NTSB Factual Report

HISTORY OF FLIGHT

On August 17, 2006, at 1138 eastern daylight time, a Scheibe SF-28A motorglider, N14KG, was substantially damaged while maneuvering near Canandaigua Airport (D38), Canandaigua, New York. The certificated private pilot was fatally injured, and the airline transport pilot sustained minor injuries. Visual meteorological conditions prevailed for the flight that departed Canandaigua Airport, about 1135. No flight plan was filed for the reexamination flight conducted under 14 CFR Part 91.

The private pilot had been involved in a prior accident, while attempting to abort a landing in a motorglider. He was completing a required reexamination flight under the provisions of 49 U.S.C. 44709, for the airline transport pilot, who was a Federal Aviation Administration (FAA) operations inspector.

The FAA inspector planned to cover the subject areas of takeoffs, landings, and aircraft performance. The FAA inspector stated that he briefed the private pilot on the general description of maneuvers to be performed, and the fact that the private pilot would be pilot in command (PIC) for the flight. The FAA inspector conducted an approximate 90-minute verbal examination with the private pilot, and then proceeded with the flight. The private pilot was seated in the front seat, and the FAA inspector was seated in the rear seat. The private pilot performed steep turns, stalls, and flight at minimum controllable airspeed. The private pilot then completed two full-stop landings on runway 13 at D38, a 3,200-foot-long, 75-foot-wide, asphalt runway. During the third takeoff on runway 13, the FAA inspector simulated an engine failure at approximately 400 feet agl, by reducing the power to idle. The simulated engine failure was unplanned and not previously briefed to the private pilot.

The FAA inspector did not recall the exact maximum lift over drag (L/D max) speed, but believed it was about 50 knots. The private pilot flew about that speed as he initiated a 30-degree right bank for a 180-degree turn to runway 31. The FAA inspector advised the private pilot to increase the bank to 45 degrees to reach the runway. The private pilot increased the bank, but held a nose-high attitude, and the airspeed began to decrease. The FAA inspector instructed corrective action and repeatedly advised that he was taking control of the glider. The private pilot did increase the engine power; however, he "froze" on the controls, and the glider stalled and impacted trees. The inspector further stated that he did not experience any preimpact mechanical malfunctions with the motorglider.

PILOT INFORMATION

The private pilot held a private pilot certificate, with a rating for gliders, and an endorsement in his pilot logbook for motorgliders. The private pilot did not possess an FAA medical certificate, and was not required to for glider operations.

According to the private pilot's logbook and witness statements, he had accumulated approximately 319 hours of total flight experience; of which, about 100 hours were in motorgliders, including 20 hours in the accident aircraft. The private pilot flew approximately 18 hours during the 90 days preceding the accident, and 13 hours during the 30 days preceding the accident. All of those hours were flown in the accident aircraft.

The FAA inspector held an airline transport pilot certificate, with ratings for airplane multiengine land and numerous air transport category aircraft. The FAA inspector also held a commercial pilot certificate, with ratings for airplane single engine land and gliders. In addition, the FAA inspector held a flight instructor certificate, with ratings for airplane single engine land, airplane multiengine land, instrument airplane, and gliders. The FAA inspector did not have a pilot logbook endorsement for motorgliders.

His most recent FAA second class medical certificate was issued on June 26, 2006.

The FAA inspector reported a total flight experience of 7,537 hours; of which, 110 hours were in gliders. The FAA inspector stated that he had "a couple" of hours in motorgliders, and no experience in the make and model of the accident motorglider. The FAA inspector further stated that he had not previously conducted a practical test or reexamination flight in a motorglider.

AIRCRAFT INFORMATION

The motorglider was operated under an experimental certificate. It's most recent annual condition inspection was completed on May 4, 2006. At that time, the motorglider had accumulated about 2,894 hours of operation, and the engine had accumulated about 949 hours of operation.

Review of the motorglider's handbook revealed that the L/D max speed was approximately 51 knots.

METEOROLOGICAL INFORMATION

The reported weather at D38, at 1145, was: wind from 140 degrees at 5 knots; visibility 10 miles; sky clear; temperature 75 degrees F; dew point 57 degrees F; altimeter 30.29 inches Hg.

WRECKAGE INFORMATION

The motorglider came to rest nose-down, in a field about 900 feet southeast of the runway 31 threshold. The motorglider was oriented about a 270-degree heading, and was approximately 787 feet above sea level. A large, partially separated tree was observed about 50 feet south of the wreckage. The right wing of the motorglider was located near the tree. The left wing of the motorglider remained partially attached to the airframe, and both wings exhibited tree-strike damage.

The cockpit area was crushed at the forward seat, and less crush damage was observed at the rear seat. Flight control continuity was confirmed from the left aileron, elevator, elevator trim, and rudder to the rear cockpit controls. Continuity was also confirmed from the right aileron, through the push-pull tubes, to the wing root. The front seat airspeed indicator displayed knots, and the rear seat airspeed indicator displayed kilometers per hour. The front seat altimeter displayed approximately 80 feet and 30.36 in the Kollsman window. The rear seat altimeter displayed approximately 500 feet and 30.41 in the Kollsman window.

The motorglider was equipped with a Limbach 60-horsepower engine. Approximately 4 inches of fuel remained in the single fuel tank. The fuel was consistent in odor with automobile gasoline. A fuel check with water finding paste did not reveal any evidence of water contamination. The engine had separated from the airframe, and the crankshaft was bent. Due to the impact damage to the crankshaft, the propeller could only be rotated about 180 degrees. Partial valve train continuity was confirmed through the 180-degree rotation. The single magneto remained attached to the engine, and was not accessible due to impact damage.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot by the Monroe County Medical Examiner's Office, Rochester, New York. Other than mild to moderate atherosclerosis, the autopsy report did not reveal any evidence of prior heart disease or heart attack.

Toxicological testing was conducted on the pilot at the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. Review of the toxicology report revealed:

"...METOPROLOL detected in Blood

METOPROLOL present in Urine

SILDENAFIL present in Blood

SILDENAFIL present in Urine

DESMETHYLSILDENAFIL present in Blood

DESMETHYLSILDENAFIL present in Urine."

TESTS AND RESEARCH

A flight instructor flew with the private pilot during the day prior to the accident, in preparation for the reexamination flight. The flight instructor stated that during the flight, the private pilot performed five simulated engine failures successfully. One of the simulated engine failures was performed at 300 feet agl, with a return to the runway, utilizing approximately 30 degrees of bank angle.

Another flight instructor, with more motorglider experience, flew with the private pilot on two prior occasions. The instructor stated that the private pilot was very comfortable with 45-degree bank turns. The instructor and private pilot simulated emergency procedures at 2,000 to 3,000 feet agl due to wind and traffic considerations. The instructor further stated that the accident motorglider can safely turn back to a runway at 200 feet agl during a simulated engine failure, but the nose must be lowered, as the turn is initiated. The instructor added in that particular situation, he takes the controls if the nose is not lowered quickly.

A handheld global positioning system (GPS) unit was recovered in the wreckage and forwarded to the manufacturer for data download under the supervision of an FAA inspector. The download revealed that there was no track data for the accident flight.

ADDITIONAL INFORMATION

FAA Re-examination Flights

The FAA inspector who conducted the reexamination flight, was approached directly by the private pilot, and subsequently scheduled the flight with himself. The FAA inspector did not schedule the flight through his supervisor.

Review of FAA Order 8700.1, General Aviation Operations Inspector's Handbook, revealed that inspectors conducting reexamination flights shall hold the same aircraft category and class ratings that the airman would be tested on; however, there was no requirement for the inspector to have any necessary logbook endorsements in the aircraft.

Further review of FAA Order 8700.1 revealed, "The inspector should test the airman only in the areas specified in the letter of notification." Emergency procedures were not specifically noted in the private pilot's notification letter; however, decision making was stated in the letter.

FAA Order 8700.1 also stated:

"...Pilot-in-Command (PIC) Status. An inspector conducts a practical test to observe and evaluate an applicant's ability to perform the procedures and maneuvers required for the pilot certificate or rating.

(1) The inspector is not PIC of the aircraft during the practical test unless acting in that capacity for the flight, or a portion of the flight, by prior arrangement with the applicant or other PIC..."

Review of FAA Order 8700.1 and FAA Order 4040.9D, FAA Aircraft Management Program Policy, did not reveal any specific guidance regarding PIC during reexamination flights. Nor did the orders reveal any guidance for FAA inspectors to brief the applicant, prior to flight; about who would be PIC, or the inspector's experience in the aircraft should the applicant need the inspector's assistance in an emergency, or a basic briefing of tasks to be covered during the reexamination flight.

According to the Operations Supervisor at the Rochester, New York, FSDO, prior to the accident, there was no guidance within the FSDO about inspectors scheduling reexamination flights. Subsequent to the accident, inspectors need to schedule reexamination flights through the Operations Supervisor.

Wreckage Release

The wreckage was released to a representative of the owner's insurance company on August 18, 2006.

NTSB Probable Cause

The private pilot's failure to maintain adequate airspeed, which resulted in an inadvertent stall and impact with trees. Factors were the FAA inspector's delayed remedial action, and his lack of experience in the make and model motorglider.