# NTSB WPR09FA005: Iniziative Industriali Italian SKY Arrow 600, N454SA, Malibu, CA, October 8, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 7, 2008, 17:15 local (Oct 8, 2008, 00:15 UTC) - Place: Malibu, CA - Coordinates: 34.036109, -118.666946 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.0361&lon=-118.6669&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report October 3, 2011 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Rotech Flight Safety Inc. - NTSB case key (mKey): 69240 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09FA005 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/69240/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=69240 - Page: https://openairdocs.org/ntsb/WPR09FA005 ## Probable cause The pilot's failure to maintain aircraft control during a low-altitude maneuver. Contributing to the accident was the pilot's decision to perform a maneuver at a low altitude that was insufficient to allow him to recover from the loss of control. Contributing to the occupants’ injuries was the inadequacy of the restraint system design by the manufacturer. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause) - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause) - [Aircraft](https://openairdocs.org/ntsb-findings/01020000): Aircraft › Aircraft systems · Design (probable cause) - [Design: equipment design](https://openairdocs.org/ntsb-findings/04011010): Organizational issues › Development · Manufacturer (probable cause) ## Analysis Witnesses observed the airplane fly at a low altitude over the water and, during a steep left turn, nose over and impact the water about 50 yards offshore. First responders rescued the pilots, a certified flight instructor (CFI) and a pilot who was receiving instruction, who told them that the airplane and engine had no mechanical failures or malfunctions during the flight. The CFI succumbed to his injuries 17 days later. Examination of the airframe and engine revealed no mechanical abnormalities that would have precluded normal operation. The airplane was equipped with a shoulder harness restraint that connected to the crotch strap; however, there was no lap belt installed. Examination of the restraint system webbing revealed no visual signs of distress or damage. During the impact sequence, the rear bulkhead separated from the fuselage allowing the rear seat and CFI to be pushed into the front seat. The investigation determined that the airplane had been designed without a lap belt restraint. The inadequacy of the restraint system likely exacerbated the CFI's injuries. The requirements under the American Society for Testing and Materials international standards stated that there must be a seat belt and harness for each occupant and adequate means to restrain the baggage. ## Factual narrative HISTORY OF FLIGHT On October 7, 2008, about 1715 Pacific daylight time (PDT), an Iniziative Industriali Italian Sky Arrow 600 Sport, a Special Light Sport Airplane (S-LSA), N454SA, impacted the Pacific ocean near Malibu, California. Northfield Aviation LLC., operated the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The certified flight instructor (CFI) was fatally injured, and the private pilot undergoing instruction (PUI) was seriously injured. The airplane sustained substantial damage to the wings, fuselage, and cockpit. The local instructional flight departed Santa Monica, California, about 1640. Visual meteorological conditions prevailed, and no flight plan had been filed. Witnesses observed the accident airplane flying low over the water. While making a steep left turn, they saw it nose over and impact the ocean. First responders rescued both pilots, and transported them to a medical trauma center. The lifeguards coordinated the removal of the airplane wreckage from the surf and up to the beach. First responders stated that both pilots stated that there were no mechanical malfunctions or failures with the airplane or engine during the flight. In a written statement, the PUI reported that he and the instructor had flown up the coast with no problems noted. The PUI recalled returning to Santa Monica at about 1,000 feet offshore and straight and level. The next thing that he recalled was being in the water. PERSONNEL INFORMATION The PUI was seated in the front seat of the airplane and the CFI was seated in the rear seat. Both pilots were transported to local area hospitals for medical treatment. The PUI was released from the hospital on October 14, 2008. The CFI remained hospitalized until he died as a result of his injuries on October 24, 2008. AIRCRAFT INFORMATION The Sky Arrow 600 Sport, serial number LSA012, was manufactured in 2000; the tandem two-seat airplane was a certified special-LSA, Iniziative Industriali Italian. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 123.8 hours at the last 100-hour inspection dated August 28, 2008. Northfield Aviation LLC., acquired the accident airplane on August 28, 2007. The Sky Arrow 600 Sport was issued a Special Airworthiness Certificate as a Light Sport Airplane on November 4, 2006. An FAA Designated Airworthiness Representative (DAR) issued the certificate after verifying that the airplane conformed to ASTM International specification standards for a Special Light Sport Airplane. WRECKAGE AND IMPACT INFORMATION According to the lifeguards who moved the airplane from the surf onto the beach, the airplane struck the water about 50 yards offshore. The National Transportation Safety Board investigator-in-charge (NTSB IIC) and a Federal Aviation Administration (FAA) inspector responded to the accident site and examined the wreckage. Investigators observed that the accident airplane was equipped with a three-point harnessrestraint system. The rear bulkhead behind the aft seat had completely separated from the fuselage. Examination of the restraint system webbing revealed no visual signs of distress or damage. MEDICAL AND PATHOLOGICAL INFORMATION The injuries of the CFI were documented in the medical records and obtained by the NTSB from the University of California, Los Angeles Medical Center. The pilot succumbed to his injuries 17 days following the accident. According to the University of California, Los Angeles Medical Center, the pilot sustained carotoid artery dissection, a bilateral subdural hematoma, a frontal subarachnoid hemorrhage and edema, fractures of the T11, L4, left first rib fracture, lateral left third to fifth rib fractures, with a substernal hematoma to the right anterior, third rib fracture, and injuries to the head and chest. TESTS AND RESEARCH On October 9, 2008, investigators examined the wreckage at Aircraft Recovery Service. The NTSB IIC investigator and Rotech flight safety personnel examined and documented the condition of the engine. The airframe and engine were examined with no mechanical anomalies identified. Rotech submitted a written report, and the NTSB IIC who observed the examination concurred with the facts in the report, which is attached to the accident docket. Under the NTSB IIC's supervision, Rotech personnel prepared the engine for a run-up. The engine was desalinated, and without modifications or adjustments was successfully started and ran normally. A handheld Garmin GPSMAP 496, Global Positioning Satellite (GPS) receiver was recovered in the wreckage, and shipped to the Vehicle Recorders Division of the NTSB, Washington, D.C., for examination. The NTSB's Vehicle Recorders Division examined the Garmin GPSMAP496 and prepared a factual report, which is attached to the accident docket. The data downloaded from the GPS recorded the accident flight, which was 46 minutes in duration. The final GPS position was recorded at 1712:48, and placed the aircraft at N34 degrees 02.295 minutes and W118 degrees 39.960 minutes at a -6 foot GPS altitude; approximately 10 feet mean sea level after correcting for local vertical GPS distance error. The last calculated recorded velocity was 61 miles per hour groundspeed, and direction of travel was 319 degrees true. ADDITIONAL INFORMATION During the course of the investigation, it was determined that the airplane had been designed without a lap belt restraint. The airplane was equipped with a shoulder harness restraint that connected to the crotch strap. At the time of the airplane's certification, section 8 of ASTM standard F2245, Standard Specification for Design and Performance of a Light Sport Airplane, has the following requirement for the restraint system: 8.5 Safety Belts and Harnesses - There must be a seat belt and harness for each occupant and adequate means to restrain the baggage. There are 22 Sky Arrow airplanes that were manufactured without a lap belt. Although a retrofitmodification to the restraint system design is not required, the manufacturer and the FAA have notified the owners that the installation of a lap belt is encouraged. The NTSB has been informed that some of the 22 owners have voluntarily upgraded their restraint systems. The FAA and the manufacturer have provided information to current owners on the safety of the restraint system, and how it can be upgraded. The FAA indicated that the intent of the original standard was that S-LSAs be designed with a shoulder harness and lap belt. All new S-LSAs (not only the Sky Arrow) are required to have both a shoulder harness and lap belt and according to the FAA, the ASTM standards are being modified to more clearly reflect this requirement. ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) ## Aircraft - Registration: [N454SA](https://openairdocs.org/deregistered/N454SA-2017-07-14), registration cancelled 2017-07-14, S/N LSA012, built 2007 (OpenAirDocs) - Reported make and model: INIZIATIVE INDUSTRIALI ITALIAN SKY ARROW 600 - Registry model: [Iniziative Industriali Italian SKY ARROW 600 SPORT](https://openairdocs.org/model/iniziative-industriali-italian-sky-arrow-600-sport) (registry code 060003R) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: LSA012 - Airframe hours: 136 - Engines: Rotax GmbH & Co. 912 ULS 98 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Northfield Aviation LLC - Registered owner: Northfield Aviation LLC - Airworthiness certificate: Special, Special light-sport (Special) - Last inspection: 100 hour, August 28, 2008, 15 hours before - Departed: SMO, Santa Monica, CA - Destination: SMO, Santa Monica, CA ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 70; injuries: serious; commercial; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: rear; flight hours: 5,000 total - Pilot; age 39; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: front; flight hours: 150 total ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 54 °F - Altimeter: 29.94 inHg - Observed at: SMO, 10 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 20081007850139A](https://openairdocs.org/incident/20081007850139A), Oct 7, 2008: Inizi 600SPORT, Malibu, CA, Destroyed, 1 fatal. Aircraft was on the return leg of an instructional flight from santa monica airport. The surviving pilot [privacy data omitted] reported there had been no… ## Docket (8 files) The files NTSB released with the investigation on August 15, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=69240. 1.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 391 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350546&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - GPS 17 - Factual Report of Group Chairman (item 2, .PDF, 634 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40319614&FileExtension=.PDF&FileName=GPS%2017%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - LSA Factual Report- Injury Table (item 3, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350548&FileExtension=.PDF&FileName=LSA%20Factual%20Report-%20Injury%20Table%20-Master.PDF - CFI Flight Review (item 4, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350549&FileExtension=.PDF&FileName=CFI%20Flight%20Review-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350557&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350558&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - ASTM Standards- F2245 -07 Seat Belt Req 8.5.1 (item 7, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40350554&FileExtension=.PDF&FileName=ASTM%20Standards-%20F2245%20-07%20Seat%20Belt%20Req%208.5.1-Master.PDF - Hoerner Flight Time Insurance Form (item 8, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352530&FileExtension=.PDF&FileName=Hoerner%20Flight%20Time%20Insurance%20Form-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; 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.