What happened
On October 12, 2019, at approximately 10:50 UTC, an SZD-42-2 Jantar 2B glider, registration SP-1492, crashed on a pasture near the village of Mnichov u Vrbna pod Pradědem. The pilot had departed from Mikulovice airport to engage in wave soaring along the Jeseníky mountains. After approximately 3.5 hours of flight at high altitude, the pilot lost control of the aircraft. During the flight, a structural failure occurred at the wing junction, causing the glider to break apart in mid-air before impacting the ground. The fuselage and tail section were destroyed upon impact. Portions of the wings and the vertical stabilizer were recovered approximately 7.1 km east of the main impact site.
The investigation
The investigation examined the pilot's physiological state, the mechanical condition of the SP-1492, and the regulatory oversight of wave soaring operations at the airfield. Investigators analyzed the pilot's use of supplemental oxygen and the method of delivery. The investigation also reviewed the procedures established by the airfield operator regarding pilot registration and equipment requirements for high-altitude soaring. Furthermore, the investigation utilized the STAMP safety model to evaluate the systemic safety controls provided by the civil aviation authority and the airfield operator.
Findings
- The pilot was using a non-standard method of oxygen delivery, inserting a tube into the mouth rather than using a nasal cannula or mask.
- The pilot experienced hypoxia due to an undetected lack of sufficient oxygen, which led to a loss of situational awareness regarding altitude and airspeed.
- The glider was technically airworthy and equipped with the required oxygen supply, but the delivery method contributed to the pilot's physiological decline.
- There was a lack of proactive safety oversight; the airfield operator relied on the pilot's self-certification regarding compliance with soaring guidelines and equipment standards.
- The civil aviation authority lacked a proactive risk assessment process for wave soaring operations, functioning primarily in a reactive capacity.