NTSB Case Study

REPORT

INTRODUCTION TO INCIDENT

BASIC INFORMATION

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2

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Slight pitch up before base leg turn.

Video showed signs of aerodynamic buffeting.

Loss of control with alternating right and left rolls.

Experimental amateur-built airplane recently purchased by two private pilots.Rear-seat pilot received a 2.5-hour familiarization flight from previous owner.Previous owner recommended further instruction; advice was declined due to pilot’s confidence.

Conducted 4 successful takeoffs and landings in traffic pattern.

Incident occurred during the 5th circuit.

Onboard video captured the events leading up to the accident.

LOCATION: PHOENIX, ARIZONA

DATE & TIME: AUGUST 20, 2018 6:45

AIRCRAFT: JAMES E CONVEY ACRODUSTER II

INJURIES: 2

AIRCRAFT DAMAGE: SUBSTANTIAL

RISKS

No Logbooks Available from Either Pilot:

Declining Recommendation for Further Training:

No pre-existing anomalies found in the airplane or engine.Stall/spin condition entered during maneuvering.Recovery was not possible due to low altitude.

Unclear which pilot was in control during the accident.No logbooks available to review pilots’ flight experience and recency.

Likelihood: Probable – A new owner declining additional training on an unfamiliar aircraft is likely to miss out on critical information and skills necessary for safe operation.

Severity: Catastrophic – The lack of proper training can lead to a lack of understanding of the aircraft's limits and emergency procedures, which in turn can result in accidents with fatal outcomes.

Risk Level: High – The combination of a probable likelihood and catastrophic severity indicates a high risk that should be addressed immediately with appropriate training measures to ensure the pilot's proficiency and safety.

Likelihood: Occasional – The absence of logbooks does not directly cause accidents but indicates a lack of documented experience which could contribute to unsafe operations.

Severity: Critical – Not knowing the pilots' experience or recency could be critical if they are put in a demanding situation that exceeds their skill level.

Risk Level: Medium – While not having logbooks is a concerning sign of potential unrecorded training gaps or recency issues, the actual risk level would depend on the true, albeit unknown, experience of the pilots.

LET'S BRAINSTORM SOLUTIONS

Propeller/Engine Were Removed and Replaced 31 Hours Ago:

Tailwheel Airplane:

HAZARDS vs

RISKS

Likelihood: Remote – Assuming proper installation and testing were conducted, modern aviation standards should minimize the risk of a mechanical failure soon after replacement.

Severity: Catastrophic – Any engine or propeller failure in flight, especially if not handled correctly, could result in a catastrophic outcome.

Risk Level: Medium – Even with a remote likelihood, the severe potential outcome dictates a cautious approach to risk management.

Likelihood: Occasional – Tailwheel (conventional gear) airplanes are known for being more challenging during takeoff and landing, especially for those with less experience with this type of gear.

Severity: Marginal to Critical – Incidents involving tailwheel airplanes are often during the takeoff or landing phase and can range from a ground loop with minor damage (marginal) to a crash upon takeoff or landing (critical).

Risk Level: Medium – Pilots need specific training and recency in tailwheel aircraft to mitigate this risk effectively.

HAZARDS

RISKS

Purchasing and Flying an Amateur-Built Airplane & Declining Recommendation for Further Training:

• PURCHASING AND FLYING AMATUER BUILT AIRPLANE
• DECLINING RECOMMENDATION FROM PREVIOUS OWNER TO GAIN MORE PROFICIENCY WITH FLIGHT INSTRUCTOR
• BOTH PILOTS OVER 40
• NO LOGBOOKS AVAILABLE FROM EITHER PILOT
• PROPELLER/ENGINE WERE REMOVED FROM THE AIRPLANE ON JUNE 1ST 2016. 31 HRS ACQUIRED SINCE REPLACEMENT
• TAILWHEEL AIRPLANE

BOTH PILOTS OVER 40

Likelihood: Remote – Age itself does not necessarily correlate with incident likelihood, but health-related issues could be a factor that increases with age.

Severity: Critical to Marginal – An incident related to the pilots' age could potentially be critical if it involves a health crisis during flight, but it could also be marginal if age does not play a direct role in the flight's outcome.

Risk Level: Medium to Low – The risk is more personalized based on the individual health and fitness level of the pilots, thus varying greatly.

Likelihood: Probable – Amateur-built airplanes can have different handling characteristics, and without adequate training, the likelihood of an incident could increase. Higher risk for operational malfunction.

Severity: Catastrophic – Inadequate proficiency in handling a unique aircraft can lead to accidents with fatal outcomes.

Risk Level: High – This combination points towards a high-risk level, warranting significant mitigation actions, such as mandatory additional training.