NTSB Factual Report

***This report was modified on October 14, 2015. Please see the docket for this accident to view the original report.***

HISTORY OF FLIGHT

On August 16, 2013, about 1600 Pacific daylight time, a special-light sport airplane (S-LSA), Urban Air SRO Samba XXL, N19UA, collided with flat desert terrain about 20 miles east of Carson City, Nevada. The airplane was operated by the owner under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. The sport pilot and passenger were fatally injured; the airplane was substantially damaged. The flight departed from the Carson Airport, (CXP), Carson City, Nevada, at an undetermined time. Visual meteorological conditions prevailed for the flight, and no flight plan had been filed.

According to a deputy from the Lyon County Sheriff's Department, a call had been received from a motorist, who had observed the airplane wreckage from the road. The motorist indicated that the accident site was a mile inland, and two people were on board. The accident location was described as flat desert terrain.

PERSONNEL INFORMATION

Sport Pilot (right seat)

The pilot, age 72, was a sport pilot, and had been issued a Federal Aviation Administration (FAA) form 8710-2 student pilot certificate on July 7, 2011, with no limitations; the expiration date was July 31, 2016. A review of the pilot's logbook by the National Transportation Safety Board investigator-in-charge (NTSB IIC) revealed that the pilot logged 80.1 hours as of January 3, 2013. The NTSB IIC estimated his total time from January 3 to August 14, 2013, as 47.7 hours. The pilot's estimated total time was 128.8 hours, with 79.1 hours in the accident airplane make and model. The pilot's logbook endorsements included an initial solo endorsement dated September 30, 2012, and his sport pilot airspace and airspeed endorsements were dated April 23, 2013.

Student Pilot-rated passenger (Left Seat)

According to the Federal Aviation Administration (FAA) airmen medical records in Oklahoma City, Oklahoma, the 63-year-old student pilot-rated passenger had been issued a medical certificate on June 15, 1983, and it listed his total flight time as 12 hours with 0 hours accrued in the 6 months prior to the medical certificate application. On the pilot's most recent medical application dated March 10, 1987, the pilot listed his total hours as 0, with 2 hours accrued in the previous 6 months.

AIRCRAFT INFORMATION

The two-seat, low-wing, fixed-gear airplane, serial number SA XXL 79, was manufactured in 2008. It was a fiberglass/carbon-fiber constructed airplane with side-by-side seating. The airplane had been powered by a Rotax 912ULS 100 hp engine, and equipped with a Woodcomp SR200 propeller.

According to the airframe logbook, the last entry dated May 29, 2013, reported a total time of 210.7 hours. A review of the engine logbook showed an entry dated June 29, 2013; total time on the engine was reported as 229.4 hours. The entry was for a 25-hour service that included an oil and filter change.

In the airplane operating manual, under AIRCRAFT DESCRIPTION, it stated that the airplane was not approved for aerobatic operation. There was also a WARNING that stated that aerobatics, intentional spins, and stalls were prohibited. Identified under MISCELLANEOUS EQUIPMENT, the airplane manual indicated that in addition to standard equipment, the airplane may be equipped with a ballistic rescue system supplied by GALAXY/BRS (Ballistic Recovery System)/STRATOS. The accident airplane had been equipped with a Magnum 601 serial number 040 S-LSA ballistic recovery system.

According to the Magnum manual Part 2, Use of the Rescue System, this section reported situations when it is possible to use the rescue system. One such situation was "a loss of piloting control on other reasons." The minimum recommended effective altitude for activation of the parachute was listed as 200 meters (656 feet), at a maximum airspeed of 180.2 miles per hour. The manual also indicated that before flight the pilot was to unlock the activation handle by removal of the locking pin and inform passengers of the operation of the parachute system.

Section 6.2 of the manual titled Location of the launching handle of the rescue system Magnum, it stated that the handle must be reachable by both pilots and visible in their peripheral vision. The best identified position for pilots seated next to each other was proved to be in between both pilots by the instrument panel. There were two ATTENTION! notes; the first one reported that the activation handle must be easily accessible, graspable, and not near another adjusting element of similar form in order to avoid confusion and unintended activation of the rescue system. The other attention note indicated that "Before the flight unlock the rescue system! [Immediately] after the flight do lock it!"

WRECKAGE AND IMPACT INFORMATION

The airplane was located intact, lying on its belly with the landing gear collapsed underneath the fuselage on the flat open desert terrain. The engine had been displaced with the nose positioned slightly downward. All flight control surfaces were accounted for. The entire horizontal stabilizer had separated from the aft empennage and lying on the ground directly below the vertical stabilizer. Immediately behind the wreckage was a short distance of ground disturbance.

FAA inspectors responded to the accident site and reported that the pilot and passenger remained in their seats secured by their seatbelts. They further reported that the parachute locking pin, with red warning flag that read "Warning! Remove Before Flight," was secured in the parachute activation handle inside of the cockpit. The parachute activation handle was physically located on the outboard left section and underneath the instrument panel.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination was conducted on the sport pilot on August 16, 2013, by the Washoe County Medical Examiner's office, Reno, Nevada. The cause of death was listed as multiple injuries due to blunt force trauma. Additionally, the autopsy identified a low-grade malignant lymphoma, and a 2 cm right occipital brain tumor.

The FAA's Forensic Toxicology Research Team, CAMI, performed forensic toxicology on specimens from the pilot. The results were negative for carbon monoxide and volatiles; cyanide screening was not performed. The specimens were positive for tested drugs; Paroxetine detected in urine, but not detected in blood (cavity), Ranitidine detected in blood, but not detected in blood (cavity). Ranitidine is a non-sedating acid reducing medication commonly marketed as Zantac. Paroxetine is used for treatment of depression.

Review of the pilot's personal medical records by the NTSB medical officer identified that the pilot had been prescribed paroxetine for treatment of depression. Paroxetine is an antidepressant medication marketed as Paxil. Patients are cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that it did not affect their ability to engage in such activities. The records documented recent examinations in April and June of 2013, which reported that the pilot had no recent abnormal neurological findings and stated his depression was well controlled with paroxetine. Additionally, the pilot reported fatigue, but testing was unable to identify a source of his symptoms.

TEST AND RESEARCH

A postaccident examination of the airplane and engine was performed at Air Transport, Phoenix, Arizona, on September 19, 2013. There was no evidence of a pre impact mechanical malfunction that would have precluded normal operation of the airplane or engine. The examination report is attached to the public docket for this accident.

Flight control continuity was established from all the flight control surfaces to the cockpit. The parachute had not deployed, and the cable remained connected; the parachute locking pin with warning flag remained inserted into the parachute activation handle.

A visual examination of the engine revealed no obvious holes in the engine case. The engine remained attached to the engine mounts and firewall. Drive and valve train continuity were established throughout the case; thumb compression was obtained in all cylinders in firing order, via manual rotation of the engine.

The propeller assembly remained connected to the engine via the crankshaft. One of the three propeller blades remained connected to the propeller hub, the other two propeller blades separated at the hub. All three of the propeller blades remained relatively undamaged with the exception of one of the separated propeller blades had a broken tip.

A Garmin GPSMap 496 device was shipped to the NTSB Vehicle Recorder Division in Washington, DC, and was downloaded by a vehicle recorder specialist. The specialist was able to download 35 sessions (flights) from June 29, 2013, through August 16, 2013, which included the accident flight. There were 92 data points extracted that began at 1600:28 and ended at 1611:29.

At 1600:28, the reported altitude was 5,610 feet and 0 knots. The data showed a square flight pattern, with a departure toward the south. The data indicated that the airplane made a left turn, and at 1611:29, the track terminated at an altitude of 4,272 feet at 0 knots, at a location consistent with the accident site. At 1609:08, the reported altitude was 7,743 ft. at 88 knots. Approximately 39 seconds later, the airplane reached an altitude of 7,579 feet at 76 knots. For the next minute 42 seconds, the data points continue to decrease in altitude and groundspeed. At 1610:34, the airplane was at an altitude of 6,998 feet and a groundspeed of 29 knots. Six seconds later the airplane had descended to 6,339 feet, and the groundspeed was 16 knots. Eight seconds later the airplane was at an altitude of 5,476 feet at a groundspeed of 9 knots. During the last 41 seconds the data points indicated that the airplane descended to 4,272 feet, and the recorded groundspeed was 0 knots. A detailed report is attached to the public docket for this accident.

ADDITIONAL INFORMATION

According to 14 CFR Part 301-303, as it pertains to sport pilot, the sport pilot needs only a valid driver's license, and should "not know or have reason to know of any medical condition that would make that person unable to operate a light-sport aircraft in a safe manner."

NTSB Probable Cause

The pilot's failure to maintain adequate airspeed while maneuvering, which led to the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall/spin. Contributing to the accident was the improper location of the parachute activation handle and the pilot's failure to remove the handle's locking pin before flight.