# NTSB ERA13LA311: Cessna 172M, N61947, Burlington, VT, June 19, 2013 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: June 19, 2013, 15:45 local (19:45 UTC) - Place: Burlington, VT - Coordinates: 44.471942, -73.153053 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.4719&lon=-73.1531&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Defining event: [Taxi-to runway: Ground collision](https://openairdocs.org/ntsb-events/200) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report January 30, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 87356 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA13LA311 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/87356/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=87356 - Page: https://openairdocs.org/ntsb/ERA13LA311 ## Probable cause The pilot's improper turn down an airport access road while attempting to taxi to a runway. Contributing to the accident was the airport management's failure to install proper signage indicating that an airport access road was prohibited to aircraft. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Airport facilities/design: taxiway markings/signage](https://openairdocs.org/ntsb-findings/03017040): Environmental issues › Operating environment · Availability of related info (probable cause); cases with it: [Cessna 172M, 1 case](https://openairdocs.org/ntsb-findings/03017040/cases.md?model=2072418), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/03017040/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 172M, 6 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=2072418), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Airport facilities/design: taxiway markings/signage](https://openairdocs.org/ntsb-findings/03017040): Environmental issues › Operating environment · Compliance w/ procedure (probable cause); cases with it: [Cessna 172M, 1 case](https://openairdocs.org/ntsb-findings/03017040/cases.md?model=2072418), [All aircraft, 6 cases](https://openairdocs.org/ntsb-findings/03017040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Taxi-to runway: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event); cases with it: [Cessna 172M, 15 cases](https://openairdocs.org/ntsb-events/200/sequence.md?model=2072418), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md) ## Analysis The pilot reported that, after contacting ground control and receiving a taxi clearance, he taxied to the end of the exit ramp and then began to taxi the airplane to the departure runway by attempting to follow the airport signs. He turned right and subsequently realized that the airplane was on an airport access road instead of a taxiway. The airplane struck a fence to the right of the access road, which resulted in substantial damage to the right wing. Photographs provided by the airport showed no "No Entry Signs" in the vicinity of the airport access road. Although the airport operated under a Part 139 certificate, it did not have signage along the access road indicating that entry was prohibited for aircraft recommended in federal guidance for Part 139 airports. The lack of proper signage resulted in the pilot taxiing the airplane down the access road instead of a taxiway. ## Factual narrative On June 19, 2013, about 1545 eastern daylight time, a Cessna 172M, N61947, impacted an airport fence while taxiing for takeoff at Burlington International Airport (BTV), Burlington, Vermont. The private pilot and one passenger were not injured. The airplane was owned and operated by Altitude Addiction LLC under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed for the flight that was originating at the time of the accident. According to the pilot, he contacted ground control and received a taxi clearance and began to taxi the airplane to the departure runway. He attempted to follow the airport signs but the pilot realized that the airplane was on an airport access road instead of a taxiway. The airplane struck a fence located to the right of the access road with the right wing and pivoted to the right, colliding nose first with the fence. This resulted in substantial damage to the right wing and nose of the airplane. Photographs provided by the airport indicated that there were no "No Entry Signs" in the vicinity of the airport access road. According to Federal Aviation Administration records, the pilot held a private pilot certificate with a rating for airplane single-engine land. His most recent third class medical certificate was issued on September 12, 2012. The pilot reported 149 hours of total flight time, of which, 35 hours were in the same make and model as the accident airplane. According to FAA Airport Certification requirements, under part 139.311, "Markings, signs, and lighting," it states that "each certificate holder must provide and maintain sign systems for air carrier operations on the airport that are authorized by the Administrator and consist of …signs identifying taxiing routes on the movement area." According to Advisory Circular 150/5340-18F, "Standards for Airport Sign Systems," it stated that a no entry sign "indicates that entry into a particular area is prohibited to aircraft and is installed on the left side as seen by the pilot approaching the prohibited area. In some pavement configurations, it may be necessary to install the sign on both the left and right sides. The sign should be located adjacent to the pavement where entry is prohibited rather than prior to the intersection." An interview with the airport manager revealed that, following the accident, airport personnel installed a "No Entry Sign" near of the airport access road where the accident occurred. ## Aircraft - Registration: [N61947](https://openairdocs.org/aircraft/N61947), registered now, S/N 17264906, built 1975 (OpenAirDocs) - Reported make and model: CESSNA 172M - Registry model: [Cessna 172M](https://openairdocs.org/model/cessna-172m) (registry code 2072418) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17264906 - Airframe hours: 6640 - Engines: LYCOMING O-320 SERIES 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Altitude Addiction LLC - Registered owner: Altitude Addiction LLC - Airworthiness certificate: Standard, Normal - Departed: BTV, Burlington, VT - Destination: DAW, Rochester, NH - Airport: BTV, Burlington International Airpo ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review May 19, 2013; seat: left; flight hours: 149 total, 35 in this make and model, 3 in the last 90 days, 2 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 37 °F - Altimeter: 30.11 inHg - Observed at: BTV ## 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 20130619021989A](https://openairdocs.org/incident/20130619021989A), Jun 19, 2013: Cessna 172M, Burlington, VT, Substantial damage. Pilot was taxing out from heritage aviation to join charlie taxiway then proceed to kilo taxiway. The pilot got onto what he thought was a taxiway, but was on… ## Docket (11 files) The files NTSB released with the investigation on November 25, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=87356. 2.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 739 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398640&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Statement (item 2, .PDF, 92 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398641&FileExtension=.PDF&FileName=Pilot%20Statement-Redacted.PDF - Memorandum for Record: FAA Inspector Statement (item 3, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398643&FileExtension=.PDF&FileName=Memorandum%20for%20Record%3A%20FAA%20Inspector%20Statement-Master.PDF - BTV Weather Observations (item 4, .PDF, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398644&FileExtension=.PDF&FileName=BTV%20Weather%20Observations-Master.PDF - Diagram of Accident Site (Courtesy of FAA) (item 5, .PDF, 401 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400283&FileExtension=.PDF&FileName=Diagram%20of%20Accident%20Site%20(Courtesy%20of%20FAA)-Master.PDF - Airport Signs Advisory Circular Excerpt - AC 150/5340-18F (item 6, .PDF, 642 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400267&FileExtension=.PDF&FileName=Airport%20Signs%20Advisory%20Circular%20Excerpt%20-%20AC%20150%2F5340-18F-Master.PDF - Part 139: Airport Certification Requirements Excerpts (item 7, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400268&FileExtension=.PDF&FileName=Part%20139%3A%20Airport%20Certification%20Requirements%20Excerpts-Master.PDF - Photo 1: Aft View of Right Wing Damage (Courtesy of FAA) (item 8, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398645&FileExtension=.PDF&FileName=Photo%201%3A%20Aft%20View%20of%20Right%20Wing%20Damage%20(Courtesy%20of%20FAA)-Master.PDF - Photo 2: Front View of Right Wing Damage (Courtesy of Airport) (item 9, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398646&FileExtension=.PDF&FileName=Photo%202%3A%20Front%20View%20of%20Right%20Wing%20Damage%20(Courtesy%20of%20Airport)-Master.PDF - Photo 3: View of Access Road Near Taxiway (Courtesy of FAA) (item 10, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398649&FileExtension=.PDF&FileName=Photo%203%3A%20View%20of%20Access%20Road%20Near%20Taxiway%20(Courtesy%20of%20FAA)-Master.PDF - Photo 4: View of "No Entry" sign on airport access road added after accident (Courtesy of Airport Manager) (item 11, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40404588&FileExtension=.PDF&FileName=Photo%204%3A%20View%20of%20%22No%20Entry%22%20sign%20on%20airport%20access%20road%20added%20after%20accident%20(Courtesy%20of%20Airport%20Manager)-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.