The files NTSB released with the investigation on September 20, 2002, on NTSB’s docket system: statements, records, photos and specialists’ reports. 107 MB in all.

Supplement AItem 1 · .PDF · 147 KBSupplement BItem 2 · .PDF · 202 KBSupplement EItem 3 · .PDF · 110 KBWitness 4 - Factual Report of Group ChairmanItem 4 · .PDF · 131 KBWitness 4 - Attachment 1Item 5 · .PDF · 572 KBWitness 4 - Attachment 2Item 6 · .PDF · 46 KBMeteorology 5 - Factual Report of Group ChairmanItem 7 · .PDF · 275 KBMeteorology 5 - Attachment 1, 14-15 Satellite ImageItem 8 · .PDF · 3.2 MBMeteorology 5 - Attachment 2, 16-17 Satellite ImageItem 9 · .PDF · 3.6 MBMeteorology 5 - Attachment 3, 18-19 Satellite ImageItem 10 · .PDF · 3.1 MBMeteorology 5 - Attachment 4, 20-21 GEOS Infared ImageItem 11 · .PDF · 3.1 MBMeteorology 5 - Attachment 5, 22-23 GEOS Infared ImageItem 12 · .PDF · 3.1 MBMeteorology 5 - Attachment 6, 24-25 GEOS Infared ImageItem 13 · .PDF · 4.1 MBMeteorology 5 - Attachment 7, 26-27 GEOS Infared ImageItem 14 · .PDF · 4.2 MBMeteorology 5 - Attachment 8, 28-30 GEOS Infared ImageItem 15 · .PDF · 7.4 MBMeteorology 5 - Attachment 9, Wind ProfilesItem 16 · .PDF · 1.1 MBMeteorology 5 - Attachment 10, WX Radar ImageItem 17 · .PDF · 4.8 MBMeteorology 5 - Attachment 11, Wind Radial Velocity Spectrum ChartsItem 18 · .PDF · 12.1 MBMeteorology 5 - Attachment 12, 12-13 Satellite ImageItem 19 · .PDF · 3.2 MBMeteorology 5 - Attachment 13, METAR ReportsItem 20 · .PDF · 396 KBMeteorology 5 - Attachment 14, Soaring ForecastItem 21 · .PDF · 86 KBMeteorology 5 - Attachment 15, Witness StatementsItem 22 · .PDF · 102 KBMeteorology 5 - Attachment 16, Skew T Log P PlotItem 23 · .PDF · 900 KBMeteorology 5 - Attachment 17, Upper Air DataItem 24 · .PDF · 109 KBMeteorology 5 - Attachment 19, Surface Isobar ChartItem 25 · .PDF · 1.2 MBAirworthiness Group Chairman's Factual ReportItem 26 · .PDF · 293 KBAirworthiness Group Chairman's Factual Report - Attachment I: Drawing, Schempp-Hirth Nimbus 4DMItem 27 · .PDF · 87 KBAirworthiness Group Chairman's Factual Report - Attachment II: Photographs of an exemplar Nimbus 4DMItem 28 · .PDF · 1.9 MBAirworthiness Group Chairman's Factual Report - Attachment III: Wreckage DistributionItem 29 · .PDF · 151 KBAirworthiness Group Chairman's Factual Report - Attachment IV: N807BB, (in flight) Wing FailuresItem 30 · .PDF · 87 KBAirworthiness Group Chairman's Factual Report - Attachment V: Photographs of the WreckageItem 31 · .PDF · 15.4 MBAirworthiness Group Chairman's Factual Report - Attachment VI: MM Diagrams, Inboard & Outboard WingItem 32 · .PDF · 146 KBAirworthiness Group Chairman's Factual Report - Attachment VII: WSU /NIAR Report, [Investigation of a Schempp-Hirth Nimbus 4DM Motor Glider "In-flight Breakup"]Item 33 · .PDF · 1.6 MBAirworthiness Group Chairman's Factual Report - Attachment VII: WSU /NIAR Report (Appendix A)Item 34 · .PDF · 2.7 MBAirworthiness Group Chairman's Factual Report - Attachment VII: WSU /NIAR Report (Appendix B)Item 35 · .PDF · 196 KBAirworthiness Group Chairman's Factual Report - Attachment VII: WSU /NIAR Report (Appendix C)Item 36 · .PDF · 831 KBAirworthiness Group Chairman's Factual Report - Attachment VII: WSU /NIAR Report (Appendix D)Item 37 · .PDF · 6.2 MBAirworthiness Group Chairman's Factual Report - Attachment VII: WSU /NIAR Report (Appendix E)Item 38 · .PDF · 11.6 MBAirworthiness Group Chairman's Factual Report - Attachment VIII: Flight Manual ReferencesItem 39 · .PDF · 376 KBMaterials Laboratory 15 - Factual Report of Group ChairmanItem 40 · .PDF · 140 KBAircraft Performance 13 - Factual Report of Radar Target EvaluationItem 41 · .PDF · 192 KBMaps or Charts of Accident Area, Wreckage DiagramsItem 42 · .PDF · 70 KBWreckage Diagram GPS CoordinatesItem 43 · .PDF · 291 KBGermany Airworthiness CertificationItem 44 · .PDF · 1.1 MBExtract of Correspondance from German LBAItem 45 · .PDF · 86 KBGerman LBA Standards for Structural SubstantiationItem 46 · .PDF · 785 KBExtract of Correspondence From Schempp-Hirth 1Item 47 · .PDF · 128 KBExtract of Correspondence with Schempp-Hirth 07-31-01Item 48 · .PDF · 161 KBCharts Detailing Effect of Airbrake Extension on Wing LoadsItem 49 · .PDF · 87 KBGraph of Control Force versus SpeedItem 50 · .PDF · 229 KBGraph of Wing Deflections Under LoadItem 51 · .PDF · 91 KBWeight and Balance ComputationsItem 52 · .PDF · 313 KBBattery Examination ReportItem 53 · .PDF · 37 KBUS Airworthiness Certificate and Operating Limitations LetterItem 54 · .PDF · 385 KBGlider Maintenance RecordsItem 55 · .PDF · 2.3 MBExtract of Pilot LogbookItem 56 · .PDF · 539 KBExtract of 14 CFR 61.23Item 57 · .PDF · 117 KBGlider Flight Manual ExtractsItem 58 · .PDF · 653 KBToxicological ReportsItem 59 · .PDF · 93 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 60 · .PDF · 95 KB

FAA reports on this event · 1

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