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NTSB investigation record

CEN18FA217

Completed

Let L23Super blanik· N317BA

Date
June 9, 2018
Location
Moose, WY
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's encounter with atmospheric conditions that resulted in a loss of lift and a subsequent loss of control near terrain that precluded recovery. Contributing to the accident was the pilot's failure to follow the operator's published tour flight procedures regarding flight over the national park and minimum altitudes over and distance from terrain.

Investigator assessment

Analysis narrative

The pilot and one passenger departed on a sightseeing tour flight in the glider. After being released from the tow airplane about 13,800 ft mean sea level (msl), the glider pilot proceeded to fly over a national park near mountainous terrain. A video recording of the flight from the passenger's cell phone recorded the pilot state, "this is not good" twice and "I'm in trouble" as the glider neared the terrain. The glider impacted terrain between two mountain peaks (elevations about 12,800 ft msl and 12,500 ft msl) at an elevation about 11,000 ft msl. A review of weather data found upper level winds were from the south-southwest, which likely provided no significant orographic lift in the area of the accident site on the western side of the mountains and likely provided some downdraft activity due to the range immediately south. It is likely that the pilot maneuvered the glider close to terrain in an attempt to attain lift, but encountered atmospheric conditions that resulted in a loss of lift, a loss of control, and a subsequent impact with terrain. According to the operator's tour flight procedures, aircraft were not permitted to fly within the boundaries of the national park and were to maintain a minimum altitude of 2,000 ft above terrain. It is likely that compliance with the company's published procedures would have ensured terrain separation during the flight even in the event of an encounter with adverse wind conditions.

Source record

Factual narrative

The pilot previously held an FAA second class medical certificate, which expired on June 20, 2016. Glider operations under 14 CFR Part 91, including personal flights, flight instruction, and sightseeing tour flights, do not require the pilot to hold an FAA medical certificate. TAC reported the pilot was hired in March 2001. Since the date of hire, she flew 650 hours of instruction in the glider and flew 559 sightseeing tour flights in the glider. The pilot's most recent recurrency flight was conducted on April 27, 2018. In postaccident interviews, TAC personnel described the pilot as, "very safety conscious," "very by the book," "very cautious," and "always thorough." The pilot's husband reported that she never expressed any concerns about working at TAC and she "enjoyed taking passengers on flights and working with her coworkers." Teton Pathology, Jackson, Wyoming, conducted an autopsy of the pilot. The cause of the death was attributed to multiple blunt force injures. The autopsy revealed no significant natural disease that could pose a hazard to flight safety. The FAA's Forensic Sciences Laboratory performed toxicology tests on specimens from the pilot; testing was negative for ethanol and drugs. A test for carbon monoxide and cyanide was not performed. The LET L-23 Super Blaník Sailplane Flight Manual stated: The LET L-23 Super Blaník sailplane is a cantilever, high-wing, two-seat glider of all-metal structure with fabric covered control surfaces. Both flight compartments are covered by a single-section canopy which may be emergency jettisoned in flight. Both cockpits are equipped with all sailplane flight control including flight and navigation instrument panels. The operator kept the glider fully assembled. Review of weight and balance information revealed that, with the pilot and passenger onboard, the glider was within weight and balance limitations for the flight. Review of the glider's maintenance records revealed no evidence of uncorrected mechanical discrepancies. On June 9, 2018, about 1115 mountain daylight time, a LET L-23 glider, N317BA, was destroyed when it was involved in an accident near Moose, Wyoming. The pilot and passenger sustained fatal injuries. The glider was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 sightseeing flight. The glider was operated by Teton Aviation Center (TAC), based at Driggs-Reed Memorial Airport (DIJ), Driggs, Idaho. The accident flight was a sightseeing flight to view the Teton Range . The operator reported that a sightseeing flight was typically about 1 hour in duration; the first 30 minutes was conducted under tow before the glider released and spent the remaining 30 minutes gliding back to DIJ. The tour predominately flew over the Caribou-Targhee National Forest, encompassing both Idaho and Wyoming. The tow pilot reported that he and the glider pilot discussed the planned route and briefed safe altitudes for the flight, and then completed the preflight duties for the glider together. After departing from DIJ, the tow airplane and glider proceeded south and climbed to 11,000 ft mean sea level (msl) and turned west toward Darby Canyon. The aircraft arrived at the foothills of Darby Canyon at 11,500 ft msl and the tow pilot reported that "there wasn't much lift." They then flew east toward the boundary of Grand Teton National Park, gaining "a little lift" off the various ridgelines. The tow pilot reported that, prior to reaching the park boundary, they flew north, paralleling the Teton Range, and were "slowly climbing." About 3 miles west of the South Teton peak, at an altitude of 13,800 ft msl, the glider pilot released from tow at 1037. The tow pilot visually confirmed the release in his rearview mirror and returned to DIJ, where he landed about 1045. The tow pilot reported that he maintained radio communication with the glider pilot throughout the tow and that they worked together to find lift to gain sufficient altitude for release. The tow pilot did not report any anomalies with the glider during the tow. The passenger's cell phone was recovered from the accident site and a video recording of the accident flight was retrieved. The recording, taken from the front seat by the passenger, began when the glider was near the Teton Range during the flight, flying over Grand Teton National Park. After about 2 minutes, the footage showed Middle Teton in front of the glider and off to the left; the glider was nearly level with the top of Middle Teton. The pilot stated "this is not good.". The glider then banked slightly right parallel to the ridgeline of Middle Teton. The last frame where the airspeed indicator was visible showed an indicated airspeed of about 42 kts. The top of the ridgeline was above the altitude of the glider. The glider then appeared to enter a steep descent. The pilot again stated "this is not good." The glider appeared to exit the steep descent as it passed by a cliff marking the end of the ridgeline. The glider then appeared to enter another steep descent. The pilot stated, "I'm in trouble." The glider returned to a neutral pitch attitude but appeared to be descending. The glider was traveling along the ridgeline between Middle Teton and South Teton. As the glider descended, it began a right turn pointing toward the ridgeline. In the last frame before the recording ended, the yaw string mounted in front of the passenger's windshield was hanging about 45° to the right. When the flight did not return as expected, TAC personnel attempted to reach the glider pilot via radio. At 1220, the glider was reported overdue to the Federal Aviation Administration (FAA), and an alert notice was subsequently issued. A National Park Service (NPS) search and rescue team consisting of NPS rangers from Jenny Lake Rescue, working in conjunction with Teton County (Wyoming) Search and Rescue, used cell phone data to determine the last known coordinates of the glider. The owner of TAC departed from DIJ about 1435 in a private helicopter and flew to the area of the last known coordinates, where he located the wreckage in steep mountainous terrain about 11,000 ft msl, between Middle Teton peak (12,809 ft msl) and South Teton peak (12,519 ft msl) near the frozen Icefloe Lake in Grand Teton National Park, as shown in Figure 1. Figure 1: Accident Site Location Photos provided by the NPS showed both wings and an impact crater located on a west-facing, snow and ice-covered saddle, which originated at South Teton Peak and extended to the northeast, culminating at Middle Teton peak. The photos showed the fuselage, empennage, and miscellaneous debris located near the base of the saddle by Icefloe Lake. Figure 2: Accident Site The wreckage was extracted via external load with an NPS-contracted helicopter to a secure location for a wreckage layout and examination. All major structural components of the glider were accounted for. Flight control continuity was established throughout the airframe, and no preimpact mechanical malfunctions or failures with the glider were noted. The 14 CFR Part 91 Letter of Authorization for Teton Aviation Center was managed by the FAA Salt Lake City Flight Standards District Office, Salt Lake City, Utah. FAA Letters of Authorization for sightseeing tour flights only include powered aircraft (such as airplanes and helicopters). Non-powered aircraft, such as gliders or balloons, are not included. The TAC Standard Operating Procedures (SOP) discussed sightseeing tour flights and stated in part: Teton Aviation Center scenic flights are operated under §119.1(e)(2) and a Letter of Authorization under 91.147, which authorize us to conduct non-stop scenic air tours within a 25 nautical mile radius of the Driggs airport (KDIJ). We do not have authorization to overfly Grand Teton National Park, and are required to remain at least ½ mile outside Park boundaries. Minimum altitude is 2000' AGL [above gr

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