Aviation Accident Summaries

Aviation Accident Summary ERA22FA189


Aircraft #1




Shortly after the tow airplane and the glider became airborne, the pilot of the glider released from the tow plane about 200 ft above ground level, then entered a left turn back toward the runway, during which the glider impacted terrain. Witnesses to the accident described the glider’s takeoff as “abnormal” and “erratic” and reported that the glider climbed above the tow plane twice before the glider pilot released from tow. Postaccident examination of the glider revealed that the elevator control was not connected as required by preflight assembly procedures, which would have resulted in the pilot’s inability to control the glider’s pitch attitude. According to the tow pilot, the glider pilot had assembled the glider by himself (as he had done many times before) on the morning of the accident. It is likely that, had the pilot completed a positive control check after assembly, he would have identified the disconnected elevator control. Toxicology testing identified two sedating drugs, cetirizine (Zyrtec) and trazodone (an antidepressant), in the pilot’s cavity blood and urine; however, the pilot’s use of these medications most likely did not contribute to the accident.

Factual Information

HISTORY OF FLIGHT On April 16, 2022, about 1315 eastern daylight time, a Schleicher ASW-19B glider, N19KW, was substantially damaged when it was involved in an accident near Jacksonville, Florida. The private pilot was fatally injured. The glider was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the tow pilot, shortly after becoming airborne, he observed the glider in his rearview mirror. He stated that the glider climbed above the tow airplane, then descended, then climbed again. As the tow pilot was reaching for his tow release handle to release the glider, he heard the glider pilot say “release” over the radio. The tow pilot immediately entered a right turn at an altitude of about 250 ft above ground level (agl). He could not immediately see the glider; however, a few seconds later, he saw the glider in the trees adjacent to the runway. The pilot of another airplane, who had just released parachute jumpers, was descending through 9,000 ft agl directly over the airport and could see the tow plane and glider taking off. The witness said that when the glider became airborne it pitched up about 30 to 40°, and he could see the entire nose of the glider. He said the glider stalled and nosed over before it entered a secondary stall and pitched up again. He heard the glider pilot on the common traffic advisory frequency yelling at the tow pilot to “take it easy…something is not right,” followed by the sound of the tow “release” mechanism. The glider then made a left “knife-edge” turn about 200 ft agl. The glider continued in a descending left turn. The left wing impacted the ground first and the tail section separated. The witness added that, right before the glider impacted the ground, the glider pilot said that he was “going down.” The glider pilot was a member of the local soaring club, and the accident was witnessed by several people on the ground. Witnesses stated that the glider made abnormal pitch oscillations before the pilot released from the tow airplane from about 100 to 150 ft agl. One witness described the glider’s takeoff as “erratic” as it climbed and descended behind the tow airplane. After release from the tow airplane, the glider entered a 30° left turn back to the airport, during which it descended and impacted the ground. One witness said the glider appeared to have no elevator authority. PILOT INFORMATION The pilot held a private pilot certificate with ratings for airplane single-engine land and glider. A review of his pilot logbook (glider only) revealed that he had accumulated a total of 324.6 flight hours in gliders, and about 320.3 hours in the accident glider at the time of his last entry on January 15, 2022. AIRCRAFT INFORMATION The Schleicher ASW 19B is a single-seat glider. The most recent annual inspection was completed on April 28, 2021, at an aircraft total time of 1,501.2 hours. WRECKAGE INFORMATION All major components of the glider were accounted for at the accident site. The glider came to rest upright in 3-to-4-ft-high brush in a wetlands area several hundred yards from the runway. The cockpit area was crushed and displaced to the right. The canopy had separated and was found forward and to the right of the main wreckage. An impact scar was observed about 6 ft behind the left wing. The outboard section of the left wing sustained impact damage and was folded over the top of the left wing but remained attached to the inboard section of the wing via control tubing. The right wing was intact and the tip came to rest against a small tree. The air brakes were extended on both wings. The glider’s tail section was partially separated at the empennage and was resting on the right horizontal stabilizer, which was bent down about 90° mid-span. The vertical and left horizontal stabilizer, rudder, and elevator were undamaged. Flight control continuity was established for all flight control surfaces to the cockpit area except for the elevator. The elevator control, which included a fixed ball joint on the base of the elevator and the elevator control tube that extended the length of the vertical stabilizer, was not connected as required by preflight flight assembly procedures. The proper function of the elevator connection was manually tested several times, and no anomalies were noted. The base of the connection clasp contained a small hole for the purpose of using a spring clip to secure the connection. No evidence of a spring clip or other securing device was found. The tow pilot reported to a Federal Aviation Administration (FAA) inspector that the pilot had trailered his glider to the airport the day of the accident and assembled the glider himself, as he had done many times before.   MEDICAL AND PATHOLOGICAL INFORMATION Toxicology testing performed by the FAA’s Forensic Sciences Laboratory identified cetirizine, trazodone, pantoprazole, carvedilol, amlodipine, tamsulosin, and losartan in the pilot’s cavity blood and urine. Cetirizine is a sedating antihistamine available over the counter, often with the name Zyrtec. Trazodone is an antidepressant that is often used off-label as a treatment for insomnia. It carries this warning about performance, “Trazodone hydrochloride may cause somnolence or sedation and may impair the mental and/or physical ability required for the performance of potentially hazardous tasks. Patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that the drug treatment does not affect them adversely.” Pantoprazole is used to treat heartburn and is not considered impairing. Carvedilol, amlodipine, tamsulosin, and losartan are blood pressure medications that are not generally considered impairing. ADDITIONAL INFORMATION The FAA Glider Flying Handbook (FAA-H-8083-13A), Chapter 8, Abnormal and Emergency Procedures, stated, Failure of any primary flight control system presents a serious threat to safety. The most frequent cause of control system failure is incomplete assembly of the glider in preparation for flight….Perform a positive control check with the help of a knowledgeable assistant. Do not assume that any flight surface and flight control is properly installed and connected during the post-assembly inspection. Instead, assume that every connection is suspect. Inspect and test until certain that every component is ready for flight.

Probable Cause and Findings

The pilot’s improper preflight assembly of the glider’s elevator control, which resulted in a loss of control on takeoff, and the pilot’s failure to complete a positive control check before the flight, which would have identified the disconnected elevator control.


Source: NTSB Aviation Accident Database

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