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NTSB Final Report, RV-6, N628JB, 8/27/2020

RV8JD

Well Known Member
Link to NTSB Final Report --> https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101878/pdf

Link to Docket --> https://data.ntsb.gov/Docket?ProjectID=101878

Excerpt:
Aviation Investigation Final Report

Location: Milton, Delaware
Accident Number: ERA20CA298
Date & Time: August 27, 2020, 14:00 Local
Aircraft: Vans RV6
Registration: N628JB
Aircraft Damage: Substantial
Defining Event: Controlled flight into terr/obj (CFIT)
Injuries: 2 Minor
Flight Conducted Under: Part 91: General aviation - Personal

Analysis:

The purpose of the flight was for the pilots to calibrate a newly installed avionic equipment in the airplane. The owner of the airplane was seated in the airplane’s right seat, while the other pilot, who was acting as pilot-in-command for the flight was seated in the left seat. After takeoff, the pilot handed off controls to the owner and requested that the owner perform two 360° turns while he calibrated the equipment. After the two turns, the owner let go of the flight controls and the pilot manipulated the controls to demonstrate the functioning of the g-meter. Both the pilot and the owner believed the other was flying the airplane after this demonstration. After deciding that they would return to the departure airport, the airplane was flying low and almost impacted the ground twice. On both occasions, the pilot pulled up, then once again let go of the controls believing that the owner was flying the airplane. Both expressed discomfort with how the other was flying the airplane, but neither communicated their concerns to the other in a way that was understood, nor did either confirm who was flying the airplane. The third time the airplane neared terrain, the owner called for the pilot to pull up just as the pilot was about to take control of the airplane. The airplane then impacted a field, flipped over, and came to rest inverted. The fuselage, wings, and empennage of the airplane sustained substantial damage. Both the pilot and owner stated that there were no preimpact malfunctions or failures of the airplane that would have precluded normal operation.

Probable Cause and Findings:

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot and owner’s failure to adequately communicate and establish an understanding of who was flying the airplane, and their failure to take timely action to avoid a collision with terrain.

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

Some further analysis: https://generalaviationnews.com/2022/11/09/human-factors-no-one-in-command/

Cartoon-for-Human-FactorsOct22.jpg
 
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"Your airplane." "My airplane."

I could almost believe this if it were a tandem model where neither could see the other's hands.

But it's a side-by-side, so I'm going with "I just cannot..."
 
From day one almost 40 years ago it was MANDATORY to verbally pass the controls to the other pilot at every exchange, with a stick wag if you were in a tandem aircraft. Seemed like a big PITA at first, but the gravity of it became crystal clear as time went on.

Even today, I do it in my own plane, including to non pilots (YE flights) ... it's a way to fix in MY mind who is flying and help them understand the same, and maybe instills an early habit in a wanna be pilot to be.

Super happy to hear that these two are able to tell their story. An old saying is that "the ground has a PK of 1" (PK=probability of kill), they were very lucky.

Wow
 
I can’t believe what I just read there. That it happened twice prior in the same flight and was not addressed is even more unbelievable. Sounds like a good pre-engine start checklist item: agree (out loud) about who the PIC is and what the control hand-off procedure shall be.
 
Another excellent reminder that the fundamentals are fundamental. Simple things, when ignored, can kill you. Many people have been killed or injured due to missed preflights, not following a simple checklist, and otherwise not following what we all know as "good practice". It can happen to any of us.
 
Wow.

Carl, Thanks for sharing this. I'm forwarding this link to several people outside of VAF.

My first reaction was to wonder how the heck is this even possible, but then I started thinking about all the accidents where a very competent pilot flew right into a mountain/ocean/whatever while another very component pilot watched it happen.

The linked article is really interesting in that it gets into mindset that led to this.
 
You can't help but wonder...

What would the NTSB likely conclusion have been if this had ended in two fatals?

There would be much grasping at straws to posit a medical or environmental event that simultaneously befell two healthy, competent pilots, or a suicidal impulse that left the other no time to react.

It's unlikely we would ever know that the truth was like the joke about the two blue-haired ladies who kept running red lights: "Oh! Am I driving?!"
 
Defining Event: Controlled flight into terr/obj (CFIT)
I think from the description of the events that it's clear that there wasn't any control at all. I can't even conceive how this could happen...
 
Had to be some odd chemistry for that to occur side by side.

Have a funny example of both of us thinking the other was flying in tandem Pitts- owner asked if I had a wild hair about the same time I mentioned I'd never seen him break redline before;)

We'd gone from a 4 cyl to a 6 cyl and the extra power meant less break needed between sequences and we got sloppy on comms before realizing the effect of using the added performance available.
 
You won't see this one again !

I could almost believe this if it were a tandem model where neither could see the other's hands.

But it's a side-by-side, so I'm going with "I just cannot..."

A very entertaining exchange between Blue Angel John "Gucci" Foley and his ride in Moscow. It even made his eyes roll.

https://youtu.be/f-KvgW5k7ro?t=463

It is not likely to happen again in the next few decades.
 
MY AIRPLANE...!!!

I could almost believe this if it were a tandem model where neither could see the other's hands. But it's a side-by-side, so I'm going with "I just cannot..."

Just when you think you've heard it ALL! :eek:

With ANY pilot (or nonpilot [eg Young Eagles])I have ever been with (mostly in tandem aircraft), there is well-known verbiage and motions that have been around since the use of Gosport tubes! (Google that: interesting story).

Voice: MY AIRPLANE: take the stick and gently shake it
Voice: YOUR AIRPLANE: both hands go up in the air to show they are no longer on the controls!

Side-by-side???:eek::eek::eek: Situational awareness!! Does it LOOK like I am flying???

A good friend was flying a Stearman and was in the front seat, accomplished pilot in the back. They finished their planned flight and were circling around looking at things when my friend noticed, in one of the circles, they were headed for this looming and ever-enlarging hill. "You going through that peak, there, friend?" "WHAT?? I thought YOU were flying!!" Neither had been flying while the Stearman had been circling them round on its own!:p
 
I think from the description of the events that it's clear that there wasn't any control at all. I can't even conceive how this could happen...

Especially when you consider that they both were staring at a screen that was giving them situational awareness and terrain avoidance......:eek:

So much for modern panels keeping you safe.
 
If I'm ever flying with a friend, CFI, DPE, or even Paul Dye, and I think that they're flying and we even come close to hitting the ground.... that's it! My plane! You're done!

Well unless there's a real nasty crosswind or something, then Paul can do the landing. But only after we're back to the airport. :D
 
Some Thots

Heard a tale of two guys in a Stearman, flying just off the coast, low over the water, each thought they were the pilot flying. No intercom. One pushing to go lower, the other, spooked, pulling back. They fought each other for while until the one pushing stopped pushing before the guy pulling stopped pulling. Fortunately. Had a friend who was a gunner on SBDs during the Big War. SBDs had a set of flight controls and basic flight instruments in the back seat. Standard procedure with at least one of the pilots he flew with was for the gunner to lock his seat facing forward while starting the dive on a bomb run (no fighter could get a shot once the dive started) and call out altitudes to the pilot. If the pilot wasn’t pulling by the time they’d dived below a certain altitude (I cannot remember the exact number of feet), the gunner was expected to start pulling without checking with the pilot. Target fixation is a real thing, or the pilot may have taken a hit from the ground. Anyway, they backed each other up. Upshot of all this, plus this RV-6 accident tells me there sure are a lot of ways to screw up with an airplane. Whenever I hand over or take the controls on an airplane I make SURE we both know who’s flying, with a verbal exchange if there’s an intercom, and a stick shake.
 
What's amazing to me is that the highest point in southern Delaware is about 100' MSL (50' where they were flying). It's not like the terrain suddenly changed...
 
I would have been interested to hear that first conversation between the two occupants as they were limping away from the crash site.
 
Whaaaaaaaaat???

I would have been interested to hear that first conversation between the two occupants as they were limping away from the crash site.

Oh, that was likely a silent walk. I want to know what was said as they were hanging from their harnesses upside-down! THAT would be an interesting conversation!
 
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