Aviation Occurrence Report Loss of Control/Spin
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AVIATION OCCURRENCE REPORT LOSS OF CONTROL/SPIN DEPARTMENT OF NATIONAL DEFENCE BELLANCA 8GCBC SCOUT C-GQIM MOUNTAIN VIEW, ONTARIO 03 DECEMBER 1994 REPORT NUMBER A94O0316 MANDATE OF THE TSB The Canadian Transportation Accident Investigation and Safety Board Act provides the legal framework governing the TSB's activities. Basically, the TSB has a mandate to advance safety in the marine, pipeline, rail, and aviation modes of transportation by: ! conducting independent investigations and, if necessary, public inquiries into transportation occurrences in order to make findings as to their causes and contributing factors; ! reporting publicly on its investigations and public inquiries and on the related findings; ! identifying safety deficiencies as evidenced by transportation occurrences; ! making recommendations designed to eliminate or reduce any such safety deficiencies; and ! conducting special studies and special investigations on transportation safety matters. It is not the function of the Board to assign fault or determine civil or criminal liability. However, the Board must not refrain from fully reporting on the causes and contributing factors merely because fault or liability might be inferred from the Board's findings. INDEPENDENCE To enable the public to have confidence in the transportation accident investigation process, it is essential that the investigating agency be, and be seen to be, independent and free from any conflicts of interest when it investigates accidents, identifies safety deficiencies, and makes safety recommendations. Independence is a key feature of the TSB. The Board reports to Parliament through the President of the Queen's Privy Council for Canada and is separate from other government agencies and departments. Its independence enables it to be fully objective in arriving at its conclusions and recommendations. The Transportation Safety Board of Canada (TSB) investigated this occurrence for the purpose of advancing transportation safety. It is not the function of the Board to assign fault or determine civil or criminal liability. Aviation Occurrence Report Loss of Control/Spin Department of National Defence Bellanca 8GCBC Scout C-GQIM Mountain View, Ontario 03 December 1994 Report Number A94O0316 Synopsis The pilot was conducting glider towing operations at Canadian Forces Detachment Mountain View, Ontario, and departed on the last launch of the day with a passenger occupying the rear seat of the aircraft. After releasing the glider and dropping the tow rope, the pilot commenced a demonstration flight. Shortly thereafter, the aircraft was observed to pass two gliders on their right side and then climb steeply in a left turn. During the climbing turn, the aircraft rolled abruptly to the right and entered a spin. The aircraft then descended steeply and struck the ground. Both occupants sustained fatal injuries. The Board determined that the aircraft stalled during a steep, climbing left turn, which induced a spin at an altitude that precluded a successful recovery. Contributing to the accident were the increased longitudinal manoeuvrability because of the aft centre of gravity, and the increased stall speed caused by the pitching up of the aircraft and the bank angle. Ce rapport est également disponible en français. TABLE OF CONTENTS Table of Contents Page 1.0 Factual Information ..................................................... 1 1.1 History of the Flight .................................................. 1 1.2 Injuries to Persons.................................................... 2 1.3 Damage to Aircraft ................................................... 2 1.4 Other Damage....................................................... 2 1.5 Personnel Information ................................................ 2 1.5.1 Pilot................................................................ 3 1.5.2 Passenger ........................................................... 4 1.6 Aircraft Information .................................................. 4 1.7 Meteorological Information ............................................ 5 1.8 Communications ..................................................... 6 1.9 Aerodrome Information ............................................... 6 1.10 Flight Recorders...................................................... 6 1.11 Wreckage and Impact Information....................................... 6 1.12 Medical Information .................................................. 7 1.13 Fire ................................................................ 7 1.14 Survival Aspects...................................................... 7 1.15 Tests and Research ................................................... 7 2.0 Analysis ................................................................... 9 2.1 Aircraft Control...................................................... 9 2.2 Standards and Procedures.............................................. 9 2.3 Aircraft Certification .................................................. 10 3.0 Conclusions .............................................................. 11 3.1 Findings ............................................................ 11 3.2 Causes.............................................................. 11 4.0 Safety Action ............................................................. 13 4.1 Action Taken........................................................ 13 4.1.1 Pilot Training........................................................ 13 4.1.2 Air Standards ........................................................ 13 TRANSPORTATION SAFETY BOARD iii TABLE OF CONTENTS 5.0 Appendix Appendix A - Glossary......................................................... 15 iv TRANSPORTATION SAFETY BOARD FACTUAL INFORMATION 1.0 Factual Information 1.1 History of the Flight The pilot of a Bellanca 8GCBC Scout aircraft was conducting glider towing operations for the Quinte Glider Centre at Canadian Forces Detachment (CFD)1 Mountain View, Ontario. The aircraft, registration C-GQIM, was being operated by the Central Region of the Department of National Defence (DND) in accordance with the Air Cadet Gliding Program (ACGP) for the Air Cadet League of Canada. During the last glider launch of the day, the pilot departed from runway 24 with a Schweizer 2-33A glider in tow and with a passenger occupying the rear seat of the tow aircraft. The passenger was a glider pilot/cadet participating in the ACGP operations at the Quinte Glider Centre. After releasing the glider, the tow pilot returned to the aerodrome, made a low approach to runway 06 at a high power setting, and dropped the tow rope. The aircraft then entered a climbing right turn and proceeded to the southeast quadrant of the aerodrome, where it circled and completed steep turn and climbing turn manoeuvres at about 1,500 feet above ground level (agl). Shortly thereafter, the aircraft was observed at approximately 1,200 feet agl, heading westbound north of the aerodrome, in the vicinity of the last two gliders that had been launched. The gliders were at the same altitude over the aerodrome in loose formation flight. The tow pilot advised the glider pilots of his intent to pass them on their right side. After overtaking the gliders, the aircraft entered a steep, climbing turn to the left. During the climbing turn, the aircraft rolled abruptly to the right and entered a spin. The aircraft then descended steeply and struck the ground in a near-vertical attitude. The accident occurred at 1630 eastern standard time (EST)2 during the hours of daylight at latitude 44°04'N, and longitude 077°20'W3. The TSB and DND conducted a coordinated investigation. 1.2 Injuries to Persons Crew Passengers Others Total Fatal 1 1 - 2 Serious - - - - 1 See Glossary at Appendix A for all abbreviations and acronyms. 2 All times are EST (Coordinated Universal Time minus five hours) unless otherwise noted. 3 Units are consistent with official manuals, documents, and instructions used by or issued to the crew. TRANSPORTATION SAFETY BOARD 1 FACTUAL INFORMATION Minor/None - - - - Total 1 1 - 2 1.3 Damage to Aircraft The aircraft was destroyed. 1.4 Other Damage No other significant property damage occurred. 1.5 Personnel Information Pilot-in- Passenger Command Age 24 17 Pilot Licence Private Glider Medical Expiry Date 01 Oct 96 01 Dec 97 Total Flying Hours 615 23 Hours on Type 87 N/A Hours Last 90 Days 33 N/A Hours on Type Last 90 Days 29 N/A Hours on Duty Prior to Occurrence 9.5 N/A Hours Off Duty Prior to Work Period N/A N/A 1.5.1 Pilot The pilot was a Cadet Instructor Cadre (CIC) Officer employed by the Central Region of the DND at the Quinte Gliding Centre as a tow pilot and qualified glider instructor. He received his flight training as a member of the Royal Canadian Air Cadets, and acquired his private pilot licence through a powered flight scholarship in August 1988. The licence was valid for single-engine land aeroplanes and included night rating privileges. The pilot had completed a tow-pilot conversion course and started towing gliders in August 1993. He had no accident record and was regarded as a competent and conscientious pilot with an outgoing personality, and was well-liked and respected by his peers. On the day of the occurrence, the pilot commenced duty at 0700 EST. Because of poor weather conditions, the scheduled cadet familiarization glider flights did not commence until late morning. At 1136 EST, the pilot flew the first of four consecutive glider flights; later in the afternoon, he started 2 TRANSPORTATION