WPR18FA143

The pilot's improper installation of the wings onto the glider, which resulted in an in-flight wing separation. Contributing to the accident were the pilot's limited familiarity with the design and a lack of reliable assembly guidance.

The private pilot of the glider and his co-owner had jointly purchased the 44-year-old Romanian-manufactured glider, which was last flown about 7 years before the sale. About 3 months after purchase, the pilot completed an annual inspection of the glider. About 2 months later, the glider was moved to the soaring club's home airport, where the pilot and co-owner, with help from a third club member, assembled the glider for the first time. The pilot held a mechanic certificate with airframe, powerplant, and inspection authorization ratings, and was said by colleagues to be a competent and thorough mechanic. The accident flight was the first flight since assembly. About 1 hour after being towed aloft and released, the pilot indicated via radio that all was well and that he planned to continue flying. There was no further communication from the pilot. When he had not returned about 5 hours later, two club pilots departed to conduct an aerial search and subsequently located the wreckage. Examination of the accident site revealed that both wings separated from the fuselage in-flight and that the pilot had unsuccessfully attempted to parachute to safety. No location or tracking data was available to determine the flight track or altitude history for the flight. Examination and analysis of the wing attach mechanism revealed that the wings had not been properly installed and secured before the flight. Email and witness information indicated that, during the wing installation, the pilot had some doubt whether he had properly secured the wings and had called the previous owner of the glider to obtain his input. The pilot's conclusion from that conversation was that the wings were secured properly and that no additional action was needed. Although some of the attach hardware did not appear to be in accordance with the manufacturer's parts catalog, which may have interfered with the installation of the wings, the effect of this hardware on the installation process could not ultimately be determined. Access to the attach mechanism during wing installation was via an approximate 2-inch diameter cutout in the fuselage skin, which provided a partial view of the assembly when installed. With basic knowledge of the wing securing design and mechanism, the pilot should have been able to readily discern whether proper wing security had been achieved. Both individuals who assisted with the wing installation reported that they did not recall any abnormalities or indications of significant difficulty with the process. They both reported that a post-installation functional check of the flight controls was satisfactory; however, the flight control system design was such that the fuselage-to-wing control link connections could be successfully made despite the improper installation of the wings. This likely provided the pilot a false positive indication of the integrity of the wing installation, reinforcing his conclusion that the wings were properly installed. Despite the incomplete and incorrect assembly, the friction resulting from the partial engagement of the attach mechanism was sufficient to hold the wings in place for at least an hour of flight. Several factors decreased the potential for ensuring that the wings were properly installed and secured; the manufacturer no longer produced or supported any gliders, precluding any direct assistance to the pilot/co-owner; the only written assembly guidance available was of poor visual and technical quality and provided only generic assembly information in poorly-translated text; and the previous owner did not live nearby and there were only two other of the manufacturer's gliders registered in the US, which significantly limited alternate information sources for the pilot. Despite the scarcity of accessible, quality assembly guidance, with the wings uninstalled, a person could access and operate the attach mechanism to determine proper assembly indications. There was no evidence that the pilot or either of the other two persons who helped install the wings ever conducted such an exercise. Additionally, the pilot's chronic back pain restricted his ability to physically examine, manipulate, and work on the glider. However, the simplicity of the design, combined with the pilot's mechanic certification and his reported mechanical skills, should have enabled him to readily determine and accomplish the procedures for the proper installation of the wings as well as to accurately verify their proper installation. In addition, despite the criticality of proper wing installation, and his explicitly-expressed uncertainty as to whether he had properly accomplished that task, the pilot did not remove the wings and re-examine the hardware and structure in order to develop a better understanding of the design, and then re-attempt the process, in order to ensure that the wings were properly installed. The pilot's toxicology test results revealed the presence of hydrocodone, an opiate (narcotic) pain relief medication. While the use of the medication would not have resulted in the wing separation, it could not be determined the effect on his ability to successfully escape the failing glider. Whether he used the medication during the period when he inspected and assembled the glider could not be determined. The wing separation altitude and sequence the resulting glider dynamics, and the effects of these factors on the pilot's ability to execute an escape could not be determined.

Pilot FAA records indicated that the pilot held a private pilot certificate with glider and airplane single-engine land ratings. The pilot was operating under the provisions of BasicMed; his most recent examination was completed on June 1, 2017. Review of his logbook indicated that he had logged about 450 total hours of flight experience, including about 217 hours in gliders. His most recent flight review was completed in April 2017. The pilot also held an FAA mechanic certificate with airframe, powerplant, and inspection authorization ratings. According to family members and CCSC colleagues, the pilot was a competent and thorough mechanic and an experienced glider pilot. Co-Owners' Proximity and Schedules The pilot and glider co-owner lived about an hour's driving time from one another. The pilot lived about 75 minutes' drive time from CA69, and the co-owner lived about 115 minutes' drive time from CA69. According to the co-owner, these distances and the individuals' respective jobs and personal obligations made it difficult for them to schedule joint activities at the glider. The Kings County (California) Office of the Coroner autopsy report indicated that the cause of death was "multiple blunt force trauma." Hydrocodone (liver and muscle) and dihydrocodeine (liver) were detected. The FAA Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, conducted forensic toxicology examinations on specimens from the pilot and reported that no ethanol was detected; hydrocodone (liver and muscle) and dihydrocodeine (liver) were detected. Hydrocodone (generic and multiple brand names, including Hysingla and Zohydro ER) is a prescription, short-term use medication used to relieve severe pain. Hydrocodone is in a class of medications called opiate (narcotic) analgesics. This medication has the potential to impair mental and/or physical ability required for the performance of potentially hazardous tasks, such as driving, flying, and operating heavy machinery. This medication is disqualifying for FAA aeromedical certification. Dihydrocodeine is an active metabolite of hydrocodone. The pilot's family reported that he had undergone several surgeries for neck/back injuries and that he was typically in significant pain. The glider co-owner reported that the pilot normally was in "a ton of pain." The pilot occasionally took some prescription medication for relief from the pain, and he had access to that medication during the period when he inspected and assembled the glider. However, the family was unable to provide any specific information regarding his use of the medication before or during those activities. According to the pilot's son, a few days before the accident, the pilot had a "minor [medical] procedure done to his back." The family and the co-owner reported that the pilot's chronic back pain restricted his ability to physically examine, manipulate, and work on the glider. The Romanian-designed and built glider was manufactured in 1974 as serial number 38. The high-performance, single-seat glider was constructed almost entirely of aluminum. It was equipped with ailerons, trailing edge flaps, upper and lower air brakes, and a T-tail trimmable horizontal stabilizer with an elevator. Flight control links were primarily push-pull and torque tubes. The canopy was designed to be jettisonable. FAA records indicated that the glider was shipped from the manufacturer to Great Britain in April 1975 and was imported into the United States (US) in late 1976. No records of any incidents or accidents involving this glider were discovered. A review of FAA records revealed that only 3 Brasov gliders (including the accident glider) were registered in the US at the time of the accident. A search of multiple internet sources indicated that the company had discontinued manufacture and support of its gliders, possibly as far back as the 1980s. Wing Attach Design The glider's wing assembly consisted of the two wings, each of which was fully assembled, complete with its own flap, aileron, air brakes, and relevant control systems/links. The flight control system/linkages were fully contained within each wing (no user installation required) and mated to their fuselage counterparts at the wing-fuselage juncture. The inboard end of the main spar of each wing was fitted with upper and lower spar cap extensions to enable the attachment of the wings to one another by means of two clevis/tang assemblies. The clevis assemblies were referred to as the "top" and "bottom," corresponding to the upper and lower spar caps, respectively. The right-wing clevis portions had a total of four legs (two in the top clevis and two in the bottom clevis). The two legs of each top and bottom clevis were referred to as "upper" and "lower," referring to each leg's relative position in its respective clevis assembly. (see Figures 1 and 2) Figure 1. Right Wing Clevis Legs and Pin/Cone Nut Assy Figure 2. Left Wing Clevis Tangs The left wing had a similar arrangement, with two single tangs, each of which was designed to be inserted between the two legs of each clevis of the right wing. The tangs and legs were all oriented horizontally. The two tangs and four legs all had approximate 1-inch diameter tapered holes machined into them, oriented vertically, so that when the wings were properly positioned into/onto the fuselage, the six holes were vertically aligned (stacked) at the glider centerline. A pin and cone nut assembly (described below) then installed vertically through all six holes to attach the two wings to one another and concurrently secure them to the fuselage. (see Figure 3) Figure 3. Pin and Cone Nut Assy The pin length was slightly less than the distance between the bottom surface of the lower leg of the top clevis and the top surface of the upper leg of the bottom clevis. The pin was threaded on each end, and long tapered nuts (cone nuts) were installed on each end of the pin. Two formed and machined plates were bolted to the inboard end of the main spar of the right wing. These plates retained the pin assembly (oriented vertically) and served as alignment guides during wing installation. The pin had a hex socket in its top end to enable rotation with a hex (allen) key. The cone nuts had vertical slots that rode on vertical tabs on the machined plates to prevent them from rotating when the pin was rotated. Thus, rotating the pin resulted in relative rotation between the pin and the cone nuts. The cone nuts travel up or down as a function of which nut and which direction the pin was rotated. Rotating the pin in one direction would move the top cone nut up and the bottom cone nut down to sequentially drive the cone nuts through the leg, tang, and the other leg of each clevis and then seat in the respective holes, securing the wings to one another. Rotating the pin in the other direction would drive the cone nuts toward the lengthwise center of the pin, clearing them of the clevis leg and tang holes and allowing the wings to be separated and removed. In the horizontal plane, wing assembly from first tang-to-leg contact to final alignment of the cone nut holes required a relative wing travel of about 1 1/3 inches. The wing structure also had six laterally-oriented pin-and-socket mechanisms. Each wing root rib was equipped with a forward and aft socket that mated with a pin on the fuselage. These constituted part of the load-transfer path between the wings and fuselage and were sometimes referred to by the pilot as "lift pins." In addition, the right-wing main spar was equipped with two pins that mated to corresponding sockets on the left-wing spar. These six pin-and-socket sets enabled proper wing alignment, provided joint rigidity, and enabled the flight and structural loads to be transferred between the wings and fuselage. When the clevis holes were aligned and secured by the pin and