Maybe a summary could be that sloppiness, and mistakes are more fatal in flying than in other, less demanding pastimes.  Some are lucky when the mistake bites them ....... most are not.  Of course, the type of mistakes vary with the pastime (for instance, cheating on your wife is more fatal to politicians than to pilots :))

The only, real bit of information I am interested in is if this accident was caused by some design problem that I need to correct in my own project.
The rest is superfluous, accept to say that the fewer mistakes I make, the better chance I have of not becoming a statistic like this guy.  At least the tragedy of including his loved ones (those who would naively trust this person) in this accident was avoided.

Know your limits, and have a plan.
phil stitzer,  Vision look-a-like w/rotary

Dave wrote:

Al..

This is probably the first time I've had to say:

I disagree with you.

All of the minutiae you are saying is superflous is actually germane in my opinion.

While the EFIS wasn't calibrated, and in theory, wasn't required to even be there, it was most likely (i.e. educated guess) situated in the primary flight display's position of front and center. By not being set up properly it was giving bad data (even the pitot static was uncalibrated).. so airspeed was unreliable. Altitude was unreliable. Unessential in theory to Day VFR flight but lets be honest here, the device was giving bad info, alarming constantly and was a distraction.

The manually controllable propeller also has bearing here. EVERY SINGLE TIME he made a throttle adjustment he had to make a prop adjustment, and he had yet to sort out if he was using prop or engine RPM. This is a big addition to the workload compared to a fixed pitch prop.

This guy was using a handheld GPS, plugging his headset into the panel to make radio calls, and unplugging it afterwards, because the panel was tied into the EFIS, which was having its own party sending alarm after alarm, from not being set up properly.

The above 3 items result in a tremendous distraction and workload increase. He was flying something faster, more powerful than anything he'd been in before. At 200 hrs, I was already past complex, high power and actual-IFR training. His logbook is unavailable but its inferred his experience is in low powered Cherokee airframes. It doesn't say if he did his checkride at 40 hrs or 100. The difference between those two makes a difference. At 70 hrs I started flying Grumman Tigers. Slick plane and I had to plan ahead much further than I ever had before in 152's and 172's. I went around more times in that airframe until I managed to get my speed control on target. And this was fixed gear, fixed prop, and a working instrument panel. Getting into a Mooney 20-E a couple hours later put me right behind all over again, even though I was by now used to gear and prop. And I originally was a 45 hr private pilot who had to transit Class B airspace to get to my checkride, and who had self studied for every written I had ever taken (and used commercial and instrument texts while prepping for Private)

Back to the report: The rudder trim was attached with duct tape. At that particular moment it was attached. You are right. Duct tape is not a safe method of attaching mission critical hardware. Combine this with the stripped/damaged pushrod and what you see here is a ticking timebomb waiting to bite you. Its germane. It tells you that there was at least ONE ticking time bomb that they DID find. I have doubts it was the only one.

The fact that clecoes were used in flight shows an approach to flight safety that is unsatisfactory. Did they fail? No. Could they have? Very likely.

We dont know if unterminated wires were a factor or not. They could have caused a short. There wasn't much mention of circuit breakers. The cable not being in its terminal IS pertinent, as is the manner of (not) crimping it, given that his engine is dependent on electrical power for continued operation. This one issue above all others is VERY germane to the the event.

Its perhaps more appropriate to look at this event in the context not of an accident CHAIN but an accident WEB. Think outside the box. Every little nitpick here comes together in a synergistic manner to result in a plane that was most likely never airworthy, and an accident waiting to happen.

The factual report is showing time after time after time of suboptimal decisionmaking. That is VERY germane to the situation as it is this habitual poor decisionmaking that is the most likely cause of the accident. The actual component or issue that caused the actual crash, the actual departure from controlled flight, may never be found or known, but the factual report as I read it will point towards "the nut behind the wheel/stick" as most proximate cause to the event.

And.. again.. this is a factual report.. the facts of the situation, the airframe and the pilot. The "probable cause" statement comes later. The investigator was obviously concerned with a thorough investigation of all RELATED and GERMANE factors that could possibly bear on the accident. And I must readily admit, this factual report was much more detailed than what I have become accustomed to reading with regards to experimental amateur built aircraft accidents over the years.

Dave

Al Gietzen wrote:

Thank you Ernest for that detailed review.  I had somewhat the same
impression. I kept reading, and reading, expecting to find at some point
what caused the accident - but never did.  Only thing that seemed clear was
that the pilot was not a thorough and rigorous person, which was likely a
contributing factor.

Al G

  I've had several private links to this posting.
  Very sad. It's an unfortunate fact of the human
  condition that rational thought processes and
  understanding of simple-ideas can be so terribly
  diminished by hazardous behaviors.

Let's not let simple ideas get lost in our sympathy for the pilot in this accident.  Most of this report is superfluous fluff with little bearing on what could have caused the accident.  In fact, there is no statement of what caused the accident that could be blamed on the lack of a rational thought processes on the part of the builder.

Most of the report was dedicated to pointing out how the high-end EFIS was not calibrated.  At no point was the lack of calibration cited as a contributing factor to the accident.  The man was flying day VFR.  The instrument was superfluous for the mission.  The fact that the pilot was not familiar with the instrument's operation was superfluous to the report.  The fact that the instrument was in the plane at all was superfluous to the report.  How could anything displayed on an uncalibrated EFIS translate into a plane taking a 35 to 60 degree nosedive during a day VFR flight?

Most of the remainder of the report was equally superfluous.  The first flight occurred on July 12.  The accident occurred on November 2.  The fact that clecoes held the cowling on for the first flight was superfluous to the accident report.  It might have been germane if an accident had occurred with the clecoes still in use, but that was not the case.
The fact that the propeller was under manual control vs some sort of electronics is superfluous.  Are there not many examples of airplanes flying just fine with manual control?  And I hear that there are a few flying with no pitch control at all.  There is some information that the pilot was having issues with coordinating the engine power with the propeller pitch controls.  But that does not translate to taking a 35 to 60 degree nose dive into terra firma.  I can't even translate it to a situation where the pilot would not be able to maintain altitude.  It might translate to an inability to maintain smooth level flight, but there is a wide gulf between smooth level flight and a dirt bath.

The report pointed out that the rudder trim was attached with duct tape. The key word is "attached".  How did a *rudder* trim that was *attached* contribute to a 60 degree nosedive?  How does an *attached* rudder trim even make it difficult to maintain altitude?  An aileron trim tab rod had been broken and poorly repaired.  Was the weak attachment cause of an accident, or more superfluous data?

The report makes hay of the pilots lack of high performance training. He was flying the plane for nearly 4 months before the accident.  I would imagine that high performance training would cover issues like severe P factors and overspeeding the airplane.  Is "maintaining altitude" taught exclusively in high performance trainging now?  If not, why is the lack of such training an issue?  The report details the pilots rush to get to Oshkosh, and the pilots willingness to falsify records in order to meet legal requirements.  How did any of that contribute to an accident that occurred months later?

There were some wires not connected.  So?  Did any of them contribute to the inability to maintain altitude?  I have several wires in my project that are slated for future upgrades.  It's much easier to run them now than when everything is closed up.  They are not connected to anything. If something really bad happens to me, those wires will have nothing to do with it, but will "unconnected cables" be cited in the report anyway?

I suggest reading the report again...but cross out all the superfluous lines that obviously have nothing at all to do with the accident.  Cross out the parts that point out "He didn't follow the rules.  He was a BAAAAD man."  It'll be a much shorter report.  The pilot of N289DT may very well be a prime candidate for a Darwin Award, but we can't know that from reading this report.  All I can tell is that the investigator was much more concerned with pointing out how the pilot was not following procedure than about what occurred.

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