Aircraft Accident/Incident Report

Minden, Nevada 89423
Saturday, October 23, 2004 12:40 PDT

NTSB Narrative Summary Released at Completion of Accident

The motorized glider broke apart during a personal flight. The pilot told an acquaintance at the airport that he intended only a short flight. The acquaintance noted that the pilot did not have oxygen and offered to loan the pilot some; however, the pilot reiterated that he only intended on doing a short local flight. The glider was not equipped with gyroscopic flight attitude reference instruments. Witnesses reported hearing an engine rev up and down prior to hearing a loud bang. Several of the witnesses observed the aircraft falling from the base of the clouds with separated wings and debris following behind. Review of the weather in the area of the accident revealed there were unstable wave conditions that were reported as rapidly changing by another glider pilot. The pilot witness said the wave conditions were not very strong, nor was the mountain wave very well established. The air gap between the mountain cap cloud and the downwind lenticular clouds was rapidly closing and opening, creating an area that one moment was free of clouds and the next moment completely obscured. There were also reports of moderate turbulence in the accident area and freezing levels were reported above 9,200 feet in clouds and precipitation. The cloud tops were reported to be between 15,000 and 16,000 feet, while the bases were between 8,000 and 9,000 feet. Review of the glider's radar data revealed it was flying along a southerly heading at 14,600 feet mean sea level (msl). The glider's radar track then depicted the glider making a turn toward the northeast and enter two spiraling right turns with a rapid descent. The glider descended from 14,600 feet to 9,200 feet in 1 minute, which was the last radar return received. Post-accident examination of the composite wings revealed the right wing spar failed in two locations while the left spar failed in four locations. All of the fractures were consistent with an overload failure and were not associated with any obvious manufacturing defects. No preimpact anomalies were noted with the flight controls. The never exceed and maneuvering speeds of the glider were 135 and 100 knots, respectively. The limit load factor was established at +5.3/-2.65. The pilot did not wear a parachute due to previous back injuries and pain. He had not had a current medical certificate for more than 7 years prior to the accident, and review of his medical history revealed he had a number of medical conditions that could have resulted in an incapacitation event; however, the autopsy results were inconclusive in determining the likelihood of this possibility. He was also taking some potentially impairing medications such as brompheniramine and diazepam; however, no blood samples were available, and it was not possible to determine precisely when the drugs might have been used nor the level of potential impairment at the time of the accident.

NTSB Probable Cause Narrative

the pilot's likely inadvertent entry into instrument meteorological conditions created by the rapidly changing cloud conditions that resulted in his spatial disorientation and exceeding the glider's ultimate design loads while in a spiral dive, which resulted in the overload failure of the wings.

Event Information

Type of Event Accident
Event Date 10/23/2004
Event Day of the Week Saturday
Time of Event 1240
Event Time Zone Pacific Daylight Time
Event City Minden
Event State NEVADA
Event Country --
Zipcode of the event site 89423
Event Date Year 2004
Event Date Month 10
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 390501N
Event Location Longitude 1194501W
Event Location Airport --
Event Location Nearest Airport ID --
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness --
Investigator's weather source Weather Observation Facility
Time of the weather observation 1153 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 210
Weather Observation Facility ID TVL
Elevation of weather observation facility 6264
Distance of event from weather observation facility (units?) 16
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height 2100
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions --
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 4
Dew Point at event time (in degress fahrenheit) 2
Wind Direction (degrees magnetic) 170
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 12
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 19
Altimeter Setting at event time (in. Hg) 29.98
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Fatal
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal 1
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All 1
Investigating Agency NTSB
NTSB Docket Number (internal use) 19211
NTSB Notification Source FAA
NTSB Notification Date Oct 23 2004 12:00AM
NTSB Notification Time 1430
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Feb 28 2006 12:35PM
User who most recently changed record NTSB\JOHB
Basic weather conditions Visual Meteorological Cond
FAA District Office WP-RNO-FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N418AP
NTSB Number LAX05LA014
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 91: General Aviation
Type of Flight Plan filed None
Flight plan Was Activated? No
Damage Destroyed
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name AMS Flight
Aircraft Model Carat A
Aircraft Series Identifier --
Aircraft Serial Number CA012
Certified Max Gross Weight 1037
Aircraft Category Glider
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 1
Number of Engines 1
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Conditional
Date of Last Inspection Aug 1 2004 12:00AM
Airframe hours since last inspection 85
Airframe Hours 85
ELT Installed No
ELT Activated --
ELT Aided Location of Event Site --
ELT Type --
Aircraft Owner Name Allen D. Pratt
Aircraft Owner Street Address --
Aircraft Owner City Minden
Aircraft Owner State NV
Aircraft Owner Country USA
Aircraft Owner Zipcode 89423
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code --
Owner has at least one certificate None
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not --
Indicates Domestic or International Flight --
Operator carrying Pax/Cargo/Mail --
Type of Flying (Per_Bus / Primary) Personal
Second Pilot on Board No
Departure Point Same as Event Yes
Departure Airport Code MEV
Departure City Minden
Departure State NV
Departure Country USA
Departure Time 1220
Departure Time Zone PDT
Destination Same as Local Flt dest & departure same, accident can occur anywhere
Destination Airport Code --
Destination City --
Destination State --
Destination Country --
Specific Phase of Flight Descent - uncontrolled
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Dec 12 2005 5:54PM
User who most recently changed record COOS
Since inspection or accident Time of Accident
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --