# NTSB ERA12CA278: Piper PA-18A, N12003, West Palm Beach, FL, April 12, 2012

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Data collection · Final report
- Date: April 12, 2012, 14:30 local (18:30 UTC)
- Place: West Palm Beach, FL
- Coordinates: 26.851667, -80.226112 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=26.8517&lon=-80.2261&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: Minor injuries
- Injuries: 1 minor, 1 uninjured
- Status: Completed, report October 15, 2012
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO
- NTSB case key (mKey): 83382
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12CA278
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/83382/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=83382
- Page: https://openairdocs.org/ntsb/ERA12CA278

## Probable cause

The inadequate assembly of the brakes, which caused them to lock during the landing roll when the airplane transitioned from asphalt to turf, resulting in the airplane nosing over.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Aircraft capability: braking capability](https://openairdocs.org/ntsb-findings/01061050): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [All aircraft, 57 cases](https://openairdocs.org/ntsb-findings/01061050/cases.md)
- [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md)
- [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Incorrect service/maintenance (probable cause); cases with it: [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md)
- [Airport facilities/design: runway/landing area condition](https://openairdocs.org/ntsb-findings/03017035): Environmental issues › Operating environment · Effect on operation; cases with it: [All aircraft, 61 cases](https://openairdocs.org/ntsb-findings/03017035/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md)
- [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md)

## Analysis

**This brief was modified on November 1, 2013. Please see the public docket for this accident to view the original report.** The pilot stated that when he returned to the airport after a local flight, he elected to land on the turf runway, which intersected an asphalt runway. He said he touched down on the main landing gear "fairly long" on the first portion of the turf runway at a speed of about 60 mph. The pilot delayed lowering the tailwheel until the airplane was crossing the asphalt surface and then lowered the tailwheel firmly to the ground. The airplane began to veer left, and the pilot applied full right rudder and a "slight amount" of right brake to regain directional control. When the airplane transitioned from the asphalt surface to the turf runway, it abruptly nosed over. The airplane came to rest inverted, incurring substantial damage to the rudder. An examination of the runway's asphalt to turf transition section revealed that the airplane's main landing gear tires dug into the turf as it left the slightly higher asphalt. The pilot reported no mechanical malfunctions or failures during the landing and rollout. While the airplane was being repaired after the accident, a mechanic determined that the bolts holding the main wheel halves in position were excessively long, causing the wheel halves to separate and the brake discs to change position when the airplane transitioned from the asphalt to the turf runway. This condition likely caused the brake discs to jam in their housing and the wheels to stop rotating.

## Factual narrative

**This report was modified on November 1, 2013. Please see the public docket for this accident to view the original report.**The pilot stated that upon returning to the airport from a local flight, he elected to land on the grass turf runway, which had an asphalt runway intersection within the first quarter of its length. His landing speed was about 60 mph, the airplane touched down long on the first portion of the grass turf. The pilot held off lowering the tail wheel initially but then lowered it firmly onto the ground. During the landing roll on the asphalt portion, the airplane began to arc to the left, the pilot applied full right rudder and then eased on a "slight amount" of right brake. As the airplane departed the asphalt section, it abruptly nosed over, the propeller struck the ground and the airplane came to rest inverted on the grass turf runway, incurring substantial damage to the vertical section and rudder. An inspection of the runway's asphalt to grass turf transition section revealed that the airplane's main landing gear tires dug into the turf as it left the slightly higher asphalt. An aviation safety inspector from the Federal Aviation Administration responded to the accident scene and interviewed the pilot, who reported no mechanical malfunctions or failures during the landing and rollout. While the airplane was being repaired after the accident, a mechanic determined that the bolts holding the main wheel halves in position were excessively long, causing the wheel halves to separate and the brake discs to change position when the airplane transitioned from the asphalt to the turf runway.

## Aircraft

- Registration: N12003 (not matched to a registry record)
- Reported make and model: PIPER PA-18A
- Category: Airplane
- Serial number: 18 6013
- Airframe hours: 6249
- Engines: LYCOMING O-320-B2B 160 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, June 4, 2011
- Departed: F45, West Palm Beach, FL
- Destination: F45, West Palm Beach, FL
- Airport: F45, North Palm Beach County, runway 08L, 3,679 × 75 ft, dirt

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 69; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review April 7, 2012; seat: front; flight hours: 640 total, 54 in this make and model, 26 in the last 90 days, 8 in the last 30 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 350° at 6 knots
- Visibility: 10 statute miles
- Temperature: 81 °F, dew point 61 °F
- Altimeter: 30.03 inHg
- Observed at: PBI, 12 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 20120412005349A](https://openairdocs.org/incident/20120412005349A), Apr 12, 2012: Piper PA-18A, West Palm Beach, FL, Substantial damage. Landing on 8L (grass surface) on rollout, crossing intersecting runway (hard surface), pilot loss control and aircraft flipped over.

## Docket (7 files)

The files NTSB released with the investigation on August 13, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=83382. 1.7 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 742 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40367280&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- FAA Inspector Statement (item 2, .PDF, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40396870&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Redacted.PDF
- Photo 1) View of the Flipped Airplane. Photo Provided by the Airplane Owner. (item 3, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40367279&FileExtension=.PDF&FileName=Photo%201)%20View%20of%20the%20Flipped%20Airplane.%20Photo%20Provided%20by%20the%20Airplane%20Owner.-Master.PDF
- Photo 2)Runway View of Asphalt to Grass Turf Transition. Note Tire Imprint on Ground. Photo Provided by Owner. (item 4, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40367336&FileExtension=.PDF&FileName=Photo%202)Runway%20View%20of%20Asphalt%20to%20Grass%20Turf%20Transition.%20Note%20Tire%20Imprint%20on%20Ground.%20Photo%20Provided%20by%20Owner.-Master.PDF
- Petition for Reconsideration (item 5, .PDF, 174 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40404322&FileExtension=.PDF&FileName=Petition%20for%20Reconsideration-Master.PDF
- Response to Petition for Reconsideration (item 6, .PDF, 614 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40404323&FileExtension=.PDF&FileName=Response%20to%20Petition%20for%20Reconsideration-Master.PDF
- Changes to Factual Report and Brief of Accident (item 7, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40404324&FileExtension=.PDF&FileName=Changes%20to%20Factual%20Report%20and%20Brief%20of%20Accident-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.

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