NATIONAL TRANSPORTATION SAFETY BOARD
Public Meeting of January 26, 1999

Aircraft Accident involving John Denver
In Flight Collision with Terrain/Water
October 12, 1997
Pacific Ocean near Pacific Grove, CA
LAX-98-FA008

EXECUTIVE SUMMARY
On October 12, 1997, about 1728 Pacific daylight time, an experimental
category, amateur-built Adrian Davis Long-EZ airplane, N555JD, crashed into
the Pacific Ocean near Pacific Grove, California. Air traffic control
communications indicated that the airplane had departed from the Monterey
Peninsula Airport's runway 28L about 1712, and the pilot performed three
touch-and-go landings and departed to the west moments before the accident.
Witness reported that they heard engine popping and a reduction in engine
noise before the accident. The pilot made no distress calls. The pilot was
killed, and the airplane was destroyed.

PROBABLE CAUSE
The National Transportation Safety Board determines the probable cause of this
accident was the pilot's diversion of attention from the operation of the
airplane and his inadvertent application of right rudder that resulted in the
loss of airplane control while attempting to manipulate the fuel selector
handle. Also, the Board determines that the pilot's inadequate preflight
planning and preparations, specifically his failure to refuel the airplane,
was causal. The Board determines that the builder's decision to locate the
unmarked fuel selector handle in a hard-to-access position, unmarked fuel
quantity sight gauges, inadequate transition training by the pilot, and his
lack of total experience in this type of airplane were factors in this
accident.

SAFETY RECOMMENDATIONS
As a result of its investigation of this accident, the National Transportation
Safety Board makes safety recommendations as follows:

to the Federal Aviation Administration: 
1. Amend FAA Order 8130.2C to specify that, before the issuance of special
airworthiness certificates, experimental, amateur-built airplanes should be
inspected for needed placards and markings on cockpit instruments and for the
appropriate placement and operation of essential system controls to ensure
that they provide clear marking, easy access, and ease of operation. 

2. Amend FAA Order 8130.2C to specify that inspection limitations be issued
with special airworthiness certificates for amateur-built airplanes requiring
that the annual condition inspection include an inspection for needed placards
and markings on cockpit instruments and the appropriate operation of essential
controls to ensure that they provide clear marking, easy access, and ease of
operation.

3. Establish, in conjunction with the Experimental Aircraft Association and
the Aviation Insurance Association, a cooperative program that strongly
encourages pilots transitioning to unusual or unfamiliar experimental amateur-
built category airplanes to undergo formalized, type-specific transition
training similar to that provided to pilots of some advanced, experimental,
amateur-built airplanes.

to the Aviation Insurance Association:

4. Establish, in conjunction with the Federal Aviation Administration and the
Experimental Aircraft Association, a cooperative program that strongly
encourage pilots transitioning to unusual or unfamiliar experimental amateur-
built category airplanes to undergo formalized, type-specific transition
training similar to that provided to pilots of some advanced, experimental,
amateur-built airplanes.

to the Experimental Aircraft Association:

5. Establish, in conjunction with the Federal Aviation Administration and the
Aviation Insurance Association, a cooperative program that strongly encourage
pilots transitioning to unusual or unfamiliar experimental amateur-built
category airplanes to undergo formalized, type-specific transition training
similar to that provided to pilots of some advanced, experimental, amateur-
built airplanes.


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http://www.ntsb.gov/publictn/1999/ABR9901.htm