# NTSB WPR12FA395: Skykits USA Savannah ADV, N9764J, Murtaugh, ID, September 3, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 3, 2012 - Place: Murtaugh, ID - Coordinates: 42.238609, -114.160835 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.2386&lon=-114.1608&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report October 9, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 84895 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12FA395 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84895/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84895 - Page: https://openairdocs.org/ntsb/WPR12FA395 ## Probable cause The pilot's failure to maintain adequate airspeed while maneuvering at or above the airplane's maximum ceiling, which resulted in a stall and a subsequent loss of airplane control. Contributing to the accident was the pilot's decision to operate the airplane in the high density altitude conditions, which placed the airplane near or above its maximum ceiling. ## 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); cases with it: [Skykits USA SAVANNAH ADV, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=060002D), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Skykits USA SAVANNAH ADV, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=060002D), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Skykits USA SAVANNAH ADV, 1 case](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=060002D), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Aircraft capability](https://openairdocs.org/ntsb-findings/01061000): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Skykits USA SAVANNAH ADV, 1 case](https://openairdocs.org/ntsb-findings/01061000/cases.md?model=060002D), [All aircraft, 57 cases](https://openairdocs.org/ntsb-findings/01061000/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Skykits USA SAVANNAH ADV, 1 case](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=060002D), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Skykits USA SAVANNAH ADV, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=060002D), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Terrain: wet/muddy terrain](https://openairdocs.org/ntsb-findings/03021035): Environmental issues › Physical environment · Not specified; cases with it: [Skykits USA SAVANNAH ADV, 1 case](https://openairdocs.org/ntsb-findings/03021035/cases.md?model=060002D), [All aircraft, 110 cases](https://openairdocs.org/ntsb-findings/03021035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Skykits USA SAVANNAH ADV, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=060002D), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot was flying over his mountainous ranch property to check on his cattle following a fire. When he did not return, the family reported him overdue. The wreckage was subsequently found on the ranch property at an elevation of about 7,115 feet mean sea level. The density altitude at ground level was estimated to be about 12,495 feet; the operating limitations for the airplane state that the maximum ceiling is about 14,000 feet pressure altitude at maximum weight. On-site wreckage documentation indicated that the airplane collided with terrain in a nearly vertical attitude. Because of the high density altitude on the day of the accident and the elevation of the terrain, the pilot had little altitude within which to operate before reaching the airplane's maximum ceiling. It is likely that, while maneuvering the airplane near or above the airplane's maximum ceiling, the pilot failed to maintain adequate airspeed, which resulted in a stall and a subsequent loss of control. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. ## Factual narrative The single-engine, high-wing airplane was a Skykits USA Corporation Savannah ADV, serial number 07-07-51-621. A review of the airplane's logbooks revealed that the airplane had a total airframe time of 300.1 hours at the last engine maintenance performed (an oil change) on August 12, 2012. The last annual inspection was on June 1, 2012, at a total airframe time of 276.6 hours. The engine was a 100-horsepower ROTAX 912 ULS, serial number 5649340. Total time recorded on the engine at the last annual conditional inspection was 276.6 hours. The operating limitations state that the maximum ceiling is about 14,000 feet pressure altitude at maximum weight. However, if the pilot is operating under sport pilot privileges, FAR Part 61.315 (C) (11), restricts the airplane to 10,000 feet msl, or 2,000 feet above ground level (agl), whichever is higher. On September 3, 2012, at an undetermined time, a Skykits USA Corp Savannah ADV, N9764J, collided with terrain near Murtaugh, Idaho. The pilot/owner was operating the airplane under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The commercial pilot sustained fatal injuries; the airplane sustained substantial damage. The local personal flight departed Twin Falls, Idaho, about 1200. Visual meteorological conditions prevailed, and no flight plan had been filed. The pilot had indicated to family members that he was going to fly up to his mountain ranch property to check on his cattle following a fire. When he did not return, the family reported him overdue, and the Federal Aviation Administration (FAA) issued an Alert Notice (ALNOT). The Cassia County Sheriff reported that the wreckage was discovered about 2030 MDT. The Cassia County Coroner, Burley, Idaho, completed an autopsy, and found blunt force trauma as the cause of death. The FAA Forensic Toxicology Research Team, Oklahoma City, performed toxicological testing of specimens of the pilot. Analysis of the specimens contained no findings for carbon monoxide, cyanide, or volatiles. The report contained the following findings for tested drugs: amlodopine detected in urine; amlodipine detected in blood (cavity); metoprolol detected in liver; metoprolol detected in blood (cavity). The closest official weather observation station was Twin Falls, Idaho (KTWF), which was 21 nautical miles (nm) northwest of the accident site at an elevation of 4,154 feet mean sea level (msl). An aviation routine weather report (METAR) for KTWF issued at 1153 MDT stated: wind from 030 degrees at 5 knots; visibility 10 miles; sky clear; temperature 23/73 degrees Celsius/Fahrenheit; dew point -1/30 degrees Celsius/Fahrenheit; altimeter 30.16 inches of mercury. The elevation of the accident site was approximately 7,115 feet, which was about 3,000 feet higher than the reporting weather station. Using a dry adiabatic lapse rate of 3 degrees F per thousand feet; the accident site temperature would be 67 degrees F with a dew point of 21 degrees F. Using a pressuredifferential (between 5,000 and 10,000 feet) of 0.86 inches per 1,000 feet, the atmospheric pressure would decrease from 30.16 to 27.20 inches. Using those numbers in a density altitude calculator, the calculated density altitude was 12,495 feet. A review of Federal Aviation Administration (FAA) airman records revealed that the 81-year-old pilot held a commercial pilot certificate with ratings for airplane single-engine land and instrument airplane. The pilot held a third-class medical certificate issued on January 7, 2010. It had the limitation that the pilot must wear corrective lenses. The pilot's medical certificate had expired, but he was operating a light-sport airplane. No personal flight records were located for the pilot. The IIC obtained the aeronautical experience listed in this report from a review of the FAA airmen medical records on file in the Airman and Medical Records Center located in Oklahoma City, Oklahoma. The pilot reported on his medical application that he had a total time of 3,000 hours with 11 hours logged in the last 6 months. The National Transportation Safety Board investigator-in-charge (IIC), the FAA, and an investigator representing ROTAX examined the wreckage at the owner's hangar on October 31, 2012. A detailed report is part of the public docket. The postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. An FAA inspector examined the wreckage on scene. The airplane came to rest nose down in a stand of willow trees in a marshy area. Only the trees in the immediate area of the wreckage had broken branches. The cabin area was crushed aft, and the leading edges of the wings were in contact with the ground. The fuselage buckled 90 degrees aft of the cabin so that the empennage was in a horizontal upright position. He established control continuity for the rudder and elevators to the crushed cabin area. The ailerons remained connected. ## Aircraft - Registration: [N9764J](https://openairdocs.org/deregistered/N9764J-2018-02-12), registration cancelled 2018-02-12, S/N 07-07-51-621, built 2008 (OpenAirDocs) - Reported make and model: SKYKITS USA CORP SAVANNAH ADV - Registry model: [Skykits USA SAVANNAH ADV](https://openairdocs.org/model/skykits-usa-savannah-adv) (registry code 060002D) (OpenAirDocs) - Registry engine: [Rotax 912ULS series](https://openairdocs.org/engine/rotax-912uls-series) (registry code 55572, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 07-07-51-621 - Year built: 2008 - Airframe hours: 276 - Engines: ROTAX 912ULS 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Joseph Tugaw - Registered owner: Joseph Tugaw - Airworthiness certificate: Special, Special light-sport (Special) - Last inspection: Annual, June 1, 2012, 24 hours before - Departed: Twin Falls, ID - Destination: Twin Falls, ID ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 81; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 3,000 total ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 30 °F - Altimeter: 30.15 inHg - Observed at: KTWF, 21 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 20120903017859A](https://openairdocs.org/incident/20120903017859A), Sep 3, 2012: Skykits USA Corp SAVANNAH ADV, Murtaugh, ID, Destroyed, 1 fatal. Pilot lost control of aircraft entering a stall-spin while manuevering searching for livestock. ## Docket (8 files) The files NTSB released with the investigation on October 6, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84895. 18.4 MB in all. - Photo 1 – Aerial view of Site 1 (item 1, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417418&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93%20Aerial%20view%20of%20Site%201-Master.PDF - Photo 2 – Aerial view of Site 2 (item 2, .PDF, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417419&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20Aerial%20view%20of%20Site%202-Master.PDF - Photo 3 – Top of Cabin at Site (item 3, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417420&FileExtension=.PDF&FileName=Photo%203%20%E2%80%93%20Top%20of%20Cabin%20at%20Site%0D%0A-Master.PDF - Photo 4 – Bottom of Cabin at Site (item 4, .PDF, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417421&FileExtension=.PDF&FileName=Photo%204%20%E2%80%93%20Bottom%20of%20Cabin%20at%20Site-Master.PDF - NTSB Airframe and Engine Examination Report (item 5, .PDF, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417422&FileExtension=.PDF&FileName=NTSB%20Airframe%20and%20Engine%20Examination%20Report-Master.PDF - Record of Conversation – FAA Inspector (item 6, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417423&FileExtension=.PDF&FileName=Record%20of%20Conversation%20%E2%80%93%20FAA%20Inspector-Master.PDF - Savannah Operating Limitations (item 7, .PDF, 649 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417425&FileExtension=.PDF&FileName=Savannah%20Operating%20Limitations-Master.PDF - Toxicology Report (item 8, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40417426&FileExtension=.PDF&FileName=Toxicology%20Report-Master.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.