# NTSB ANC13CA069: Cessna A185E, N4557F, Kotzebue, AK, July 29, 2013 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: July 28, 2013, 18:17 local (Jul 29, 2013, 02:17 UTC) - Place: Kotzebue, AK - Coordinates: 66.70861, -162.419448 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=66.7086&lon=-162.4194&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Nose over/nose down](https://openairdocs.org/ntsb-events/096) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report September 5, 2013 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: Federal Aviation Administration - NTSB case key (mKey): 87618 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC13CA069 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/87618/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=87618 - Page: https://openairdocs.org/ntsb/ANC13CA069 ## Probable cause The pilot's lack of situational awareness and failure to maintain adequate clearance from terrain during takeoff. Factors contributing to the accident was the check airmen’s inadequate supervision. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna A185E, 6 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2072818), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Cessna A185E, 6 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2072818), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Runway/land/takeoff/taxi surface](https://openairdocs.org/ntsb-findings/03023000): Environmental issues › Physical environment · Decision related to condition; cases with it: [Cessna A185E, 3 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md?model=2072818), [All aircraft, 253 cases](https://openairdocs.org/ntsb-findings/03023000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna A185E, 12 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072818), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Takeoff: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [Cessna A185E, 7 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2072818), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot was demonstrating a confined area takeoff for a part 135 Visual Flight Rules (VFR) competency check from a remote lake in a float equipped airplane. The check airman, seated in the right seat, instructed the pilot to begin his takeoff run 90 degrees from the prevailing wind, and turn into the wind as the airplane accelerated for departure. During the takeoff water run the pilot failed to turn away from the shoreline. The airplane was almost on the step when the shoreline jutted out perpendicular to the takeoff run. He attempted to force the airplane into the air by applying flaps, and pulling aft on the control yoke, but the airplane impacted the shore, bounced into the air, and slid across the ground for approximately 100 yards before nosing down. The airplane sustained substantial damage to the left wing. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. In the recommendation section of the NTSB Accident/Incident Reporting Form 6120.1, the check airman stated that the accident may have been prevented if he had ensured the pilot understood his instructions, or if he would have discontinued the maneuver before an unsafe condition developed. ## Factual narrative The pilot was demonstrating a confined area takeoff for a part 135 Visual Flight Rules (VFR) competency check from a remote lake in a float equipped airplane. The check airman, seated in the right seat, instructed the pilot to begin his takeoff run 90 degrees from the prevailing wind, and turn into the wind as the airplane accelerated for departure. During the takeoff water run the pilot failed to turn away from the shoreline. The airplane was almost on the step when the shoreline jutted out perpendicular to the takeoff run. He attempted to force the airplane into the air by applying flaps, and pulling aft on the control yoke, but the airplane impacted the shore, bounced into the air, and slid across the ground for approximately 100 yards before nosing down. The airplane sustained substantial damage to the left wing. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. In the recommendation section of the NTSB Accident/Incident Reporting Form 6120.1, the check airman stated that the accident may have been prevented if he had ensured the pilot understood his instructions, or if he would have discontinued the maneuver before an unsafe condition developed. ## Aircraft - Registration: [N4557F](https://openairdocs.org/aircraft/N4557F), registered now, S/N 185-1061, built 1966 (OpenAirDocs) - Reported make and model: CESSNA A185E - Registry model: [Cessna A185E](https://openairdocs.org/model/cessna-a185e) (registry code 2072818) (OpenAirDocs) - Registry engine: [Continental IO-520 series](https://openairdocs.org/engine/continental-io-520-series) (registry code 17032, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 185-1061 - Airframe hours: 5630 - Engines: CONT MOTOR IO 520 SERIES 300 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Northwestern Aviation Services Inc - Registered owner: Northwestern Aviation Services Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2013 - Departed: Kotzebue, AK - Destination: Kotzebue, AK - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: none; commercial; airplane ratings: single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review July 28, 2013; seat: left; flight hours: 8,671 total, 600 in this make and model, 8,500 as pilot in command, 63 in the last 90 days, 20 in the last 30 days - Check pilot; age 63; injuries: none; flight instructor, airline transport; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review April 17, 2013; seat: right; flight hours: 11,992 total, 3,359 in this make and model, 11,940 as pilot in command, 202 in the last 90 days, 100 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 200° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: 2,400 ft overcast - Temperature: 57 °F, dew point 126 °F - Altimeter: 30.09 inHg - Observed at: PAOT, 8 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20130728015449A](https://openairdocs.org/incident/20130728015449A), Jul 28, 2013: Cessna A185E, Kotzebue, AK, Substantial damage. Airman stated he was taking a check ride and doing a confined area take off and got behind the power curve and couldn't see where he was going. Then realized… ## Other investigations on N4557F (3) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB ANC05CA060](https://openairdocs.org/ntsb/ANC05CA060), Apr 18, 2005: Cessna A185E (N4557F), Wasilla, AK, substantial damage. Probable cause: The flight instructor's failure to provide adequate supervision of the second pilot during the landing roll, which resulted in a loss of control and an intentional ground-loop by the instructor. A… - [NTSB ANC80DA053](https://openairdocs.org/ntsb/ANC80DA053), Jun 17, 1980: Cessna 185 (N4557F), Iliamna, AK, substantial damage - [NTSB ANC76DAH41](https://openairdocs.org/ntsb/ANC76DAH41), Jul 1, 1976: Cessna 185E (N4557F), Gibralter Lake, AK, substantial damage ## Docket (1 files) The files NTSB released with the investigation on August 23, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=87618. 3.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398119&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.