What REALLY caused John Denver's death?

Everything I’ve heard said it was due to his experimental ultralight airplane.

But was it ever determined to be pilot error, mechanical failure, weather or a little bit of everything?
CJ

tHE plane he was flying, was designed by a veritable genius of aviation, Burt Rutan.

So, I doubt it’s a design error.

Since witnesses saw it STALL, rather than, say, fall apart, I’d likely say pilot error.

But who knows.

Full report:
http://www.avweb.com/other/ntsb9905.html

Brian

IIRC, the FAA determined that the problem was caused by the modifications made to the plane made by the previous owner. He put the switch to switch from one fuel tank to the other in a location inconvienent for the pilot (behind the pilot’s seat), so Denver either couldn’t get to the switch in time, or he bumped the controls while he was trying to flip it.

Trite/snarky answer: The real cause was gravity.

Sneaky suspicion:

bird strike. According to local rumor, the body was ID’d by fingerprints, and the Long EZ is a bathtub with a 1/8" plexi canopy, and being a canard, is next to impossible to stall, and barring deliberate pilot action (read: suicide), getting a Long EZ to strike water nose down would be a trick - so water probably did not shear the canopy - a pelican, OTOH, encountered at 200 mph, will go through a 1/8" plexi canopy real well.

I suspect the NTSB wanted to soften the blow for fans, and since it was not a situation likely to be repeated, absolute accuracy is not needed.

And, the re-location of the fuel valve is not an issue - the FAA certified that device as being an airplane - and the pilot is expected to be able to safely pilot any airplane he/she decides to fly. If the pilot is physically unable to reach the fuel valve, he should not fly that airplane.

From here we could go into the question of who is the manufacturer of a homebuilt (hint: it wasn’t Burt Rutan, or anybody else at RAF) and who gets to decide things like where to place the fuel valve (hint: the manufacturer).

That’s only if it’s built according to the design. It wasn’t.

The canard design, if built and loaded correctly, is extremely stall resistant.

I’d say smacking into the water at a high rate of speed was what killed him.

Having started in the homebuilt segment of aviation, it’s been a chronic problem that pilots with lots of experience in more conventional aviation frequently do not appreciate just how different some of these aircraft are. His “transition training” mentioned in the NTSB report linked was, in my opinion, inadequate. The fastest I ever transitioned to a new airplane was 3 hours - but that was moving from one airplane to one very similar. Usually, I take 5-10. Yes, some people can transition faster. Chuck Yeager took 1-2 hours to transition to an ultralight. Hey, if 2 hours is required for General Yeager I’d say that’s a rock-bottom minimum. OK?

Again, this was an airplane of unusual design. Good design - Rutan designs very good aircraft (and currently he’s designing a spaceship) - but it’s not like the Cessnas/Pipers/Beech/whatever of more conventional, factory-built aircraft. And homebuilts are infamous for builder/owner modifications. No two - even two built from the same plans - are ever quite the same. Which is another thing to be wary of - putting a fuel selector in an unusual place is hardly the most extreme modification I’ve seen in a homebuilt. A pilot of conventional aircraft stepping into a homebuilt with quirks can have some very unpleasent surprises.

Now, about that fuel selector. Heck, lets talk about that whole fuel indicator system. It doesn’t sound real, um… precise. Which isn’t that unusual. Even in conventional airplanes I visually check the fuel, use dipsticks to measure quantity, and otherwise confirm how much is in there independent of the fuel gauges - because sometimes the gauges are wrong. In a homebuilt, with a float-indication system, particuarly one that (apparently) was not calibrated, it’s even more important to check and doublecheck your fuel levels. Did he do this? I’m not sure. Did he take off on the tank with the most fuel?

You know, if I was faced with a fuel selector in such an awkward position I think I’d tank up on both sides and only change the switch on the ground. He was already planning to have the fuel selector moved to a more accessible position, which indicates he didn’t like the set-up, either.

Another point: An E-Z is a very light airplane. Even if it was very stable in the air while flying, an adult man shifting his weight in the cockpit was probably enough to cause a significant shift in flight attitude (I’ve been know to steer a Cessna 150 - an airplane heavier than an E-Z - merely by shifting my weight side-to-side or front-to-back while in my seat. And I’m a small woman) From the sound of it, the “autopilot” wasn’t terribly sophisicated. Could probably hold things straight and level with the pilot sitting reasonably still - the pilot twisting 90 degrees, and maybe leaning on a rudder pedal as well would probably exceed the ability of the autopilot to hold things steady. Which was MY first thought, even before I read the full report.

To sum up: It is the opinion of this pilot, with some experience in ultralights, homebuilts, and small general aviation (although I wouldn’t call myself an expert) that

  1. John Denver’s death was caused by smacking into the ocean surface at high speed - i.e. blunt force trauma - which was caused by

  2. Unfamillarity with the quirks of the airplane he was flying due to inadequate transition training, leading him to perform actions in the cockpit during flight that, in this particular airplane were far more hazardous that the pilot realized.

Weather was NOT a factor. I’d say mechanical failure was not a factor, but a poorly designed modification was certainly a contributing factor. Mainly, though, it was the action of the pilot. That is, pilot error.

I’d like to emphasize that switching fuel tanks in an E-Z with a fuel selector in the designed location is far less hazardous.

But just a couple points for accuracy’s sake:

ChocolateJesus, an E-Z is not an ultralight. It is four times heavier than the maximum allowable weight, carries three times as much fuel as an ultralight is permitted, and is about twice as fast as the maximum speed permitted with the originally designed engine. With a heavier, more powerful engine (such as we’re discussing here) it would be faster still.

PhilAlex, for all practical purposes a canard can NOT be stalled. Oh, I suppose you could come up with some weird, bizarre circumstance in which it could be called “stalled”, but that didn’t happen here. You can put them into a very steep dive, and being “slick” aerodynamically they can easily build up such speed that you can not recover from such a dive when low to the ground (or water). But he most certainly neither stalled nor spun in that aircraft.

All that said, for an experimental homebuilt design they are pretty good, with a decent safety record for the category. They are not considered a beginner’s airplane, but then John Denver was not a beginning pilot, either. He actually had more training and experience than most of the E-Z pilots I currently know or know of. My home field had an E-Z pilot who bought his E-Z when he had only about 100 hours total and the man quite successfully flew it thousands of miles and about 50 hours before he had to make an emergency landing after dark on a road and elected to hit the lightpole instead of on-coming traffic. In that case, the pilot survived although he spent some time in the hospital. I might also emphasize that this gentleman took, if I recall (and don’t quote me on it) something like 15-20 hours of transition training in that airplane.

It’s not just total time and experience but also experience in the particular aircraft that counts. Sure, Mr. Denver flew his own Lear Jet - that does NOT qualify him to fly an E-Z safely without some instruction. As I said, even Chuck Yeager, who has the incredible distinction of being both “old” and “bold”, took transition training with an instructor before stepping into the unconventional arena of the lightplane and ultralight world of flight. Likewise, although I knew how to safely fly an ultralight when I walked into a general aviation airport and announced I wanted to earn a license, my prior experience was of only limited use in conventional general aviation.

I suspect that you have no clue what you are talking about. I suspect that the NTSB has something approximating zero interest in John Denver’s fans and what they think or feel. I suspect that it is a situation that may well be repeated, if it happens once, it can happen again. Finally, I suspect that absolute accuracy is vital.

**The notion of the NTSB falsifying a report to “soften the blow for fans” is a little ridiculous, don’t you think? The man is dead, no matter what the cause.

How does the fact that the FAA issued it an experimental airworthiness certificate make the fuel valve a non-issue? Experimental aircraft are not certified to the standards set forth in FAR part 23.

Adrian D. Davis, Jr.

Well, yeah, rumor had it he was decapitated and they found the body before the head. So it’s either fingerprints, toeprints (if available), or DNA.

Um, it’s a fiberglass shell. It’s thinner than a bathtub.

Hardly. You don’t have to stall an airplane to put it into a steep dive. They will nose down, they will enter steep spirals, and do pretty much anything BUT stall.

OK. I have seen the actual wreck of an actual E-Z that crashed two blocks from my home (the above-mentioned person from my home airport) I also saw the wreck - what was left of it - after the NTSB turned it over to the salvagers. An E-Z doesn’t break, it shatters. I have no trouble with the idea that it could break apart in a water impact. Also, if the pilot’s restraints failed to hold a human body could shear off a canopy just as easily as a pelican.

One drawback to the E-Z airplanes is that they aren’t very “crashworthy”. They provide almost no protection to the pilot in an accident. Granted, no one plans to have an accident, but E-Z’s are worst than most small planes in this regard.

WHOA! That I have trouble with. The NTSB is not perfect, but I don’t think they’d “soften the blow”. It’s pretty damning to say he screwed up - which is essentially what they did say.

Why would the NTSB have any care about what Denver’s fans think? They certainly didn’t cut any corners or soften any blows for JFK, Jr. If anything, they’d show less mercy to a celebrity because it offers them a chance to educate other pilots not to do this, that, or the other less than wonderful thing.

The rules are different for homebuilts. Anything registered under the experimental homebuilt category is required to have a placard in full and easy view of both pilot and passenger(s) (if there is a place for a passenger) stating that the aircraft is amateur built and does NOT necessarially conform to FAA standards. Yes, there is an inspection process but there is NO formal testing program for these airplanes and they are very much “fly at your own risk”.

Seems straightforward, doesn’t it? Fact is, he COULD reach the fuel selector, he just couldn’t move it without getting into an unsafe position.

And sometimes you have to futz with things before you work out how you can reach and manipulate everything. I’ve spent a half an hour adjusting seats, rudder pedals, restraints, and so forth in order to determine a position from which I can operate everything with maximum ease. I’ve also used booster cushions when necessary. That’s part of the transition to a new aircraft - working out you’re best position in the cockpit. Yeah, sometimes you find out that the airplane isn’t a good fit. If you can’t come up with a way to compensate yeah, you should elect not to fly it - but again, Denver could reach the control, he just couldn’t manipulate it safely. Which he should have been able to determine on the ground. The onus is on the pilot to know how to manipulate everything in the cockpit before he takes off.

I think Broomstick nailed it. This was a human factors accident. I wouldn’t call it ‘pilot error’. Nor would I call it ‘design error’. The fuel selector was certainly placed in an awkward position. This is not necessarily a fatal flaw - If the designer knew what he was doing, knew the limitations of the design, and took steps to minimize the drawbacks of the location (for example, by practicing fuel management such that he never had need to switch tanks at low altitude), it might be a manageable issue.

But when you sell the airplane to a 3rd party, who may not be intimately familiar with the issues such a design creates, the potential for disaster comes along.

It sounds to me like Denver tried to switch tanks low and slow, and while engaged in that activity neglected to fly the airplane. Perhaps he thought it was trimmed up for level flight, and never considered the effect of a Cg change from moving around in the cockpit. Perhaps he was so used to slower, draggier airplanes that he just trimmed it up and then bent around to change tanks, confident in the notion that if the airplane went out of trim he’d feel it, or hear the added wind rush, or whatever. He underestimated just how quickly a slick airplane like an EZ can dive if it falls out of trim, and paid with his life.

Short of a bird strike, how exactly did a Long EZ get its canopy sheared - the only explanation consistent with fingerprint ID - for the water to have done it, the plane would have struck nose-down or inverted - real difficult for a canard, short of a deep stall.

The fuel valve is not an issue because it did not change location during the flight - the pilot took it upon himself to fly an airplane with the fuel selector where it was during pre-flight. This is a red herring to try to mitigate your basic “pilot error”.

It’s not likely to happen again, because the plane with the re-located valve was destroyed, and I doubt if too many Long EZ’s were built with the valve in the over-the-shoulder location. If any others were, I suspect simply everyone owning/operating them is aware of the location of the valve, and can safely operate it in-flight.

Karma.

**You don’t think hitting the water at 200mph would shear the canopy off? In almost any attitude?

**If the fuel valve didn’t change position during the flight, it probably means he was unsuccessful at switching tanks. Doesn’t mean that he didn’t die trying.

John Denver couldn’t.

And he’s dead, and the airplane destroyed - again, there is no likelyhood of a repeat of the incident - hence, there was no issue relating to other operators - no reason for an AD - hence the NTSB could shave the report for whatever reason(s). e.g. bury the fact that he was decapitated by a birdstrike.

And no, given the design of the Long EZ, I do not believe it possible for any water landing to have generated sufficient force to shear the canopy and the head of the pilot - that bathtub is a very sturdy structure - and even if it had hit with enough force to kill, the head would have remained intact - unless nose-down or inverted. A birdstrike is much more likely.

If the NTSB followed this line of reasoning with other accidents then there would be no accident investigations:

“Well look here Bob, the crew are dead and it looks like a particular set of circumstances caused this accident, it won’t happen again, no point doing an investigation.”

We’re not talking about a “water landing” here, we’re talking about high speed impact. It can and does cause significant damage.

An experiment you might like to try is to go flying in an aircraft and let go of the controls, start fidling around with something behind you, don’t look where you’re going or what the aircraft is doing. Chances are, the aircraft will gradually enter a steep high speed spiral dive. An impact at speed with ground or water will cause severe damage to aircraft and occupant.

I’m curious, do you actually know anything about the subject? Cause a lot of other people here who do, seem to disagree with you.

There’s an interesting Ask Tog article about the fuel tank selector issue:

http://www.asktog.com/columns/027InterfacesThatKill.html

Also, from the NTSB report:

Not meaning to Hijack the thread, but what’s the official word on the JFK crash? I keep hearing spiral dive, but what lead up to that?

Spatial disorintation - confusing the city lights, reflections of city lights on water, and stars on a clear night - a classic “don’t go there” in pilot training materials - your eyes have three sets of lights umongst which to find an airport - if you guess high or low, you die.