# NTSB CEN12CA132: Piper PA-18-135, N9952Q, Del Norte, CO, January 2, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: January 2, 2012, 13:50 local (19:50 UTC) - Place: Del Norte, CO - Coordinates: 37.702499, -106.351669 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.7025&lon=-106.3517&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report March 8, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 82672 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12CA132 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82672/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82672 - Page: https://openairdocs.org/ntsb/CEN12CA132 ## Probable cause The pilot's loss of directional control during the landing roll, which resulted in a runway excursion. Contributing to the accident were the sensitivity of the brake system and the certified flight instructor pilot's delayed remedial action. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-18-135, 2 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7101820), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Landing gear system: landing gear brakes system](https://openairdocs.org/ntsb-findings/01023240): Aircraft › Aircraft systems · Not specified (probable cause); cases with it: [Piper PA-18-135, 2 cases](https://openairdocs.org/ntsb-findings/01023240/cases.md?model=7101820), [All aircraft, 92 cases](https://openairdocs.org/ntsb-findings/01023240/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA-18-135, 4 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7101820), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-18-135, 9 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7101820), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/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: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Piper PA-18-135, 10 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7101820), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Piper PA-18-135, 3 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7101820), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis The pilot, who held a private pilot certificate, was receiving dual instruction from a certified flight instructor (CFI) to become familiar with his newly acquired tailwheel-equipped airplane. After practicing some standard flight maneuvers at altitude, the pilot returned to the departure airport to practice full stop landings and takeoffs. The CFI demonstrated the first landing, and then the pilot performed the next four landings and takeoffs with the CFI monitoring the controls and providing assistance when necessary. The CFI stated that the pilot's first landing was normal, the second landing required minor directional control assistance, the third landing required no assistance, and the fourth landing required some assistance from the base leg to final approach but the landing and roll were normal. On the fifth landing, the pilot made a nice three-point touchdown and rolled straight ahead. During the landing roll, the airplane suddenly swerved to the right and the CFI noticed that the pilot had already applied full left corrective rudder. The CFI then applied the left brake, but the application was ineffective. He then applied right brake to slow the airplane's pending departure off the runway. The airplane nosed over and came to rest in a snow bank that was bordering the runway. The top of the rudder sustained substantial damage. The airplane was equipped with a supplemental type certificate non-standard brake system. The CFI stated that, when he had ferried the airplane, he noted that the brake system was extremely sensitive. The CFI stated that he told the pilot early in his instruction that the use of the brakes should be avoided in normal operations due to their sensitivity. The CFI stated that he believes that the sensitivity of the brake system was a causal factor in the accident. ## Factual narrative The pilot, who held a private pilot certificate, was receiving dual instruction from a certified flight instructor (CFI) to become familiar with his newly acquired tail wheel equipped airplane. After practicing some standard flight maneuvers at altitude, the pilot returned to the departure airport to practice full stop landings and takeoffs. The CFI demonstrated the first landing, and then the pilot performed the next four landings and takeoffs with the CFI monitoring the controls and providing assistance when necessary. The CFI stated that the pilot's first landing was normal, the second landing required minor directional control assistance, the third required no assistance, and the fourth required some assistance from base leg to final but the landing and roll out were normal. On the fifth landing, the pilot made a nice three point touchdown and rolled straight ahead. During the roll out, the airplane suddenly swerved to the right and the CFI immediately saw that the pilot had already had full left corrective rudder applied. The CFI then applied corrective left brake to try and correct the swerve, but the application seemed ineffective. He then applied right brake to try and slow the airplane's pending departure off of the runway. The aircraft then pitched over on its nose, then over onto its back, coming to rest in a snow bank that was bordering the runway. The top of the rudder sustained substantial damage. The airplane was equipped with a STC non-standard brake system. The CFI stated that when he had ferried the airplane, he noted that the brake system had extreme sensitivity. The CFI stated that he told the pilot early in his instruction that the use of the brakes should be avoided in normal operations due to their sensitivity. The CFI stated that he believes that the sensitivity of the brake system was a causal factor in the accident. ## Aircraft - Registration: [N9952Q](https://openairdocs.org/aircraft/N9952Q), registered now, S/N 18-3579, built 1954 (OpenAirDocs) - Reported make and model: PIPER PA-18-135 - Registry model: [Piper PA-18-135](https://openairdocs.org/model/piper-pa-18-135) (registry code 7101820) (OpenAirDocs) - Category: Airplane - Serial number: 18-3579 - Airframe hours: 3962 - Engines: Lycoming O-360-B2B 160 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Jimmy K. Adelman - Registered owner: Jimmy K. Adelman - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, May 15, 2011 - Departed: 8V1, Del Norte, CO - Destination: 8V1, Del Norte, CO - Flight plan: Unknown - Airport: 8V1, Del Norte Kent Rominger Field, runway 24, 6,050 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: none; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; seat: front; flight hours: 425 total, 3 in this make and model, 3 in the last 90 days, 3 in the last 30 days, 1 in the last 24 hours - Flight instructor; age 46; injuries: none; flight instructor, private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review December 29, 2011; seat: rear; flight hours: 9,040 total, 93 in this make and model, 7,850 as pilot in command, 12 in the last 90 days, 5 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 25 statute miles - Lowest ceiling: none - Temperature: 27 °F ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 20120102000169I](https://openairdocs.org/incident/20120102000169I), Jan 2, 2012: Piper PA-18-135, Del Norte, CO, Minor damage. At 1330 local on 01/02/2012 at 8V1 (Del Norte Municipal And County Airport, Colorado) aircraft impacted snow bank on landing rollout causing minor damage. ## Other investigations on N9952Q (1) 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 LAX01LA056](https://openairdocs.org/ntsb/LAX01LA056), Dec 28, 2000: Piper PA-18-135 (N9952Q), Ramona, CA, substantial damage. Probable cause: The pilot's inadvertent encounter with a pothole during taxi, after landing. ## Docket (1 files) The files NTSB released with the investigation on January 19, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82672. 4.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40361372&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.