History of Flight
On July 24, 2021, about 1152 Pacific daylight time, a SIAI Marchetti SM-1019B, N28U, was substantially damaged when it crashed at Lewiston-Nez Perce County Airport (LWS), Lewiston, Idaho. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
According to the pilot's wife, the pilot planned to fly to Hungry Ridge Ranch Airport (37ID), Grangeville, Idaho, where he owned a residence. She stated that he was in no hurry and there was no time-sensitive reason to be at the destination.
Airport security video cameras captured the airplane positioned on runway 12 at the intersection of taxiway D before takeoff. The airplane began the takeoff roll and continued about 400 ft down the runway before taking off in a three-point departure configuration. It pitched nose-up to about 45° while climbing to an altitude of about 80 ft above ground level, after which it rolled 90° to the left as the nose dropped. The airplane continued to roll left while descending and impacted the ground in a nose-down, left-wing-low attitude between runway 12 and taxiway C, about 970 ft beyond where the takeoff roll began. A postimpact fire ensued.
Witnesses described the airplane taking off normally before it aggressively pitched up and rolled left.
Personnel Information
The pilot was a retired naval aviator and current air show performer with extensive flight experience. He held a commercial pilot certificate with ratings for airplane single-engine land and sea, airplane multi-engine land, and instrument airplane. At his last medical examination on October 29, 2020, he reported 6,500 total hours of civilian flight experience. His logbooks were not available.
The pilot purchased the airplane on April 21, 2021, and it was delivered in June by a friend who was also a flight instructor. The instructor flew with the pilot for the first flight after delivery, performing slow flight, stalls, steep turns, and multiple stop-and-go landings. The instructor stated that the pilot demonstrated proficiency and at no time did he need to take the controls. He noted the pilot's thorough 90-minute preflight walk-around and exemplary checklist discipline. During preflight, the pilot performed a full check of flight controls and discussed the control lock operation, stating it was similar to those on other airplanes he had owned.
Varying accounts indicated the pilot had flown the airplane about twenty times since purchase. The pilot's wife had flown with him to LWS earlier in the day in their other airplane. She left him at the airport at 1110, with the accident airplane still in the hangar. She stated he normally performed preflight checks after the airplane was pulled out, and she was surprised he could have completed them and departed by the accident time.
The general manager of the FBO next to the hangar stated he had known the pilot for many years and routinely observed him perform an engine runup at the approach end of the runway before takeoff. He had never seen the pilot perform an intersection takeoff from midfield, and noted his preflight inspections took a very long time.
Aircraft Information
The airplane was manufactured in Italy in 1977, imported into the United States in 1997, and issued an experimental-exhibition special airworthiness certificate in February 1998. It was a single-engine, all-metal, high-wing aircraft with a fixed tailwheel landing gear configuration. The cabin was enclosed with conventional flight controls for two pilots in tandem. It had been upgraded with an avionics suite and autopilot, and was equipped with a 400-shaft-horsepower Allison M250-B17B turbine engine. The last condition inspection was completed on May 3, 2021, at a total time of 509.5 hours.
Wreckage and Impact Information
The initial impact point was an area of disturbed ground consistent with a left wing strike about 30 ft from the main wreckage. A large, shallow impact crater consistent with engine impact was found between the initial impact point and main wreckage. The wings sustained impact and thermal damage and remained partially attached. The forward fuselage sustained thermal and crush damage focused on the left side. The engine remained attached; the propeller assembly separated and was found on the runway.
Engine disassembly revealed evidence of power at impact, including torsional overload of couplings and compressor blade stages with detached airfoils bent opposite rotation direction. Propeller blades exhibited signatures of stoppage at high power and high impact angle.
The pilot's seat remained engaged and locked just forward of midrange; the rear seat was in center of travel. Both seats were attached to their rails. Elevator control cable continuity was established from the bellcrank to the aft control stick, connected to the forward stick via interconnect tube. The left elevator servo tab was intact; the right elevator trim tab was set to an almost full tab-up (airplane nose-down) position based on jackscrew extension.
The only undamaged autopilot component, the Garmin GSA-28 elevator pitch control servo, was firmly attached and showed no anomalies. All flight control cable pulleys not damaged were intact and moved smoothly. No evidence of cable interference or foreign objects was found. Both flaps had drive actuators corresponding to a flap extension of 30°.
The flight control locking system was examined. The control lock remained connected to the rudder pedal assembly, was intact, and found in the raised position near the lower edge of the instrument panel. The cabin floor forward of the control stick base was compressed aft; the control stick base was 4 inches away from the control lock pivots. The floor retainer clip was undamaged. The locking arm and pin assembly remained attached to the control stick and was undamaged but rotated 90° to the right. No evidence of contact with other components was found.
Examination of the airframe and engine revealed no preaccident mechanical malfunctions or failures that would have precluded normal operation.
Additional Information
The airplane's flight manual, found after the accident, contained a preflight check item for removing the flight control lock. The before take-off section stated to check for freedom of movement and maximum range of travel. The flight characteristics section described trim changes: flap extension causes nose-up moment, and an increase in power causes nose-up moment. The aircraft remained controllable with slight stick movements.
Communications
At 1150:15, the pilot made initial contact with ground control. Eight seconds later, he requested taxi clearance from the FBO ramp for a runway 12 departure at taxiway D. The controller instructed to taxi via taxiway D. At 1150:48, the pilot asked if cleared for takeoff; about 20 seconds later, the controller cleared him for takeoff from runway 12 at taxiway D. The pilot responded and was asked to switch to tower frequency. After apologizing, he contacted the tower controller, who confirmed and cleared the airplane for takeoff. At 1151:41, the pilot replied "for takeoff." At 1152:17, expletives were heard. Relatives and acquaintances who listened to the recordings stated the expletives came from the pilot.
Medical and Pathological Information
On his most recent FAA medical certificate application, the pilot reported using lisinopril for high blood pressure and levothyroxine for low thyroid hormone, both under CACI criteria. These medications are generally not considered impairing. He was issued a second-class medical certificate with a requirement for glasses for near vision.
The Spokane County Office of the Medical Examiner performed an autopsy. The cause of death was blunt force injuries. The autopsy revealed heart disease with a dilated heart and mild coronary artery narrowing, but no other significant natural disease. Toxicology testing was negative for drugs and ethanol.
Tests and Research
Examination of a similar airplane confirmed that with the control lock engaged, ailerons and elevators were completely locked, but rudder and tailwheel could move nearly fully, allowing taxiing unhindered. The control lock is painted red, but from the pilot's view, it is seen at its narrowest profile.
Another 1019 series owner described an experience where he forgot to remove the control lock before flight. He taxied for departure unaware, became distracted during pre-takeoff checks, and completed initial stages of takeoff with the lock engaged. He struggled to remove it due to forces on the stick during takeoff but freed it after a few seconds.
The pilot's friend who delivered the airplane stated you could easily enter with the control lock engaged. He noted that tailwheel aircraft require heavy differential braking for steering, and limited rudder movement. After the accident, he performed checks in a similar airplane and determined it could be taxied uninhibited with the lock engaged. He could not remove it with reasonable force if there was control pressure on the stick.
A section of the forward flight control stick, locking arm, and control lock were sent to the NTSB Materials Laboratory. Examination revealed normal wear between components. The control lock exhibited a slight longitudinal twist where it connected to the buckled cabin floor but was otherwise undamaged.
The airport security video allowed estimation of flight control deflections. Review showed that elevator and aileron deflections were either zero or so small they could not be seen. The flaps were identified in an extended position.