14 CFR Part 91: General Aviation
Accident occurred Friday, August 16, 2013 in Carson City, NV
Probable Cause Approval Date: 10/19/2015
Aircraft: URBAN AIR SRO SAMBA XXL, registration: N19UA
Injuries: 2 Fatal.
NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
During the local area personal flight, the sport pilot/owner was seated in the right seat, and a student-pilot-rated passenger was seated in the left seat. Data downloaded from a GPS unit on board the airplane showed that the airplane departed from the airport and climbed to an altitude of about 3,000 ft above ground level while maneuvering. The airplane then made a 180-degree turn followed by a rapid, near-vertical descent to ground impact.
The wreckage was located on flat open terrain. The airplane was intact, lying flat on its belly with the landing gear collapsed underneath the fuselage, consistent with impact in a flat spin. Postaccident examination of the airframe and engine revealed no evidence of mechanical malfunction or failure that would have precluded normal operation. Based on the GPS tracking data and the condition of the wreckage, the pilot likely failed to maintain adequate airspeed, which led to the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall that developed into a flat spin, which the pilot was unable to recover from before ground impact.
The airplane was equipped with a ballistic recovery system parachute that was not deployed before impact. The parachute system manual states the following: 1) position the activation handle such that it is reachable by the occupants of both seats; 2) remove the handle's locking pin before flight; and 3) inform all passengers of the operation of the system. Postaccident examination found that the locking pin, which was equipped with a red warning flag, was secured in the parachute activation handle. The handle was located on the lower left side of the instrument panel (beneath the flight instruments) and was only readily accessible to the left seat occupant. It is unknown if the passenger in the left seat was aware of the parachute system and its operation. Had the parachute been activated, the accident may have been survivable.
The pilot's autopsy revealed that he had a low-grade malignant lymphoma and a brain tumor. He also had a history of depression, which had been well controlled with medication. After a review of the pilot's medical history, autopsy, and toxicology findings, the investigation was unable to determine if medical impairment contributed to the loss of airplane control.
The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to maintain adequate airspeed while maneuvering, which led to the airplane exceeding its critical angle of attack and experiencing an aerodynamic stall/spin. Contributing to the accident was the improper location of the parachute activation handle and the pilot's failure to remove the handle's locking pin before flight.
***This report was modified on October 14, 2015. Please see the docket for this accident to view the original report.***
HISTORY OF FLIGHT
On August 16, 2013, about 1600 Pacific daylight time, a special-light sport airplane (S-LSA), Urban Air SRO Samba XXL, N19UA, collided with flat desert terrain about 20 miles east of Carson City, Nevada. The airplane was operated by the owner under the provisions of 14 Code of Federal Regulations (CFR) Part 91 as a personal flight. The sport pilot and passenger were fatally injured; the airplane was substantially damaged. The flight departed from the Carson Airport, (CXP), Carson City, Nevada, at an undetermined time. Visual meteorological conditions prevailed for the flight, and no flight plan had been filed.
According to a deputy from the Lyon County Sheriff's Department, a call had been received from a motorist, who had observed the airplane wreckage from the road. The motorist indicated that the accident site was a mile inland, and two people were on board. The accident location was described as flat desert terrain.
PERSONNEL INFORMATION
Sport Pilot (right seat)
The pilot, age 72, was a sport pilot, and had been issued a Federal Aviation Administration (FAA) form 8710-2 student pilot certificate on July 7, 2011, with no limitations; the expiration date was July 31, 2016. A review of the pilot's logbook by the National Transportation Safety Board investigator-in-charge (NTSB IIC) revealed that the pilot logged 80.1 hours as of January 3, 2013. The NTSB IIC estimated his total time from January 3 to August 14, 2013, as 47.7 hours. The pilot's estimated total time was 128.8 hours, with 79.1 hours in the accident airplane make and model. The pilot's logbook endorsements included an initial solo endorsement dated September 30, 2012, and his sport pilot airspace and airspeed endorsements were dated April 23, 2013.
Student Pilot-rated passenger (Left Seat)
According to the Federal Aviation Administration (FAA) airmen medical records in Oklahoma City, Oklahoma, the 63-year-old student pilot-rated passenger had been issued a medical certificate on June 15, 1983, and it listed his total flight time as 12 hours with 0 hours accrued in the 6 months prior to the medical certificate application. On the pilot's most recent medical application dated March 10, 1987, the pilot listed his total hours as 0, with 2 hours accrued in the previous 6 months.
AIRCRAFT INFORMATION
The two-seat, low-wing, fixed-gear airplane, serial number SA XXL 79, was manufactured in 2008. It was a fiberglass/carbon-fiber constructed airplane with side-by-side seating. The airplane had been powered by a Rotax 912ULS 100 hp engine, and equipped with a Woodcomp SR200 propeller.
According to the airframe logbook, the last entry dated May 29, 2013, reported a total time of 210.7 hours. A review of the engine logbook showed an entry dated June 29, 2013; total time on the engine was reported as 229.4 hours. The entry was for a 25-hour service that included an oil and filter change.
In the airplane operating manual, under AIRCRAFT DESCRIPTION, it stated that the airplane was not approved for aerobatic operation. There was also a WARNING that stated that aerobatics, intentional spins, and stalls were prohibited. Identified under MISCELLANEOUS EQUIPMENT, the airplane manual indicated that in addition to standard equipment, the airplane may be equipped with a ballistic rescue system supplied by GALAXY/BRS (Ballistic Recovery System)/STRATOS. The accident airplane had been equipped with a Magnum 601 serial number 040 S-LSA ballistic recovery system.
According to the Magnum manual Part 2, Use of the Rescue System, this section reported situations when it is possible to use the rescue system. One such situation was "a loss of piloting control on other reasons." The minimum recommended effective altitude for activation of the parachute was listed as 200 meters (656 feet), at a maximum airspeed of 180.2 miles per hour. The manual also indicated that before flight the pilot was to unlock the activation handle by removal of the locking pin and inform passengers of the operation of the parachute system.
Section 6.2 of the manual titled Location of the launching handle of the rescue system Magnum, it stated that the handle must be reachable by both pilots and visible in their peripheral vision. The best identified position for pilots seated next to each other was proved to be in between both pilots by the instrument panel. There were two ATTENTION! notes; the first one reported that the activation handle must be easily accessible, graspable, and not near another adjusting element of similar form in order to avoid confusion and unintended activation of the rescue system. The other attention note indicated that "Before the flight unlock the rescue system! [Immediately] after the flight do lock it!"
WRECKAGE AND IMPACT INFORMATION
The airplane was located intact, lying on its belly with the landing gear collapsed underneath the fuselage on the flat open desert terrain. The engine had been displaced with the nose positioned slightly downward. All flight control surfaces were accounted for. The entire horizontal stabilizer had separated from the aft empennage and lying on the ground directly below the vertical stabilizer. Immediately behind the wreckage was a short distance of ground disturbance.
FAA inspectors responded to the accident site and reported that the pilot and passenger remained in their seats secured by their seatbelts. They further reported that the parachute locking pin, with red warning flag that read "Warning! Remove Before Flight," was secured in the parachute activation handle inside of the cockpit. The parachute activation handle was physically located on the outboard left section and underneath the instrument panel.
MEDICAL AND PATHOLOGICAL INFORMATION
A postmortem examination was conducted on the sport pilot on August 16, 2013, by the Washoe County Medical Examiner's office, Reno, Nevada. The cause of death was listed as multiple injuries due to blunt force trauma. Additionally, the autopsy identified a low-grade malignant lymphoma, and a 2 cm right occipital brain tumor.
The FAA's Forensic Toxicology Research Team, CAMI, performed forensic toxicology on specimens from the pilot. The results were negative for carbon monoxide and volatiles; cyanide screening was not performed. The specimens were positive for tested drugs; Paroxetine detected in urine, but not detected in blood (cavity), Ranitidine detected in blood, but not detected in blood (cavity). Ranitidine is a non-sedating acid reducing medication commonly marketed as Zantac. Paroxetine is used for treatment of depression.
Review of the pilot's personal medical records by the NTSB medical officer identified that the pilot had been prescribed paroxetine for treatment of depression. Paroxetine is an antidepressant medication marketed as Paxil. Patients are cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that it did not affect their ability to engage in such activities. The records documented recent examinations in April and June of 2013, which reported that the pilot had no recent abnormal neurological findings and stated his depression was well controlled with paroxetine. Additionally, the pilot reported fatigue, but testing was unable to identify a source of his symptoms.
TEST AND RESEARCH
A postaccident examination of the airplane and engine was performed at Air Transport, Phoenix, Arizona, on September 19, 2013. There was no evidence of a pre impact mechanical malfunction that would have precluded normal operation of the airplane or engine. The examination report is attached to the public docket for this accident.
Flight control continuity was established from all the flight control surfaces to the cockpit. The parachute had not deployed, and the cable remained connected; the parachute locking pin with warning flag remained inserted into the parachute activation handle.
A visual examination of the engine revealed no obvious holes in the engine case. The engine remained attached to the engine mounts and firewall. Drive and valve train continuity were established throughout the case; thumb compression was obtained in all cylinders in firing order, via manual rotation of the engine.
The propeller assembly remained connected to the engine via the crankshaft. One of the three propeller blades remained connected to the propeller hub, the other two propeller blades separated at the hub. All three of the propeller blades remained relatively undamaged with the exception of one of the separated propeller blades had a broken tip.
A Garmin GPSMap 496 device was shipped to the NTSB Vehicle Recorder Division in Washington, DC, and was downloaded by a vehicle recorder specialist. The specialist was able to download 35 sessions (flights) from June 29, 2013, through August 16, 2013, which included the accident flight. There were 92 data points extracted that began at 1600:28 and ended at 1611:29.
At 1600:28, the reported altitude was 5,610 feet and 0 knots. The data showed a square flight pattern, with a departure toward the south. The data indicated that the airplane made a left turn, and at 1611:29, the track terminated at an altitude of 4,272 feet at 0 knots, at a location consistent with the accident site. At 1609:08, the reported altitude was 7,743 ft. at 88 knots. Approximately 39 seconds later, the airplane reached an altitude of 7,579 feet at 76 knots. For the next minute 42 seconds, the data points continue to decrease in altitude and groundspeed. At 1610:34, the airplane was at an altitude of 6,998 feet and a groundspeed of 29 knots. Six seconds later the airplane had descended to 6,339 feet, and the groundspeed was 16 knots. Eight seconds later the airplane was at an altitude of 5,476 feet at a groundspeed of 9 knots. During the last 41 seconds the data points indicated that the airplane descended to 4,272 feet, and the recorded groundspeed was 0 knots. A detailed report is attached to the public docket for this accident.
ADDITIONAL INFORMATION
According to 14 CFR Part 301-303, as it pertains to sport pilot, the sport pilot needs only a valid driver's license, and should "not know or have reason to know of any medical condition that would make that person unable to operate a light-sport aircraft in a safe manner."
http://registry.faa.gov/N19UA
14 CFR Part 91: General Aviation
Accident occurred Friday, August 16, 2013 in Carson City, NV
Aircraft: URBAN AIR SRO SAMBA XXL, registration: N19UA
Injuries: 2 Fatal.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.
On August 16, 2013, about 1600 Pacific daylight time, a special-light sport airplane (S-LSA), Urban Air SRO Samba XXL, N19UA, crashed under unknown circumstances about 20 miles east of Carson City, Nevada. The airplane was operated by the owner under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The sport pilot and student pilot-passenger were fatally injured; the airplane was substantially damaged. The flight departed from the Carson Airport, (CXP), Carson City, Nevada, at an undetermined time on August 16. Visual meteorological conditions prevailed for the flight and no flight plan had been filed.
According to a deputy from the Lyon County Sheriff's Department, a call had been recieved from a motorist, who had observed the airplane from the road. The motorist indicated that the accident site was a mile inland, and two people were on board. The accident location was described as flat desert terrain.
The pilots and airplane were not subject to an Alert Notification (ALNOT), nor was the emergency locator transmitter (ELT) activated.
The airplane was recovered for further investigation.
Paul's accident:
On Friday morning August 16th around 830am, Paul Guttman and good friend and aviation partner Bill Bohn departed Carson City Airport in their Light Sport Aircraft Samba, N19UA. Their intent was to fly to the dry lake bed "Misfit Flat" near Dayton Nevada and practice standard aircraft maneuvering. Paul made routine radio calls between 830am and 9am time-frame. Paul had intended to be back on the ground in Carson before lunch time. For reasons we do not know, and most likely will not know until the NTSB publishes a report about the incident, the aircraft went down on the dry lake bed. Paul's plane was discovered by someone later that day around 330pm in the afternoon and reported to the Sheriff's office. While the plane was equipped with a "ballistic parachute", it was not activated indicating that they were not able to react to the situation.
Paul and Bill were passionate aviation enthusiasts and careful pilots. Their presence in our lives will be terribly missed.
Source: Friends of Dr. Paul Guttman - https://www.facebook.com
Family, Friends and the many who Paul reached and benefited remember his passion for practical acts of kindness and utility, his excitement for sports of land, sea and air, his dedication to his patients over decades of practice as a physician, his unwavering support for his children and fondness for his family, his vision as a man of business, community organizer, teacher, philanthropist and lifelong learner.
Dr. Paul Henry Guttman, Jr. is survived by his brother Alan, his sons Erik and Mark and daughter Sarah, his grandchildren, nephews and nieces and wider family.
Memorial services will take place at Oakmont Memorial Park, Lafayette, CA at 11:00am on Friday August 30.
Memorial donations may be made to Space Science for Schools, www.ss4s.org.
Obituary: http://www.legacy.com
Guest Book: http://www.legacy.com
Feb. 17, 1950
Aug. 16, 2013
To say Bill Bohn lived life with inspired enthusiasm would be an understatement. William Randall Bohn was born in Missouri on February 17, 1950. After his father passed way he relocated to southern California. When Bill headed to college he was determined to become an architect. But the innovative freedom of industrial design drew him instead to the Art Center College in Pasadena, where he secured a degree in transportation and product design. Somewhere in our lives we have probably been influenced by Bill's creativity: he worked for the Airstream Corporation, designing interiors for their iconic trailers. Bill then embarked on a career many of us would call a dream job. He spent the next 18 years working for Walt Disney's WED Enterprises as an imagineer. His varied projects included design for Disneyland, Disney World, Epcot Center, Disneyland Paris, and Tokyo DisneySea. He went to become the senior industrial designer for Walt Disney Imagineering in Glendale, CA, working on such large-budget projects as the Indiana Jones Adventure rides and Disney's Animal Kingdom.
His many design contributions to Disney projects were numerous and full of familiar names, but his loftier passion for design was for smaller settings. The finite spaces of yacht and airplane interiors presented a particular aesthetic challenge which appealed to Bill. He was commented in an interview that "aircraft and yachts are the pinnacle of environmental design." Combining large-scale with small projects, Bill's consulting business spanned even farther into the realm of transportation, working on hybrid electric trams, light rail projects, taxi design, and more. His love for the efficient use of space fueled a very imaginative career; his love of fuel and asphalt spurred his vintage auto racing. And a desire to explore the space above our heads motivated him to pursue his pilot's license.
Bill and wife Eileen spent many hours exploring their cherished Tahoe environment, enjoying many miles on cross-country skis, bicycles, kayaks, and taking hikes with their dog Levi. Bill was involved in many social events in the Tahoe area, including the Lake Tahoe Summerfest Board of Directors and Sierra Nevada College Community Outreach Board. Bill fervently encouraged everyone to pursue their passion and to think outside the box. His energetic passion for his work and his appreciation for the gorgeous world around him made you want to spend more time with him.
Bill passed away Friday, August 16, 2013, in a small plane accident. We would never want to miss a minute with this wonderful husband and friend, but we are so grateful he was doing something he loved, exploring space. Bill is survived by his wife, Eileen Bohn; brother Jeff Bohn (Jan); sister Suzie Mills (Terry); daughter Gabrielle Fueyo Aura (Ryan); and cousin John Bohn (Rhonda). He is predeceased by his parents, William Kasper Bohn and Donna W. Weeks.
A celebration of Bill's life was held in Incline Village. In lieu of flowers, please remember Bill by donating to the charity of your choice .
Online condolences may be expressed in the Book of Memories at www.waltonsfuneralhomes.com.
Source: http://www.legacy.com
Urban Air Sro SAMBA XXL (N19UA) on Misfit Flats near Stagecoach
UPDATE: Lyon County Sheriff's Office (LCSO) officials are releasing the names of the two people killed in Friday's small plane crash at Misfit Flats. They name the victims as 72-year-old Paul Guttman and 63-year-old William Bohn.
According the FAA Registry website, the plane is registered to Nevada Aerospace Education Company, LLC in Incline Village. The Aircraft Owners and Pilots Association (AOPA) website lists Nevada Aerospace Education Company, LLC as having a managing member
named Paul H. Guttman, MD.
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UPDATE: Lyon County officials confirm the bodies of two people were found inside the wreckage of a plane which crashed at Misfit Flats near Stagecoach.
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RENO, Nev. -- Lyon County Manager Jeff Page confirmed to KOLO 8 News Now a plane crashed in Lyon County in the Stagecoach area.
The Federal Aviation Administration's Ian Gregor says it was a single-engine Urban Air Samba XXL plane that crashed under as-yet unknown circumstances. In an email, Gregor says, "Local authorities are reporting that two fatalities were found in the wreckage," however, he emphasized confirmation of fatalities would have to come from "local authorities."
Despite several calls, no Lyon County Sheriff's Office officials have returned phone calls.
According to Gregor, a driver in the area spotted the wreckage Friday afternoon.
According to the FAA Registry website, the plane is registered to Nevada Aerospace Education Company, LLC in Incline Village.
Little additional information is available at this time. KOLO 8 News Now has messages in to Lyon County Sheriff's Office officials, stay with KOLO 8 News Now for the latest information.
Story, Photos and Comments/Reaction: http://www.kolotv.com
CARSON CITY, Nev. (MyNews4.com & KRNV) – A small plane has crashed 25 miles east of Carson City in Lyon County.
According to Ian Gregor of the FAA the plane went down late Thursday or early Friday in Misfit Flats in Stagecoach, Nevada . A motorist driving by the crash site discovered the plane around 3:30 pm Friday afternoon.
The plane is single-engine Urban Air Samba XXL.The tail number is N19UA, which is registered to a company in Incline Village.
Lyon County Police has confirmed two people were found dead on the plane and their names are being withheld pending notification of the next of kin.
The FAA and NTSB are investigating the crash.
Story, Video and Comments/Reaction: http://www.mynews4.com
