Primary finding
Probable cause
The pilot's failure to latch the canopy before takeoff, and his failure to maintain pitch control following the in-flight opening of the canopy during the initial climb resulting in a subsequent impact with terrain and ground fire.
Investigator assessment
Analysis narrative
A private pilot departed on a local flight in his experimental, amateur-built airplane equipped with a tip-up (forward-opening) canopy. A witness saw the airplane during its initial climb after takeoff and stated that it descended "straight down and burst into a ball of flames" upon impact. Examination of the accident site revealed that items from the cabin were found on the ground near the runway threshold and before the impact site. There were no preimpact anomalies of the airframe or engine and kit manufacturer fuel tank Service Bulletins were compiled with. The airplane's before takeoff checklist stated, "Canopy – CHECK Latched." However, the metal canopy latching mechanisms on the roll bar frame exhibited soot-colored discoloration and its polyethylene latch block was not present, and the latch handle on the canopy was intact, not deformed, and not discolored, consistent with the latch being unsecured at the time of impact. Additionally, the presence of items from the cockpit before the impact site is consistent with the canopy opening in flight. About 9 months before the accident, the kit manufacturer published a service letter regarding the in-flight opening of tip-up canopies. The letter stated that, based on previous events, the aircraft will most likely pitch nose down abruptly if the canopy opens in flight. The severity of the pitching moment can depend on speed, attitude, and weight and balance. The letter further stated that most instances of in-flight canopy openings were the result of the pilot forgetting to latch the canopy properly before takeoff, and cautioned pilots to ensure that the latching mechanism fully engaged as designed. Based on the available evidence, it is likely that the accident pilot failed to properly latch the canopy before takeoff, did not maintain airplane control following the canopy opening, and the airplane subsequently impacted terrain to the extent that the incorporated service bulletins remedies did not keep the fuel tank from breaching, causing the ground fire.
Source record
Factual narrative
At 1129, the recorded weather at the Indianapolis Regional Airport (MQJ), near Indianapolis, Indiana, included wind 070° at 5 kts, visibility 10 statute miles, sky condition clear, temperature 21° C, dew point 17° C, and altimeter 30.11 inches of mercury. The 78-year-old pilot held a Federal Aviation Administration (FAA) private pilot certificate with an airplane single engine land rating. His most recent application for a FAA third-class medical certificate was dated June 28, 2012. As of this medical exam, the pilot reported that he had accrued 1,200 total hours of flight time and 23 hours of flight time in the 6 months before the medical certificate. That medical certificate had a limitation: Must wear corrective lenses. An on-scene examination of the wreckage was conducted. A page from the airplane's checklist, a section of foam, and a pair of glasses were found in the grass near the departure threshold of the runway. Airport operations personnel examined the runway after the accident and no liberated airplane parts were found. A linear impact mark was found about 225 ft southeast of the departure end of runway 15; it had a depression at its center, consistent with the size of the airplane's wings, engine cowling, and nose landing gear, indicative of an initial impact point. That linear mark revealed an impact heading of 140°. The airplane came to rest upright on a heading of about 100° about 104 ft after that initial impact point. The grass along a linear path between the initial impact point and where the airplane came to rest was chafed. That linear path heading was about 150°. The nose landing gear was separated from the airplane and was found near the depression at the initial impact point. Sections of the airplane were liberated along the path. One side of a headset was found about 13 ft from the impact point. A composite propeller blade was found about 20 ft from the impact point. A section of cowling was found about 80 ft from the impact point. The fuselage by the cabin area and inboard sections of the wings exhibited discoloration, deformation, and consumption damage consistent with a postimpact ground fire. Rudder and elevator control cables were traced from their respective flight control surfaces to the cabin area near their controls. Aileron control continuity could not be traced due to fire damage. The throttle, choke, and cabin heat were found in their forward positions. Engine control cables were traced from the cabin to the engine. Electrical power was applied to the trim motor and it was operational. The metal canopy latching mechanisms on the roll bar frame exhibited a soot-colored discoloration and its UHMW latch block was not present. However, the latch handle on the canopy was intact, not deformed, and not discolored. N212ZF was an experimental operating light-sport kit-built Van's Aircraft Inc. RV-12 airplane with serial number 120136. The airplane was a single engine, low-wing monoplane, configured to seat two occupants in a side-by-side seating arrangement. It had a fixed tricycle landing gear arrangement and was constructed primarily from aluminum alloy materials. The airplane was powered by a 100-horsepower Rotax 912 ULS engine, serial number 6775819. The engine drove a two-bladed, Sensenich composite, ground adjustable, propeller. An endorsement in the airplane's logbooks indicated that a condition inspection was completed on November 20, 2016, and that the airplane had accumulated 153.4 hours of total time at that date. Logbook endorsements indicated that Service Bulletin (SB) 11-12-14, which was released to make the fuel system more breach resistant by the addition of clips and installation of frangible bolts, was complied with on June 30, 2013, and SB 13-12-19, which was released to add more robust hardware in conjunction with doublers inside the fuel tank in order to make the fuel tank more resistant to a breach, was complied with on July 15, 2013. The airplane was equipped with a forward-hinged tip-up canopy with a locking mechanism. The mechanism was a handle attached near the center and at the rear of the canopy frame. Once closed, the handle was turned 90° so that a tang on the end of the handle extended under the adjacent fuselage roll bar frame where the tang is retained under an ultra-high-molecular-weight polyethylene (UHMW) latch block. The kit manufacturer supplied an excerpt from the pilot operating handbook from the closest available revision to the one sent with the kit to the builder. The handbook's before takeoff checklist, in part, stated, "Canopy – CHECK Latched." A canopy open warning system was developed by the kit manufacturer. The warning system is applicable to SkyView or Garmin display equipped RV-12 airplanes and are not designed for Dynon FlightDEK-D180 display equipped RV-12 airplanes. The accident airplane was equipped with a Dynon FlightDEK-D180 seven-inch wide screen display unit. The unit's primary functions include attitude, airspeed, altitude, vertical speed, gyro-stabilized magnetic compass, slip/skid ball, turn rate, clock, timers, g-meter, and horizontal situation indicator. This instrument features ADAHRS (Air Data, Attitude and Heading Reference System) to provide air data, attitude and heading information to the display. The unit integrates up to 16 engine related instruments including manifold pressure, temperatures, RPM and fuel system information, and annunciate any abnormality immediately upon detection. The Dynon's internal memory is capable of logging data depending on the firmware version installed in the unit. The data logging must be configured by the operator to enable logging and set the data log interval. On August 31, 2017, about 1130 eastern daylight time, an experimental amateur-built Vans Aircraft Inc. RV-12 airplane, N212ZF, impacted terrain after takeoff from runway 15 at the Indianapolis Metropolitan Airport (UMP), near Fishers, Indiana. The private pilot, who was the sole occupant, was fatally injured. The airplane was destroyed during the impact and a post impact ground fire. The airplane was registered to and was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Day visual meteorological conditions prevailed in the area about the time of the accident, and the flight was not operated on a flight plan. The local flight was originating from UMP at the time of the accident. A flight instructor giving dual instruction in a helicopter stated that he was preparing to conduct an autorotation to land on runway 15 at UMP. About 4 miles from UMP, his student announced over the airport's common traffic advisory frequency their intentions to make a straight-in landing on runway 15. As the helicopter descended through short final, an airplane began to cross the runway 15 hold short line while simultaneously announcing his departure over the radio. As soon as the radio call ended the airplane had reached the runway 15 threshold markings. The instructor immediately made a radio call announcing that the helicopter was on short final. The airplane pilot did not respond and continued to take the runway. The instructor indicated, "At this point it was clear we would have to initiate a go around in order to avoid a collision. Instead of proceeding upwind and risking a collision while he was taking off, I opted to do a right 360 off of the southwest side of the approach end of 15 to ensure we would remain clear of his departure path. As we began the right 360 I made a calmly mannered radio call directed toward the aircraft explaining that it was bad practice to cut off approaching aircraft on short final." The airplane pilot never responded. The instructor further stated, "As we came back around on final after executing the right 360 I noticed a fire in the grass off of the departure end of the runway. I began to look for the departing airplane and also noted that he had not made any other radio calls announcing