# NTSB ERA12LA305: Aviat A-1B, N388AS, Sylacauga, AL, April 27, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: April 27, 2012, 16:44 local (21:44 UTC) - Place: Sylacauga, AL - Coordinates: 33.159442, -86.449722 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.1594&lon=-86.4497&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report October 15, 2012 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA FSDO - NTSB case key (mKey): 83496 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA305 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/83496/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=83496 - Page: https://openairdocs.org/ntsb/ERA12LA305 ## Probable cause The pilot's attempt to take off with the carburetor heat in the hot position, which limited the airplane’s performance, and the pilot's subsequent failure to maintain adequate airspeed, which resulted in an aerodynamic stall. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine fuel and control: fuel control/carburetor](https://openairdocs.org/ntsb-findings/01057322): Aircraft › Aircraft power plant · Incorrect use/operation (probable cause); cases with it: [Aviat A-1B, 1 case](https://openairdocs.org/ntsb-findings/01057322/cases.md?model=2210406), [All aircraft, 195 cases](https://openairdocs.org/ntsb-findings/01057322/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aviat A-1B, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2210406), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Aviat A-1B, 2 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2210406), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Aviat A-1B, 3 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2210406), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Aviat A-1B, 4 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2210406), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Aviat A-1B, 23 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2210406), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was attempting a water takeoff to the southwest. After picking the left float off the water, the amphibious airplane did not accelerate as expected. The pilot reported that he attempted to keep the wings level; however, the right wing "fell," and the airplane stalled and impacted the terrain. A video of the accident sequence indicates that the airplane became airborne and the pilot began a right-hand turn to avoid the trees at the boundary of the lake. Postaccident examination revealed no evidence of a preimpact mechanical malfunction or failure that would have precluded normal operation. Both landing gear floats were dry inside when examined. The carburetor heat knob was found in the "hot" position. The "Before Takeoff" checklist for the airplane specifies that the carburetor heat should be “cold” for takeoff. ## Factual narrative On April 27, 2012, about 1644 central daylight time, an Aviat Aircraft Inc. A-1B, N388AS, was substantially damaged following a loss of aircraft control and collision with terrain near Sylacauga, Alabama. The certified flight instructor was not injured and a student pilot had serious injuries. The airplane was registered to a private individual and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as an instructional flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight originated at Alabaster, Alabama, about 1330. According to the pilot, he landed on the water at Lay Lake on a southwesterly heading. He then attempted a takeoff. During the takeoff sequence, he raised the left float off the surface first. The airplane began to climb, but did not accelerate as expected. He attempted to maintain wings level; however, the right wing "fell." As he attempted to recover from the stall, the airplane impacted the terrain. A Federal Aviation Administration (FAA) inspector responded to the accident site and examined the wreckage. Flight control and internal engine continuity was established. The magnetos were rotated by hand and produced spark on all leads. The landing gear floats were dry inside. The wreckage was moved to a storage facility in Clarksville, Tennessee. The wreckage was examined on May 29, 2012 by the NTSB Investigator-in-Charge (IIC). An external inspection of the engine revealed no damage to the case or cylinders. The spark plugs and ignition leads were re-installed and the starter was activated with an external battery. The engine turned through several times and no unusual noises or binding were observed. An engine run was not attempted due to impact damage to the intake system. The lower spark plugs were removed and the engine was manually rotated with the propeller. Valve action on all four cylinders was correct and compression and suction were observed using the "thumb" method. The spark plug electrodes were normal in color and wear with the exception of some light rust on some surfaces and the plug threads. The fuel strainer was removed and the screen was clean and unobstructed. About 1 ounce of a substance that resembled brown mud was found in the bottom of the strainer bowl. The carburetor was removed and opened and the accelerator pump operated normally. All carburetor control linkages were intact. The venturi was intact and in place. The white plastic floats were uncompromised and empty of fuel. The carburetor bowl contained about 3 ounces of muddy water with an odor of 100 low lead aviation fuel. An examination of the cockpit revealed that the carburetor heat knob was in the "hot" position. The knob was bent by impact forces and could not be moved. The FAA inspector provided the NTSB IIC with a video of the accident sequence. The video was produced by a local witness. A review of the video showed the airplane taking off and entering a gradual, right-handturn. Trees and terrain were visible at the boundary of the lake. The airplane disappeared behind some trees and the sound on an impact was heard. Engine noise was apparent until the sound of the collision was heard. The Aviat Husky A-1 "Before Takeoff" checklist, step 13, states, "Carburetor Heat – COLD." ## Aircraft - Registration: [N388AS](https://openairdocs.org/deregistered/N388AS-2018-02-07), registration cancelled 2018-02-07, S/N 2245, built 2003 (OpenAirDocs) - Reported make and model: AVIAT AIRCRAFT INC A-1B - Registry model: [Aviat A-1B](https://openairdocs.org/model/aviat-a-1b) (registry code 2210406) (OpenAirDocs) - Registry engine: [Lycoming O-360 series](https://openairdocs.org/engine/lycoming-o-360-series) (registry code 41575, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2245 - Airframe hours: 585 - Engines: LYCOMING O-360 SERIES 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Last inspection: Annual, June 9, 2011 - Departed: EET, Alabaster, AL - Destination: EET, Alabaster, AL ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 44; injuries: none; flight engineer, airline transport, flight instructor; airplane ratings: single-engine land, multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review June 18, 2011; seat: rear; flight hours: 9,000 total, 2,000 in this make and model, 3,000 as pilot in command, 5 in the last 90 days, 2 in the last 30 days - Student pilot; age 52; injuries: serious; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: front; flight hours: 2,700 total ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 63 °F - Altimeter: 30.01 inHg - Observed at: EET, 22 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 20120427006819A](https://openairdocs.org/incident/20120427006819A), Apr 27, 2012: Aviat Aircraft Inc A-1B, Fayettville, AL, Destroyed. On April 27, 2012, about 1630 CST, an Aviat aircraft, A-1B, N388AS, single engine seaplane, stalled during a steep climb to avoid trees on lay lake, and… ## Docket (8 files) The files NTSB released with the investigation on August 9, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=83496. 2.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 915 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372869&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Written Statement from Flight Instructor (item 2, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372870&FileExtension=.PDF&FileName=Written%20Statement%20from%20Flight%20Instructor-Redacted.PDF - Retention / Release of Wreckage Form (item 3, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372873&FileExtension=.PDF&FileName=Retention%20%2F%20Release%20of%20Wreckage%20Form-Redacted.PDF - FAA Inspector Statement (item 4, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372871&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - NTSB Record of Conversation with FAA Inspector (item 5, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372874&FileExtension=.PDF&FileName=NTSB%20Record%20of%20Conversation%20with%20FAA%20Inspector-Master.PDF - Excerpt from Husky A-1 Pilot Checklist (item 6, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372872&FileExtension=.PDF&FileName=Excerpt%20from%20Husky%20A-1%20Pilot%20Checklist-Master.PDF - NTSB Photo: Carburetor Heat Control Knob (item 7, .PDF, 741 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372875&FileExtension=.PDF&FileName=NTSB%20Photo%3A%20Carburetor%20Heat%20Control%20Knob-Master.PDF - Witness Video (item 8, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372885&FileExtension=.PDF&FileName=Witness%20Video-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.