WPR13FA399

NTSB accident investigation · Tyler Ives SD-1 TG · Spanish Fork, UT · September 6, 2013

Accident · FatalField investigationFinal report
Date
September 6, 2013, 08:09 local (14:09 UTC)
Place
Spanish Fork, UT
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N123SDTyler Ives SD-1 TG
Defining event
Maneuvering: Abrupt maneuver
Weather
Visual (VMC) · Day
Status
Completed · report August 5, 2015
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Owner/Builder, Federal Aviation Administration
FAA report
20130906018489A
Case key
87995

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 failure to maintain airplane control while performing prohibited aerobatic maneuvers and the deployment and separation of the ballistic parachute system from the airframe for reasons that could not be determined due to the severity of impact damage to the system.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotTyler Ives SD-1 TG: 1 caseAll aircraft: 9,295 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedTyler Ives SD-1 TG: 1 caseAll aircraft: 2,247 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedTyler Ives SD-1 TG: 1 caseAll aircraft: 1,269 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The owner/builder reported that the accident flight was the fourth test flight for the experimental airplane. One of the three ground crewmembers reported that, for this flight, the pilot wanted to test the airplane's G limits, perform stalls, and conduct touch-and-go takeoffs and landings. While the pilot was flying the airplane in the traffic pattern, two of the ground crewmembers observed the airplane perform an unscheduled roll. About 1 minute later, they observed the airplane perform a second roll. One of the ground crewmembers reported that, about midway through the second roll, the pilot lost airplane control, and the ballistic parachute subsequently deployed with the airplane traveling at a high rate of speed; almost immediately after deployment, the parachute separated from the airframe. The airplane then spun toward the ground and was destroyed by impact forces. The Pilot's Operating Handbook (POH) contained a warning that aerobatics and intentional spins were prohibited. The POH also indicated that the minimum deployment altitude for the parachute was 210 ft and recommended that the parachute be deployed at the lowest airspeed possible and not above 150 mph; the airplane was operating at the airport's traffic pattern altitude of about 1,000 ft above ground level when the parachute deployed. The airplane's never-exceed speed was 131 mph; the airplane's actual speed at the time of the parachute's deployment could not be determined. Although the airplane was likely traveling within the speed and altitude specified for parachute deployment, the pilot was performing a prohibited roll when it deployed. All of the parachute system's hardware was accounted for during the postaccident examination of the system. The examination of the three parachute lines that were attached to the fuselage per the kit specifications revealed that two of the lines had been cut and that the third line exhibited overstress fractures. It is likely that the lines were severed when the parachute was deployed during the roll and that the remaining line then failed due to overload. Due to the severity of the damage and fragmentation of the airframe, it could not be determined if the pilot intentionally deployed the parachute following the loss of control during the roll maneuver or if a malfunction occurred that caused the parachute to deploy unintentionally. Once the parachute separated, the airplane was likely uncontrollable. Although postaccident toxicological tests detected chlorpheniramine, a sedating antihistamine, in the pilot's cavity, it is unlikely that the pilot was impaired at the time of the accident.

Factual narrative

The single-seat, low-wing, fixed-gear, experimental amateur built Skycraft Airplane SD-1 Minisport (SD-1-TG), serial number USA00103, was issued a special airworthiness certificate on February 13, 2013. A Hirth F-23 LW engine, serial number 903429, powered the airplane. The airplane's operating limitations were dated February 16, 2013. A review of the airplane logbook indicated that between August 2013, and September 5, 2013, the airplane and engine had accrued 5.16 hours of flight time. On August 24, following a flight test, which included stall characteristics, the airplane ground looped upon landing. The wing was repaired, and on August 31, the airplane underwent another test flight, which included spin and stall characteristics. The logbook entry indicated that the airplane was spin resistant. The airplane came equipped with a ballistic parachute, Galaxy Rescue Systems (Galaxy Holding s.r.o.); the retaining cables had three anchoring points on the airplane. Two were located at the firewall/engine structure, and the third was located at the aft bulkhead. The parachute cables were attached per the kit specifications, and the activation handle was located on the right side just forward of the flap control. According to the maintenance manual, depending on the model, the main canopy is open and fully inflated between 50-60 feet, in the direction of firing, which is about 1.5-3.2 seconds after being activated. The owner/builder reported that operation testing for the ballistic parachute system was accomplished via computer modeling and information attained from the manufacturer. According to the Pilot's Operating Handbook, under the Operating Limitations for the ballistic recovery system, parachute deployment was recommended to be done at the lowest airspeed possible, and not to exceed 150 miles per hour (mph), and it was recommended that the parachute not be deployed if the airplane becomes inadvertently inverted. The minimum deployment altitude was 210 feet. The airplane's never-exceed-speed was 131 mph. In addition, the Operating Limitations contained a warning that aerobatics and intentional spins were prohibited. The instruction manual for assembly and use of the GRS (Galaxy Rescue System) stated in part that once the system has been activated, once the airplane starts to descend under the canopy to the ground, there may be some aircraft control available, assuming the control surfaces are intact (Part 8. Activation of the system in a hazardous situation page 21 section 8.2 After firing the system). Section 8.5 titled Possible emergency scenarios, identified a "fall into a spin from a low altitude" situation. It stated in part that if the airplane entered into a spin, the pilot should not try to control the spin, but should fire the GRS unit immediately. Another scenario was "pilot disorientation", where the section indicated that in the event of an incapacitation scenario, use of the GRS unit may be the only solution out of theincapacitation event. According to the Airport/Facility Directory for the Spanish Fork Airport-Springville-Woodhouse Field (U77), Spanish Fork, the traffic pattern altitude is 1,000 feet above ground level (5,500 mean sea level) On September 6, 2013, at 0809 mountain daylight time, an Ives SD-1 TG experimental amateur-built airplane, N123SD, departed controlled flight and impacted flat open terrain in a nose-low attitude about 1 mile west of the Spanish Fork Airport-Springville-Woodhouse Field (U77), Spanish Fork, Utah. The pilot operated the airplane under the provisions of 14 Code of Federal Regulations Part 91, as a test flight for the owner/builder of the airplane. The pilot, the sole occupant, was fatally injured; the airplane was destroyed. Visual meteorological conditions prevailed for the local area flight that departed U77 about 0805, and no flight plan had been filed. According to the owner of the airplane, the accident flight was the fourth test flight. Ground crew members reported that the pilot arrived at the airport about 0645, and a preflight inspection was performed, with no discrepancies noted with the airplane. Three GoPro cameras were mounted to the airplane and to the pilot. The ground crew also reported that the pilot was flying the airplane in the traffic pattern at the time of the accident. One of the ground crew reported that he did not personally witness the accident, but he stated that the other ground crew started shouting about the pilot performing barrel rolls, which he had never performed before. He further reported that the barrel rolls were not scheduled for the day's test flight. Another one of the ground crew reported that the pilot performed one roll, and midway through the second roll, the ballistic parachute was deployed, almost immediately separating itself from the airframe. He stated that the airplane began to spin at a rapid rate until it impacted the ground. The last ground crew member reported that the pilot had wanted to test G-limits of the airplane, perform a few stalls, and some touch-and-go takeoffs and landings. He stated that the pilot performed a few stalls to full recovery, and then proceeded to do one successful roll. As the pilot attempted to do a second roll, he lost control of the airplane. The parachute was pulled at a high rate of speed, detaching from the airplane. Two of the ground crew reported that the pilot was equipped with a radio, but he had not made radio contact with them. A postmortem examination was conducted by the Utah Department of Health, office of the Medical Examiner. The cause of death was reported as total body blunt force injuries. The toxicology was positive for carboxyhemoglobin detected in the abdominal cavity blood (USL) 7.4 percent. Chlorpheniramine detected in cavity blood (FAA) 0.012 mg/L, as well as a positive detection in the liver. The Federal Aviation Administration's (FAA) Forensic Toxicology Research Team, Civil Aerospace Medical Institute, performedforensic toxicology on specimens from the pilot. The toxicology was negative for carbon monoxide, and volatiles. A cyanide screening was not performed. The toxicology was positive for chlorpheniramine which was detected in the liver, and 0.012 (ug/ml, ug/g) chlorpheniramine detected in blood (cavity). Chlorpheniramine is a sedating antihistamine used to treat allergy and common cold symptoms. It is available over the counter under various trade names, including Chlor-Trimeton and Chlortabs. The pilot, age 40, held a commercial pilot certificate with ratings for airplane single-engine and multiengine land, and instrument airplane. He also held a certified flight instructor (CFI) certificate with ratings for airplane single-engine and multiengine land, and instrument airplane. The pilot was issued a second-class airman medical certificate on May 3, 2013; it had the limitation that the pilot must wear corrective lenses. At the time of his medical examination, the pilot reported a total time of 930 hours with 130 hours accrued in the last 6 months. The pilot's logbook was not located during the investigation. According to the airplane owner, the accident pilot had been their test pilot; the pilot had flown the airplane on each of its three previous test flights, accumulating about 3-4 hours of flight time. Flight control continuity was established from the cockpit to the rudder, and through identification of the associated hardware; aileron control tubes and associated hardware were identified. The wooden propeller had been destroyed during the accident sequence. Also during the accident sequence, the engine case had been split in two. All major components were accounted for. Examination of the parachute system revealed that all hardware was accounted for. However, due to extensive damage to the parachute system, a functional check could not be performed. Three fiber rope cables from the parachute to include attached fuselage fragments, two pieces of control tube, and a portion of fiberglass fragment, were sent to the National Transportation Safety Board (NTSB) Material/s Laboratory for examination. The control tubes exhibited bending overstress fracture features. According to the NTSB Materials Laboratory specialist, the airplane had been equipped with a Galaxy GRS 6/375 ballistic parachute system. The parachute was located immediately behind the cockpit and the cables were attached to three mounting points on the fuselage. For the purpose of this report, the three parachute cables had been labeled Line A, B, and C. Examination of parachute line A utilizing 50X to 200X zoom digital microscope revealed that the filaments at the frayed end had fractured in overstress. The Materials Laboratory specialist further noted that a fragment of the fuselage remained connected to line A; it exhibited overstress fractures as well. Examination of parachute lines B and C revealed that the lines were unremarkable, and that both lines had been cut. The detailedreport is attached to the public docket for this accident. The pilot's Apple iPhone 4 had been recovered and shipped to the NTSB's Vehicle Recorder Division. The recorder specialist reported that two photos were recovered from the day of the accident. One picture, partially blurred the occupant, showed the nose of the airplane pointed toward the ground. The second picture recorded the weather. A detailed report is attached to the public docket for this accident. Two GoPro's were also located in the wreckage, and shipped to the NTSB Vehicle Recorder Division. Due to impact damage, the recorder specialist was not able to recover any information. The airplane impacted an open field, with a debris field of about 200 feet. The entire airplane came to rest at the accident site; however, it was destroyed by impact forces.

Aircraft

Registration
N123SD
Reported as
Tyler Ives SD-1 TG
Category
Airplane, amateur-built
Serial number
USA00103
Airframe hours
5
Engine
Hirth F-23 LW, 50 horsepower, reciprocating
Damage
Destroyed
Flight
Flight test · Part 91
Airworthiness certificate
Special, Experimental (Special)
Last inspection
Continuous airworthiness · August 30, 2013
Departed
U77 · Spanish Fork, UT
Destination
U77 · Spanish Fork, UT
Airport
U77 · Spanish Fork Airport

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
40
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Single
Restraint
3-point
Toxicology
Performed
Flight hours
930 total · 0 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
120° at 5 knots
Visibility
15 statute miles
Lowest ceiling
None
Temperature
66 °F, dew point 55 °F
Altimeter
30.17 inHg
Observed at
KPVU, 5 nm away

Docket · 18

The files NTSB released with the investigation on July 30, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 17.2 MB in all.

FAA reports on this event · 1

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