NTSB Factual Report

1.1 HISTORY OF FLIGHT

On April 6, 2005, at 1300 Hawaiian standard time, a Schweizer SGS 2-32 glider, N693U, impacted mountainous terrain 0.4 miles south of the Dillingham Airfield, Mokuleia, Hawaii. The commercial glider pilot was fatally injured and the two passengers sustained minor injuries. The glider sustained substantial damaged. Sailplane Ride Adventures, Inc., owned and operated the glider under the provisions of 14 CFR Part 91 as a scenic sailplane ride. Visual meteorological conditions prevailed, and a flight plan had not been filed for the local flight. The 20-minute commercial scenic flight was in the air approximately 17 minutes.

1.1.1 Passenger and Witness Statements

According to an interview summary provided by the Federal Aviation Administration (FAA), the passengers reported that they were circling around a hill and thought that they were returning to the airport. The glider crossed over a ridge to a valley to look at a waterfall. The glider turned left then right in a gentle but accelerating manner. The glider also pitched up and down, and the passengers felt like they were falling. The pilot announced that they were "going in." The glider impacted trees and terrain, and came to rest upside down.

A witness, who had 7,000 hours of glider experience and was flying at the time of the accident, observed the accident glider behind her, heading east approximately 400 to 500 feet above the ridge. She checked back on the glider's position relative to hers and noticed the glider "turn right (toward the ridge) and its nose come up slightly." The glider turned "approximately 45 degrees to the right, then turned back to the left and immediately entered a spin to the left." The witness reported that the glider rotated twice before it entered a spin to the right. The witness then lost sight of the glider behind trees before it completed a rotation to the right.

1.1.2 Onboard Video and Audio Recording System

The glider was equipped with a custom designed and installed video and audio recording system intended to provide customers with a video record of their tour flight. The videotape was retrieved from the accident glider and sent to the National Transportation Safety Board Vehicle Recorders Division located in Washington, D.C. A Vehicle Recorders Division engineer provided a factual summary and partial transcripts gleaned from the onboard video recording. The VHS tape was recorded by an on-board video/audio recording system that would normally provide two camera views; one inside the glider looking rearward at the passenger(s) in the rear seat, and another camera in the tail of the glider with a view looking forward. Both cameras could be recorded at the same time, with one set as the "main view" that would fill the viewing screen, and the other as a smaller inset overlaid on top of the main view, in the upper left portion of the viewing screen, in a "picture-in-picture" type of configuration. Two individual video frames (about 0.06 seconds), located at the beginning of the recording, show the "main view" from the internal camera and the smaller inset view from the external tail camera. However, for the remainder of the recording the view from the tail camera was not recorded. Both the main full screen view and the small inset area contained the same video, from the interior passenger view camera. The VHS tape contained about 20 minutes 12 seconds of recorded data

While primarily an internal view of the glider, small portions of the side and overhead canopy were visible, along with a waist up view of the passengers. The pilot was generally not visible, though occasionally his left arm/shoulder, neck, and left side of his face were visible. No controls or instruments could be seen in the recording. Audio was recorded consisting of communication between the pilot and the passengers, describing the landmarks and sights on the tour. Some relative motion can be seen in the clouds above and behind the glider, and at times, some ground features can be seen in the background. There were no audio or visual cues that indicated any problems with the glider or its operation, the weather, or any other concerns, until about 1 second before the end of the recording. While the location and altitude of the glider at the time of the end recording could not be determined from the video, it appeared that the recording ended prior to impact, and after the airplane had been rolling toward the left (the roll attitude could not be determined, only the trend in roll as indicated by the clouds in the background).

A partial transcript of the conversation between the pilot and passengers was generated by the Safety Board Vehicle Recorders Division. The transcript was limited to statements or observations that may provide information about the location or operation of the glider, other traffic, weather conditions, and conversations about the pilot's experience. Review of the transcripts revealed that the male passenger asked, "with these wind currents you guys can stay up for, hours?" The pilot answered, " Yup. Today not so much cause it's mostly ah east wind...but when it's a northeast wind we can stay up for as long as we want." Later the male passenger asked if, "the weather was good would you go further south and north...?" The pilot responded, "...if lift was a little better, I'd go you know, further west and further east but...lift just isn't doin well for us so that's our main concern since we don't have any other ways...of makin it back to the airport. And when the lift is good and we're at about 3,500 feet, I'll go way into the Great Valley way over there and cruise around, have some fun over there, but, its just not enough today." The pilot then mentioned a waterfall and conducted a steep turn. Following the steep turn, he began to report on some of the local highlights. The male passenger then asked, "So how long did it take you to get your license...six months?" The pilot answered, "Uh I think it was close to that...but I was flyin everyday, so..." Near the end of the recording the pilot began to point out a 200-foot waterfall to the passengers and said he would make a slight turn so they could see it (clouds/horizon in background indicate a roll to the right). He pointed it out and said it was tough to see and began a roll back toward the left. About 8 seconds later the pilot said, "Whoa, we're in some sink here," which was the last recorded communication.

2.1 PERSONNEL INFORMATION

2.1.1 Pilot Information

The pilot began his glider flight training in January 2005, and received his student pilot certificate on February 18, 2005. On March 16, 2005, the pilot failed his first attempt to obtain his private pilot certificate with a glider rating (in the areas of weather information, operation of systems, visual signals, airport, national airspace, and runway and taxiway signs, markings and lighting), but on March 24, 2005, he successfully passed the private pilot check ride with a FAA Designated Examiner (DE). On March 26, 2005, he obtained his commercial pilot certificate with a glider rating from the same DE that gave him his private pilot certificate 2 days prior. According to the pilot's logbook, as of April 5, 2005 (the day before the accident), he accumulated a total of 48.4 hours of flight time, of which 31.2 hours were as pilot-in-command and 7.1 hours were accumulated in the accident glider make and model. The logbook entries indicated that the pilot provided 7.8 hours of scenic tour flights prior to the accident. Review of the pilot's logbook revealed that he began providing scenic flights to the public on the day of his commercial check ride.

2.1.2 Pilot Training

Review of the pilot's Glider Flight & Ground Training Syllabus for the student, private, and commercial course revealed he obtained ground and flight training in spins and spin recovery (left and right spins, spins from a steep turn, uncoordinated over-the-top spins, and secondary stall-spins) on the same day (February 19, 2005) that he received training in the following subject areas:

Knowledge and Practical Training:

Simulated Off-Field Landings

Steep Spirals

Aircraft Weight and Balance

Cross-Country Flight Profiles

Dillingham Field Checkout

Recovery From Bad Bounce Procedures

Simulated Off Field Landing Procedures

Landing - Crab for Cross Wind

Spot Landing - Spoilers Open and Closed

Traffic Patterns with All Instruments Covered

Glide Slope Angles - No Altimeter Used

Unusual Attitudes Recognize & Recovery

Wings Level Full Rudder Stall with/without Spoilers

Proper Clearing Turns

Practical Training:

Transition Up & Down Through Wake

Wake Orientation

Slack Creation in a Turn with Recovery

Slack Prevention

Box the Wake Procedures

Steering the Tow Plane

Collision Avoidance

Rope Break Procedures 100 feet

Rope Break Procedures 500 feet

Full Traffic Pattern - Landing Alternatives

Emergency Procedures - Can't Release

Down Draft Recognize and Recovery

Simulation Spoilers Stuck Open

Simulation Spoilers Stuck Closed

Emergency Procedures Too Low on Final

Low Pattern Entry (Emergency Procedures)

Emergency Procedures Land on Tow

Rope Break 300 feet (180-degree Turn Downwind)

Actual Tow-Plane Wave-Off

Downwind Landing (below 10 knots)

Simulated Off-Field Landing

Determine Safe Altitude

Final Approach Pitch Down After Opening Spoilers

Slips vs. Skids

Slips to a Spot Landing

Turning Slip Procedures

Side Slip Procedures

Spiral Dive Entry Recovery/Prevention

Turning Stalls - Spoilers Open/Closed

Knowledge Training:

The Use of and Calculation of Thermal Index

Density Altitude

Air Traffic Control (ATC) Clearance Lights

Wave Soaring Techniques

Convergence Lift Techniques

Determine Wind Direction From Field Circle

Base Turn Call Out - Too High/Low or OK

Landing - Wings Level Side Step Maneuver

Cloud Clearance & Visibility Requirements

Tow Plane Pilot Requirements

Review of the pilot's logbook revealed he flew his first solo flight on February 19, 2005, and continued flying solo flights until March 15, 2005, when he began receiving training in preparation for the private pilot check ride. When asked to review the accident pilot's pre-solo written exam, the operator reported that he could not find the exam and indicated that he remembered the pilot "did very well." When asked if he knew why the accident pilot failed his private pilot certificate, the operator indicated that he failed the knowledge portion of the exam and the examiner didn't fly with the pilot. The operator added that after the failure, he asked the pilot what he had been studying. The pilot presented the operator with the training books used for the certified flight instructor (CFI) course, specifically the CFI oral test guide. The operator added that the pilot never received the private pilot test guide.

The pilot logged 1.3 hours of spin training, which was received in the accident glider make and model. According to the operator, the pilot received spin training from three instructors; his usual instructor, the operator, and another instructor. The operator indicated that he required all commercial students to obtain spin training in the accident glider (Schweizer SGS 2-32) and the accident pilot had received emergency procedure and spin training from the operator. He added that he conducted two flights with the accident pilot where they climbed to 5,000 feet to conduct spin training. He said on one occasion the accident pilot didn't get the stick forward enough on a spin recovery and got into a secondary stall. He then had the accident pilot demonstrate two more successfully. The operator reported overseeing the pilot's training in spins that included steep turn spin entries and recoveries, cross-control spins, over-the-top spin entries and recoveries. After the accident pilot demonstrated these, the operator indicated he was "Good to go and give rides."

The operator informed investigators that he told the pilot not to go back so far on the ridge due to the possibility of severe downdrafts. He also indicated that their standard operating procedure was to stay at least 2,500 to 3,000 feet mean sea level (msl) while flying over the ridge where the accident was located. He expressed the importance of not going toward the south side of the ridgeline, which was subject to downdrafts. The operator also reported that he emphasized this because in 1995, they had a SGS 2-33 glider experience a similar situation and crash in the same area (Safety Board accident number LAX95LA184).

According to the operator, the accident pilot received about 3 or 4 rides a day in preparation for his commercial certificate.

3.1 AIRCRAFT INFORMATION

3.1.1 Glider Information

The glider was issued a standard airworthiness certificate in June 1965, and underwent its last 100-hour inspection on January 10, 2005, at an aircraft total time of 5,692 hours, and its last annual inspection on March 29, 2004, at a total time of 5,310.0 hours. The total time of the glider at the time of the accident is unknown.

The glider was 26.75 feet in length, with a wingspan of 57 feet, a wing area of 180 square feet, and an aspect ratio of 18.05. The glider was equipped with ailerons and a dive brake mechanism (similar to a spoiler). The published stall speeds for the glider ranged between 41 and 47 miles per hour (mph) with associated weights ranging between 1,020 to 1,430 pounds.

According to the flight manual, under general description, the glider was "ideal for transition training from low or intermediate to high performance, single place sailplanes." The flight manual also indicated that, "spin entries are normal throughout the C.G. [center of gravity] range. After the entry, there will probably be one nose up and down oscillation before the stable spin occurs. The rotations are relatively slow with an altitude loss of approximately 300 feet per turn. Recovery technique is normal, except that considerably more control is needed to stop the rotation and lower the nose. Instead of easing off back pressure on the stick, it must be pushed forward of neutral and instead of neutralizing the rudder, opposite rudder must be applied. The rotation can be stopped in 1/4 to 1/2 turn. Pull outs, depending on the loading of the sailplane, can be made at airspeeds of 75 - 90 mph without appreciable G-loads."

The rear seat control stick was removed prior to the accident flight, but the rudder pedals and spoiler handle were kept in place. Neither was guarded.

3.1.2 Weight and Balance Information

According to the glider's flight manual, it had an approved maximum gross weight of 1,430 pounds for a utility class glider and an approved maximum gross weight of 1,340 pounds for a high-performance glider. Utilizing the accident glider's last weight and balance information (dated January 4, 2002), the pilot and passenger weights (147, 195, and 133 pounds), and a 24-pound ballast beneath the pilot's seat, investigators determined that the maximum gross weight was exceeded by about 34 pounds, but the center of gravity (cg) was determined to be 17.38 inches aft of the datum, within the 15.2 to 19.3 range.

4.1 METEOROLOGICAL INFORMATION

The weather observation facility located at the Wheeler Army Airfield (HHI), 10 nautical miles southeast of the accident site, reported the following meteorological information at 1255: wind from 090 degrees at 2 knots; visibility 7 statute miles in light rain showers; a few clouds at 1,500 feet above ground level (agl) and broken clouds at 3,000 feet agl; temperature and dew point of 21 degrees Celsius; and an altimeter setting of 30.15 inches of mercury.

The weather observation facility at the Honolulu International Airport (HNL), 22 nautical miles southeast of the accident site, reported the following meteorological information at 1253: wind from 060 degrees at 19 knots with gusts to 24 knots; visibility of 10 statute miles; a few clouds at 2,800 feet agl and scattered clouds at 5,500 feet agl; temperature 27 degrees Celsius; dew point 18 degrees Celsius; and an altimeter setting of 30.10 inches of mercury.

The witness who observed the accident indicated that normally

NTSB Probable Cause

the pilot's failure to maintain an adequate airspeed while maneuvering during a scenic flight, which led to an inadvertent stall/spin and secondary stall/spin encounter. Contributing factors were the pilot's lack of total flight experience, his inadequate flight training, and the unfavorable wind conditions.