# NTSB CEN19LA267: De Havilland DHC6, N322AV, San Marcos, TX, August 15, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: August 15, 2019, 12:33 local (17:33 UTC) - Place: San Marcos, TX - Coordinates: 29.892778, -97.863052 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.8928&lon=-97.8631&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Minor injuries - Injuries: 3 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Federal Aviation Administration; San Antonio FSDO - NTSB case key (mKey): 100063 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA267 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100063/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100063 - Page: https://openairdocs.org/ntsb/CEN19LA267 ## Probable cause The pilot's delayed go-around attempt and the flight instructor's delayed remedial action that resulted in a nose-down impact with terrain during an attempted go-around. ## 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: [Dehavilland DHC-6-300, 4 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2802630), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Dehavilland DHC-6-300, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2802630), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Dehavilland DHC-6-300, 2 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=2802630), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Dehavilland DHC-6-300, 2 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=2802630), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Dehavilland DHC-6-300, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=2802630), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Dehavilland DHC-6-300, 1 case](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=2802630), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Dehavilland DHC-6-300, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2802630), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Dehavilland DHC-6-300, 4 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2802630), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The airline transport pilot receiving company flight training was flying an approach; the airplane was too high and entered an increasing descent rate. The flight instructor told the pilot to go around, about the same time the pilot elected to go around. However, the pilot’s corrective control and power inputs did not arrest the descent rate, and the airplane impacted the ground, resulting in substantial damage to the left wing and fuselage. The operator reported there were no mechanical anomalies that would have precluded normal airplane operation. ## Factual narrative On August 15, 2019, at 1233 central daylight time, a De Havilland DHC-6-300 airplane, N322AV, impacted runway 13 during a go-around at San Marcos Regional Airport (HYI), San Marcos, Texas. The airplane sustained substantial damage. The airline transport pilot, flight instructor, and a passenger observer received minor injuries. The airplane was registered to Wells Fargo Trust CO NA Trustee and was operated by Berry Aviation, Inc. under Title 14 Code of Federal Regulations Part 91 as a company training flight that was operating on a visual flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident. The local flight originated from HYI. The airline transport pilot, seated in the left seat pilot, was receiving company training and was the flying pilot during the accident flight. The left seat pilot stated they were practicing an ILS approach for landing with a full stop on runway 13. The airplane was configured with 20° of wing flaps for landing. He said the airplane was above the glidepath, and he transitioned his scan from the flight instruments to the outside visual environment. He lowered the nose when the airplane was about 100 ft above ground level and noted the airplane was slightly left of runway centerline. He attempted to align the airplane with the centerline and thought the airplane was getting fast, so he increased the airplane pitch attitude about 50 ft above ground level. The airplane was still high when it crossed over the runway numbers and the descent rate increased. He said the flight instructor called for a go-around at the same time he decided to initiate a go-around. The left seat pilot said he attempted to add airplane energy with forward control input, which cause the airplane to pitch down with not a lot of airspeed or altitude. The left seat pilot started to increase backpressure on the flight controls and add engine power but the airplane continued to descend into the ground. The airplane struck the ground in a nose down attitude and then veered off of the runway to the left, coming to rest in the grass. The left wing and fuselage sustained substantial damage. The company/operator reported there were no mechanical anomalies that would have precluded normal airplane operation. ## Aircraft - Registration: [N322AV](https://openairdocs.org/deregistered/N322AV-2023-06-28), registration cancelled 2023-06-28, S/N 320, built 1971 (OpenAirDocs) - Reported make and model: De Havilland DHC6 (300) - Registry model: [Dehavilland DHC-6-300](https://openairdocs.org/model/dehavilland-dhc-6-300) (registry code 2802630) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-27 series](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-27-series) (registry code 52247, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 320 - Year built: 1971 - Airframe hours: 32258.8 - Engines: Pratt & Whitney PT6A-27 680 horsepower turbo prop; Pratt & Whitney PT6A-27 680 horsepower turbo prop - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Berry Aviation, Inc. - Registered owner: Wells Fargo Trust Co Na Trustee - Airworthiness certificate: Standard, Normal - Last inspection: Continuous airworthiness, August 11, 2019 - Departed: T82, Fredericksburg, TX - Destination: HYI, San Marcos, TX - Flight plan: VFR - Airport: HYI, San Marcos Regional Airport, runway 13, 5,601 × 100 ft, asphalt - Equipment: Stall warning system, ADS-B, Satellite tracking device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; injuries: minor; airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review June 27, 2017; seat: left; restraint: 4-point; flight hours: 1,833 total, 2 in this make and model, 1,513 as pilot in command, 2 in the last 90 days, 2 in the last 30 days, 2 in the last 24 hours - Flight instructor; age 34; injuries: minor; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review May 29, 2019; seat: right; restraint: 4-point; flight hours: 1,775 total, 162 in this make and model, 1,364 as pilot in command, 32 in the last 90 days, 13 in the last 30 days, 7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 77 °F - Altimeter: 30.01 inHg - Observed at: HYI ## 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 20190815017749A](https://openairdocs.org/incident/20190815017749A), Aug 15, 2019: Dehavilland DHC-6-300, San Marcos, TX, Substantial damage. During an aborted landing the flying pilot mismanaged the controls and lowered the angle of attack to where the aircraft stuck the ground at a steep angle ## Docket (4 files) The files NTSB released with the investigation on October 9, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100063. 4.0 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11163064&FileExtension=pdf&FileName=NTSB%206120.1%20(N322AV)%20MASTER_Redacted-Rel.pdf - Crew statements (item 2, PDF, 4 pages, 882 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11146974&FileExtension=pdf&FileName=Crew%20Statements%20MASTER-Rel.pdf - Surveillance video (item 3, AVI, 860 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=10121900&FileExtension=avi&FileName=Surveillance%20Video-Rel.avi - Wreckage photo (item 4, PDF, 1 page, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11334867&FileExtension=pdf&FileName=Wreckage%20Photo-Rel.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.