In a final report that is unusual in many respects, the National Transportation Safety Board (NTSB) concluded that the crash that killed well-known and highly experienced pilot Dale Snodgrass in 2021 was caused by the pilot’s failure to remove the control lock from the plane, a SIAI-Marchetti SM-1019B, before his takeoff from Lewiston-Nez Perce County Airport in Idaho. The accident sequence, which was recorded in high quality, shows the plane lifting off and the nose pitching up sharply just before at an altitude of around 80 feet. It rolled to the left, the nose dropped, and it impacted the ground in an extreme nose-low attitude, killing the pilot and destroying the plane.
Dale Snodgrass was a highly experienced and highly respected aviator. A former Naval aviator and current air show performer, the Board wrote, he had around 6,500 hours of time as a civilian pilot at the time of his last medical.
A few months before the crash, Snodgrass had purchased the plane, often referred to as the “Italian Bird Dog,” though this model was modified with a Rolls-Royce M250-B17B turboprop engine instead of a conventional gas-piston internal combustion engine. Snodgrass had around 20 hours in the plane. The flight, which the NTSB concluded was under no time pressure, was to the pilot’s vacation home around 20 minutes away from the Lewiston-Nez Perce County Airport.
The Board closely inspected the nature of the control lock in the plane and concluded from its extensive examination of the wreckage and interviews with experts in the aircraft type that it had been installed at the time of the crash. There were no other “pre-impact abnormalities” with the engine or airframe, it also concluded. When it is installed, the control lock, which is painted red, is immediately below the pilot’s knees and, despite its bright color, can be difficult for the pilot to see.
The device allows full rudder use but disables the ailerons and elevator, so it allows the plane to be taxied with the control lock in place but doesn’t allow the pilot to input elevator or aileron inputs. In one near-disaster noted by the investigators, a pilot described how he had taken off with the lock installed but was able to just barely uninstall it enough to allow him to recover before the plane would have crashed. In the Snodgrass crash, the pilot seemed to become aware at the last second of the mistake he had made—audio and video recordings of the crash exist—but was unable to effect a recovery or to remove the lock in time. The elevator trim was found in the full forward position, an indication that the pilot was attempting to lower the nose as it rose after takeoff.
The pilot did use medications for, among other things, high-blood pressure, but they were approved by the pilot’s FAA medical examiner and were unlikely to have affected the pilot’s performance. In the autopsy, the medical examiner found that Snodgrass had heart disease, but it wasn’t advanced enough, the Board found, to have affected the pilot’s judgment in performing the pre-flight check, which was not recorded. That check should have revealed the presence of the control lock, as should a pre-takeoff check of control travel.
The report is unusual reading in that it seems to pay great respect to the pilot who was killed in the crash as a result, it found, of his own pre-flight and pre-takeoff failure. The report should serve as a crucial reminder to pilots of just how critical the pre-flight and pre-takeoff process is and how even talented and highly experienced pilots can make mistakes.