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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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July 4, 1993 · Curtis RANS S-12 · N410ZE

Samoa, CA

Overview

Report Status
Probable Cause
Event Type
Accident
Date
July 4, 1993
Injury Outcomes
1 injury (1 fatality)
Location
Samoa, CA
Aircraft
Curtis RANS S-12
Tail Number
N410ZE
Operator
Bish Gregory Keith
Injuries
Fatal
Aircraft Damage
Substantial
NTSB Number
LAX93LA276

Several witnesses reported that the airplane, which has a rear mounted engine, seemed to be having some difficulty with controllability due to the high winds in the area. The consensus was that the airplane appeared to enter a stall, and then it spun several times before impacting the ground. The aircraft ballistic parachute system was manually deployed by the pilot, but did not inflate behind the airplane. The parachute was found entangled in the crankshaft just forward of the propeller. The parachute owners manual states the engine should be stopped prior to deployment of the parachute. It also recommends not deploying the parachute in 'strong winds or convection', although no specific guidelines were found for the pilot to follow in the event he encountered such phenomena. A senior technician who worked at the parachute manufacturer approved the installation of the parachute per photo documentation, as required by the manufacturer. The company could not provide a written record of the approval. The manual does not address a minimum recommended altitude or a minimum speed for the deployment of the parachute. Post crash investigation failed to find any pre existing failure/malfunction of the propeller or powerplant.

NTSB Probable Cause

THE INADVERTENT STALL OF THE AIRPLANE. FACTORS RELATED TO THIS ACCIDENT WERE: THE EMERGENCY PARACHUTE SYSTEM THAT WAS DEPLOYED BY THE PILOT, THE PARTIAL FAILURE OF THE PARACHUTE SURVIVAL EQUIPMENT TO DEPLOY PROPERLY, AND THE INSUFFICIENT INFORMATION PROVIDED BY THE AIRCRAFT PARACHUTE MANUFACTURER.

Full Narrative

SEVERAL WITNESSES REPORTED THAT THE AIRPLANE, WHICH HAS A REAR MOUNTED ENGINE, SEEMED TO BE HAVING SOME DIFFICULTY WITH CONTROLLABILITY DUE TO THE HIGH WINDS IN THE AREA. THE CONSENSUS WAS THAT THE AIRPLANE APPEARED TO ENTER A STALL, AND THEN IT SPUN SEVERAL TIMES BEFORE IMPACTING THE GROUND. THE AIRCRAFT BALLISTIC PARACHUTE SYSTEM WAS MANUALLY DEPLOYED BY THE PILOT, BUT DID NOT INFLATE BEHIND THE AIRPLANE. THE PARACHUTE WAS FOUND ENTANGLED IN THE CRANKSHAFT JUST FORWARD OF THE PROPELLER. THE PARACHUTE OWNERS MANUAL STATES THE ENGINE SHOULD BE STOPPED PRIOR TO DEPLOYMENT OF THE PARACHUTE. IT ALSO RECOMMENDS NOT DEPLOYING THE PARACHUTE IN 'STRONG WINDS OR CONVECTION', ALTHOUGH NO SPECIFIC GUIDELINES WERE FOUND FOR THE PILOT TO FOLLOW IN THE EVENT HE ENCOUNTERED SUCH PHENOMENA. A SENIOR TECHNICIAN WHO WORKED AT THE PARACHUTE MANUFACTURER APPROVED THE INSTALLATION OF THE PARACHUTE PER PHOTO DOCUMENTATION, AS REQUIRED BY THE MANUFACTURER. THE COMPANY COULD NOT PROVIDE A WRITTEN RECORD OF THE APPROVAL. THE MANUAL DOES NOT ADDRESS A MINIMUM RECOMMENDED ALTITUDE OR A MINIMUM SPEED FOR THE DEPLOYMENT OF THE PARACHUTE. POST CRASH INVESTIGATION FAILED TO FIND ANY PRE EXISTING FAILURE/MALFUNCTION OF THE PROPELLER OR POWERPLANT.

Flight

Event TypeAccident
Event Time14:53 PDT
Nearest Airport0nm N
Runway0
Flight Plan FiledNone
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftCurtis RANS S-12
Tail NumberN410ZE
Aircraft CategoryAir
DamageSubstantial
OperatorBish Gregory Keith
Operating RulePart 91
Engines1
Engine TypeReciprocating
Engine DetailsRotax · 582 · Reciprocating · 65
Seats2

People & Injuries

Injury Summary1 injury (1 fatality)
Fatal1
Serious0
Minor0
Uninjured0
Total1
Crew 1Age 39 · Third Class

Conditions

ConditionsVMC
LightDaylight
Wind330° @ 20 kt, gusting 25 kt
Visibility30 sm
CeilingNone
Temperature / Dew Point66 F / 52
Altimeter29.00 inHg
Observation Time21:59
Weather SourceWFAC

Appendix: Source Data