# NTSB ERA09LA244: De Havilland DHC2, N258PA, Plattsburgh, NY, April 12, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: April 12, 2009, 09:00 local (13:00 UTC) - Place: Plattsburgh, NY - Coordinates: 44.650554, -73.467498 - Nearby events: https://openairdocs.org/map.md?lat=44.6506&lon=-73.4675&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report August 12, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 73659 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA244 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73659/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73659 - Page: https://openairdocs.org/ntsb/ERA09LA244 ## Probable cause The pilot's improper application of brakes during the landing rollout. ## 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 2 MK III, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2808005), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: surface speed/braking](https://openairdocs.org/ntsb-findings/01062045): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Dehavilland DHC 2 MK III, 1 case](https://openairdocs.org/ntsb-findings/01062045/cases.md?model=2808005), [All aircraft, 238 cases](https://openairdocs.org/ntsb-findings/01062045/cases.md) - [Wing structure: attach fittings (on wing)](https://openairdocs.org/ntsb-findings/01035740): Aircraft › Aircraft structures · Capability exceeded; cases with it: [Dehavilland DHC 2 MK III, 1 case](https://openairdocs.org/ntsb-findings/01035740/cases.md?model=2808005), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/01035740/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: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Dehavilland DHC 2 MK III, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=2808005), [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) (defining event); cases with it: [Dehavilland DHC 2 MK III, 2 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2808005), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot, seated in the left seat, was performing touch-and-go practice in the tailwheel-equipped airplane and had just performed a short-field landing and takeoff. Upon landing again, the pilot began to apply braking to the airplane. The owner/pilot-rated passenger, seated in the right seat, felt the "tail coming off the ground" and applied full back pressure on the control column. As the owner informed the pilot to "get off the brakes," the pilot applied more toe brake pressure, causing the tail of the airplane to rise and the propeller to strike the runway. Postaccident examination of the airplane revealed that the right wing aft attachment point was fractured. Metallurgical examination revealed that the right wing failed in forward bending due to an overstress event; the most likely source of the overstress was the propeller strike. ## Factual narrative HISTORY OF FLIGHT On April 12, 2009, about 0900 eastern daylight time, a deHavilland DHC2 III, N258PA, was substantially damaged during touch-and-go landing practice at Plattsburgh International Airport (PBG), Plattsburgh, New York. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which departed Lake Placid Airport (LKP), Lake Placid, New York about 0730. The certificated commercial pilot and the airplane's owner/pilot-rated passenger were not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. During a telephone interview, the pilot, who had been seated in the left front seat, reported that on the day before the accident, they flew to Adirondack Regional Airport (SLK), Saranac Lake, New York. While at SLK, they practiced touch-and-go crosswind landings and then returned to LKP after approximately 2 hours. The day of the accident, they departed LKP and flew to SLK to fuel the airplane. On arrival, the fixed base operator reported to them via radio that the fuel truck was inoperative and was unable to supply fuel. Due to their state of fuel, they elected to fly to PBG and perform some more touch-and-go pattern work, then fuel the airplane and return to LKP. During the flight from SLK to PBG, the pilot stated that there was a slight "buffet feeling" in the control column; however, he did not know what caused the "buffet." After performing about four "normal" touch-and-go landings, the owner of the airplane informed the pilot that they should practice short field landings. The owner further informed the pilot that upon landing, differential braking was required to "steer the airplane." The pilot performed one short field landing, departed, and on the subsequent landing, adjusted the propeller to the beta setting and applied toe brakes. The tail of the airplane began to rise and he and the owner utilized full back pressure on the control yoke in order to try and lower the tail. As the tail continued to rise and the airplane was almost stopped, the sound of the propeller contacting the runway was heard. The pilot further stated that the wing tip fuel tanks were almost full and held about 30 gallons of fuel per tank, and that the main fuselage tanks were almost empty. Prior to being towed to parking, the owner/pilot elected to gravity transfer the fuel from the tip tanks to the fuselage tank, in order to reduce the weight on the wings. According to the owner/pilot, who had been seated in the right front seat, the flying pilot was practicing touch-and-go pattern work at PBG. Upon landing on runway 35, the pilot began to apply braking to the airplane. The owner stated that he felt the "tail coming off the ground" and applied full back pressure on the control column. As the owner informed the flying pilot to "get off the brakes," the flying pilot applied more toe brake pressure, allowing the tail of the airplane to rise, striking the propeller on therunway. After exiting the airplane and examining the wing, the owner saw what he perceived to be a gap seal coming apart and the airplane was towed to an airplane parking ramp. PERSONNEL INFORMATION The pilot, age 44, held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land and instrument airplane. He also held a private pilot certificate, with a rating for airplane single-engine sea. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on July 2, 2007. At the time of the accident, the pilot reported that he had 1,095 total hours of flight experience, and about 6 hours of flight experience in the accident airplane make and model. He completed his commercial checkride on January 10, 2009. The owner/pilot-rated passenger, age 52, held a commercial pilot and certified flight instructor certificate. His most recent FAA second-class medical certificate was issued on May 30, 2008. At the time of the accident, the owner/pilot reported that he had 2,000 total hours of flight experience, 500 hours of flight experience in the accident airplane make and model, and 100 hours of flight experience in the make and model as an instructor. His most recent flight review was conducted on March 25, 2009. AIRCRAFT INFORMATION According to the FAA records, the airplane was manufactured in 1968 and was registered to the owner in October 2003. According to written documentation from the owner, the airplane's most recent annual inspection was completed on June 20, 2008, at which time it had accumulated approximately 15,000 total hours. During a telephone interview, the owner reported that in 2004 the wings of the airplane were rebuilt and all attachment fittings were replaced with new parts. A Baron MK Beaver Wing Angle modification was also installed at that time. Since 2004, the airplane had flown approximately 200 total flight hours and was stored in a hangar when it was not flying. METEOROLOGICAL INFORMATION The reported weather at PBG, at 0853, included wind from 010 degrees at 13 knots, visibility 10 miles, few clouds at 4,200 feet and at 5,500 feet, temperature minus 1 degree C, dew point minus 11 degrees C, altimeter 30.14 inches of mercury. WRECKAGE AND IMPACT INFORMATION The FAA inspector responding to the accident examined the airplane. On further examination, it was noted that the right wing aft spar attachment point had been fractured and the trailing edge of the right wing was canted downward. TEST AND RESEARCH The right and left wing attach points were removed and sent to the NTSB Materials Laboratory for analysis. The parts were examined on November 24, 2009. The left attachment point had no visible fracture nor was there any visible bending or elongation at the attachment point. The right wing attachment points had fractures and physical deformation consistent with ductile and tensile overstress, and the wing spar was bent forward outboard of the attachmentpoint. There was no indication of fatigue on any fracture surface. ## Aircraft - Registration: [N258PA](https://openairdocs.org/aircraft/N258PA), registered now, S/N 1690TB58 (OpenAirDocs) - Reported make and model: DE HAVILLAND DHC2 (III) - Registry model: [Dehavilland DHC 2 MK III](https://openairdocs.org/model/dehavilland-dhc-2-mk-iii) (registry code 2808005) (OpenAirDocs) - Registry engine: [Pratt & Whitney PT6A series](https://openairdocs.org/engine/pratt-whitney-pt6a-series) (registry code 52032, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 1690TB58 - Airframe hours: 15000 - Engines: Pratt and Whitney Canada PT6-20 550 horsepower turbo prop - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Clemente Motor Inc - Registered owner: Clemente Motor Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 20, 2008 - Departed: LKP, Lake Placid, NY - Destination: PBG, Plattsburgh, NY - Airport: PBG, Plattsburgh International, runway 35, 11,758 × 200 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; commercial, private; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review January 10, 2009; seat: left; flight hours: 1,096 total, 6 in this make and model, 27 in the last 90 days, 14 in the last 30 days - Flight instructor; age 52; injuries: none; commercial, flight instructor; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review March 25, 2009; seat: right; flight hours: 2,000 total, 500 in this make and model, 1,850 as pilot in command, 30 in the last 90 days, 20 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 10° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 30 °F, dew point 12 °F - Altimeter: 30.13 inHg - Observed at: PBK ## 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 20090412009099A](https://openairdocs.org/incident/20090412009099A), Apr 12, 2009: Dhav DHC2MK3, Plattsburgh, NY, Substantial damage. (-23) Pilot was practicing short field landings with aircraft owner in right seat. While using reverse thrust to slow aircraft pilot over applied brakes… ## Docket (6 files) The files NTSB released with the investigation on June 20, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73659. 2.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (Pilot) (item 1, .PDF, 461 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326064&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(Pilot)-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (Pilot/Owner) (item 2, .PDF, 383 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331697&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(Pilot%2FOwner)-Redacted.PDF - Materials Laboratory 15 - Factual Report 09-092 (item 3, .PDF, 681 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321683&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2009-092-Master.PDF - Plattsburgh Weather (item 4, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326066&FileExtension=.PDF&FileName=Plattsburgh%20Weather-Master.PDF - Photo 1: Right Wing Leading Edge Attach Point Damage (Courtesy of the FAA) (item 5, .PDF, 534 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326068&FileExtension=.PDF&FileName=Photo%201%3A%20Right%20Wing%20Leading%20Edge%20Attach%20Point%20Damage%20(Courtesy%20of%20the%20FAA)-Master.PDF - Photo 2: Right Wing Trailing Edge Attach Point Damage (Courtesy of the FAA) (item 6, .PDF, 510 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326069&FileExtension=.PDF&FileName=Photo%202%3A%20Right%20Wing%20Trailing%20Edge%20Attach%20Point%20Damage%20(Courtesy%20of%20the%20FAA)-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.