# NTSB ERA18LA023: Great Lakes 2T1A, N3512L, Montague, MA, November 2, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: November 2, 2017, 14:00 local (18:00 UTC) - Place: Montague, MA - Coordinates: 42.594165, -72.524719 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.5942&lon=-72.5247&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report July 23, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 96320 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA023 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96320/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96320 - Page: https://openairdocs.org/ntsb/ERA18LA023 ## Probable cause The pilot’s failure to maintain directional control during the attempted takeoff, which resulted in a runway excursion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Great Lakes 2T-1A-2, 4 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=3910101), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Great Lakes 2T-1A-2, 5 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=3910101), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Great Lakes 2T-1A-2, 4 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=3910101), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Great Lakes 2T-1A-2, 3 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=3910101), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Great Lakes 2T-1A-2, 3 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=3910101), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Great Lakes 2T-1A-2, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=3910101), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Takeoff: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Great Lakes 2T-1A-2, 4 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=3910101), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The private pilot was initiating takeoff for the positioning flight with no winds and with the airplane's tail off the runway when the airplane suddenly veered left, which he could not correct. The airplane exited the left side of the runway and then slid down a sharp incline into a ditch and nosed over. Postaccident examination of the runway revealed skid marks made by the right main landing gear (MLG) tire that continued off the runway, and by the tailwheel tire, which began 50 ft past the beginning of the right MLG tire marks and also continued off the runway. The left MLG tire only made light tire marks, which indicates that the airplane was light on the left MLG tire during the takeoff. No flat spots were noted on either MLG tire, and examination of both brakes and the flight controls revealed no evidence of a preimpact mechanical malfunctions or failures that would have precluded normal operation. During an operational test, the left brake operated normally. The right brake could not be operationally tested due to damage to its components Given the evidence, it is likely that the pilot lost directional control during the attempted takeoff. ## Factual narrative On November 2, 2017, about 1400 eastern daylight time, a privately owned and operated Great Lakes Aircraft Company 2T-1A-2, N3512L, experienced a runway excursion during takeoff and nosed over at Turners Falls Airport (0B5), Montague, Massachusetts. The private pilot was not injured and the airplane, which was being operated under the provisions of 14 Code of Federal Regulations Part 91, as a personal flight, was substantially damaged. Visual meteorological conditions prevailed at the time and no flight plan was filed. The flight was originating at the time of the accident and was destined for the Orange Municipal Airport (ORE), Orange, Massachusetts.The pilot stated that he flew to 0B5 the day before the accident and assisted the mechanic with removing panels and bleeding the airplane's brakes as part of an annual inspection. He also reported that the left brake pads were replaced. He returned home that evening, then arrived at 0B5 the afternoon of the accident. After arrival he performed a preflight inspection, which included a visual inspection of the brakes, and rudder cables. He started the engine and began taxiing to the approach end of runway 16, reporting no discrepancies with the brakes while taxiing or during the run-up. He taxied onto the runway and with no wind, began the takeoff roll reporting all was normal for the first 200 ft. With the empennage off the runway, the airplane suddenly veered to the left, which he could not correct. The airplane went off the left side of the runway, down a sharp incline, then nosed over. He immediately released the restraint and exited the airplane. According to a Federal Aviation Administration inspector who examined the runway and airplane the same day, the airplane departed the left side of the runway about 425 from the approach end, and came to rest inverted in grass off the east side of the runway. Inspection of the runway revealed dark marks made by the right tire on runway centerline beginning about 350 feet from the approach edge of the runway. The marks were continuous off the east edge of the runway onto grass. Marks from the left tire were too light to capture in a photograph, while "squiggly" marks associated with the tailwheel tire began about 50 feet past the beginning of the right tire marks and continued off the east edge of the runway onto grass. The inspector reported no flat spots of either main landing gear tire. Visual inspection of the brakes while the airplane was inverted revealed both wheels rotated with no resistance. Both brakes were attached and appeared to be serviceable. The brake lines were also intact with no evidence of fluid loss. The airplane was then uprighted, which further damaged the right main landing gear, fractured the right brake line and right outer wheel half, and sheared a bolt of the brake caliper causing it to separate. Fluid was noted leaking from the right brake line when it fractured, leaving about a one-foot round stain on the pavement. Operationaltesting of the left brake revealed no evidence of failure or malfunction. The right brake could not be tested because of damage caused by recovery. Flight control continuity was confirmed for roll, pitch, and yaw with no evidence of binding or malfunction reported. ## Aircraft - Registration: [N3512L](https://openairdocs.org/deregistered/N3512L-2019-03-02), registration cancelled 2019-03-02, S/N 0794, built 1978 (OpenAirDocs) - Reported make and model: GREAT LAKES 2T1A (2) - Registry model: [Great Lakes 2T-1A-2](https://openairdocs.org/model/great-lakes-2t-1a-2) (registry code 3910101) (OpenAirDocs) - Registry engine: [Lycoming AEIO-360 series](https://openairdocs.org/engine/lycoming-aeio-360-series) (registry code 41522, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 0794 - Year built: 1978 - Airframe hours: 1520 - Engines: Lycoming AEIO-360-B1G6 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Aerobatic - Last inspection: Annual, November 1, 2017 - Departed: 0B5, Montague, MA - Destination: ORE, Orange, MA - Airport: 0B5, Turners Falls Airport, runway 16, 3,200 × 75 ft, asphalt - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 78; injuries: none; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: basicmed, without waivers/limitations; last flight review March 5, 2016; seat: rear; restraint: 3-point; flight hours: 4,220 total, 1,575 in this make and model, 4,070 as pilot in command, 30 in the last 90 days, 20 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: 12,000 ft broken - Temperature: 63 °F, dew point 57 °F - Altimeter: 30.20 inHg - Observed at: ORE, 11 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 20171102018139A](https://openairdocs.org/incident/20171102018139A), Nov 2, 2017: Great Lakes 2T-1A-2, Montague, MA, Substantial damage. On November 1, 2017. At approximately 2:30 pm, aircraft N3512L (Great Lakes model 2T-1A-2) was involved in an accident at the Turners Falls Airport (0B5)… ## Docket (8 files) The files NTSB released with the investigation on March 6, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96320. 3.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470898&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - NTSB Record of Conversation (item 2, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470899&FileExtension=.PDF&FileName=NTSB%20Record%20of%20Conversation-Master.PDF - FAA Record of Conversation (item 3, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470900&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation-Master.PDF - FAA Inspector Statement (item 4, .PDF, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470901&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF - Statement from Mechanic (item 5, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470902&FileExtension=.PDF&FileName=Statement%20from%20Mechanic-Master.PDF - Excerpt from Maintenance Records (item 6, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470903&FileExtension=.PDF&FileName=Excerpt%20from%20Maintenance%20Records-Master.PDF - Investigative Photographs (item 7, .PDF, 2 photos, 640 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470904&FileExtension=.PDF&FileName=Investigative%20Photographs-Master.PDF - NTSB Evidence Control Form (item 8, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40470905&FileExtension=.PDF&FileName=NTSB%20Evidence%20Control%20Form-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.