# NTSB ANC16CA069: Piper PA18, N743R, Willow, AK, September 25, 2016 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: September 24, 2016, 16:03 local (Sep 25, 2016, 00:03 UTC) - Place: Willow, AK - Coordinates: 61.754165, -150.051391 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=61.7542&lon=-150.0514&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report January 18, 2017 - Report: Approved by Office Director - NTSB office: Alaska Regional Office - Parties: FAA Anchorage FSDO - NTSB case key (mKey): 94082 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ANC16CA069 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94082/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94082 - Page: https://openairdocs.org/ntsb/ANC16CA069 ## Probable cause The pilot's failure to maintain airplane control during the landing roll, which resulted in a nose-over. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-18-150, 160 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7101828), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-18-150, 14 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7101828), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Piper PA-18-150, 10 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7101828), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Piper PA-18-150, 109 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7101828), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Piper PA-18-150, 83 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7101828), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot reported he was conducting stop-and-go-landings in a tailwheel-equipped airplane to a dry, gravel runway. During the third landing, he reported all three wheels from the landing gear were in contact with the runway and he slowed with normal braking application. He reported that he abruptly felt the tail of the airplane lift, the propeller impacted terrain, and the airplane nosed over. The airplane sustained substantial damage to the fuselage, the right wing struts, and the rudder. During a telephone conversation with the National Transportation Safety Board investigator-in-charge, the pilot stated that he was unsure if a tail wind or his braking application caused the airplane to nose over. The pilot reported there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. The pilot wore a surplus U.S. Navy Flight Deck Crewman's helmet for the flight in addition to utilizing a four-point restraint system. He reported that if he was not wearing a helmet, the injuries sustained to his face, head, and brain would have been serious or fatal. The closest weather reporting facility was the Wasilla Airport, Wasilla, Alaska, about 20 miles southeast of the accident site. At 1556, an Aviation Routine Weather Report (METAR) was reporting in part: wind, calm. In the weather section of the National Transportation Safety Board Accident/Incident Reporting Form 6120.1, the pilot reported the wind direction was variable and the wind speed was light and variable at the accident site. The Federal Aviation Administration (FAA) has published the Airplane Flying Handbook FAA-H-8083-3A (2004). This handbook discusses braking application procedures for tailwheel-equipped airplanes and states in part: Some models of tailwheel airplanes are equipped with heel brakes rather than toe brakes. In either configuration the brakes are used primarily to stop the airplane at a desired point, to slow the airplane, or as an aid in making a sharp controlled turn. Whenever used, they must be applied smoothly, evenly, and cautiously at all times. The FAA and the Medallion Foundation has published the Alaska Flight Review Guide (2014). This guide discusses aviation life support equipment and states in part: Considering the type of aircraft and mission, a helmet may help survive an accident. The U.S. military and European community has established standards for flying helmets. Emphasize the importance of choosing a helmet which meets an appropriate standard for the type of operation, and which is kept in good repair. Fatal and serious injury data suggests that helmets are most useful in tandem seat aircraft. A three-point harness is the minimum installation recommended for both front and back seats. The four and five point harnesses are a great improvement to the security of the user due to the geometry of the belts installation. Any properly installed and worn shoulder harness is an improvement over noshoulder harness at all. ## Factual narrative The pilot reported he was conducting stop-and-go-landings in a tailwheel-equipped airplane to a dry, gravel runway. During the third landing, he reported all three wheels from the landing gear were in contact with the runway and he slowed with normal braking application. He reported that he abruptly felt the tail of the airplane lift, the propeller impacted terrain, and the airplane nosed over. The airplane sustained substantial damage to the fuselage, the right wing struts, and the rudder. During a telephone conversation with the National Transportation Safety Board investigator-in-charge, the pilot stated that he was unsure if a tail wind or his braking application caused the airplane to nose over. The pilot reported there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. The pilot wore a surplus U.S. Navy Flight Deck Crewman's helmet for the flight in addition to utilizing a four-point restraint system. He reported that if he was not wearing a helmet, the injuries sustained to his face, head, and brain would have been serious or fatal. The closest weather reporting facility was the Wasilla Airport, Wasilla, Alaska, about 20 miles southeast of the accident site. At 1556, an Aviation Routine Weather Report (METAR) was reporting in part: wind, calm. In the weather section of the National Transportation Safety Board Accident/Incident Reporting Form 6120.1, the pilot reported the wind direction was variable and the wind speed was light and variable at the accident site. The Federal Aviation Administration (FAA) has published the Airplane Flying Handbook FAA-H-8083-3A (2004). This handbook discusses braking application procedures for tailwheel-equipped airplanes and states in part: Some models of tailwheel airplanes are equipped with heel brakes rather than toe brakes. In either configuration the brakes are used primarily to stop the airplane at a desired point, to slow the airplane, or as an aid in making a sharp controlled turn. Whenever used, they must be applied smoothly, evenly, and cautiously at all times. The FAA and the Medallion Foundation has published the Alaska Flight Review Guide (2014). This guide discusses aviation life support equipment and states in part: Considering the type of aircraft and mission, a helmet may help survive an accident. The U.S. military and European community has established standards for flying helmets. Emphasize the importance of choosing a helmet which meets an appropriate standard for the type of operation, and which is kept in good repair. Fatal and serious injury data suggests that helmets are most useful in tandem seat aircraft. A three-point harness is the minimum installation recommended for both front and back seats. The four and five point harnesses are a great improvement to the security of the user due to the geometry of the belts installation. Any properly installed and worn shoulder harness is an improvement over noshoulder harness at all. ## Aircraft - Registration: [N743R](https://openairdocs.org/aircraft/N743R), registered now, S/N 18-8109055, built 1981 (OpenAirDocs) - Reported make and model: PIPER PA18 (150) - Registry model: [Piper PA-18-150](https://openairdocs.org/model/piper-pa-18-150) (registry code 7101828) (OpenAirDocs) - Registry engine: [Lycoming O-320-B2B](https://openairdocs.org/engine/lycoming-o-320-b2b) (registry code 42138, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18-8109055 - Year built: 1981 - Airframe hours: 4426 - Engines: Lycoming O-320-B2B 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Utility - Last inspection: Condition, August 12, 2016 - Departed: AA06, ANCHORAGE, AK - Destination: AA06, ANCHORAGE, AK - Airport: UUO, Willow, runway 31, 4,400 × 75 ft, gravel - Equipment: Satellite tracking device, Electronic flight bag or handheld device, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: minor; commercial; airplane ratings: single-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review April 16, 2016; seat: front; restraint: 4-point; flight hours: 904 total, 53 in this make and model, 877 as pilot in command, 18 in the last 90 days, 7 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 7,500 ft overcast - Temperature: 55 °F, dew point 36 °F - Altimeter: 29.70 inHg - Observed at: PAWS, 18 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 20160924024249A](https://openairdocs.org/incident/20160924024249A), Sep 24, 2016: Piper PA-18, Willow, AK, Substantial damage. The PIC was doing some touch and go landings. He was on the ground roll of his third landing with all 3 gear on the runway and he applied brakes and the… ## Docket (3 files) The files NTSB released with the investigation on November 21, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94082. 3.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446676&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photographs (Courtesy of Pilot) (item 2, .PDF, 5 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446677&FileExtension=.PDF&FileName=Accident%20Photographs%20(Courtesy%20of%20Pilot)-Master.PDF - Pilot's Statement (item 3, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446678&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.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.