# NTSB ERA21LA114: Aviat A1, N480F, Terrell, NC, January 23, 2021 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 4 · Limited · Final report - Date: January 23, 2021, 14:30 local (19:30 UTC) - Place: Terrell, NC · In Lake Norman - Coordinates: 35.6238, -80.9305 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.6238&lon=-80.9305&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-flare/touchdown: Nose over/nose down](https://openairdocs.org/ntsb-events/096) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 102560 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA114 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/102560/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=102560 - Page: https://openairdocs.org/ntsb/ERA21LA114 ## Probable cause The pilot’s failure to retract the landing gear on the amphibious airplane prior to a water landing, resulting in a nose over and structural damage to the airframe. The mechanic’s failure to remove electrical tape from the pitot tube, the pilot’s inadequate preflight inspection, and the pilot’s failure to visually confirm the landing gear position prior to touchdown were all factors in the accident. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: landing gear selector](https://openairdocs.org/ntsb-findings/01023234): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Aviat A-1B, 1 case](https://openairdocs.org/ntsb-findings/01023234/cases.md?model=2210406), [All aircraft, 54 cases](https://openairdocs.org/ntsb-findings/01023234/cases.md) - [Maintenance: scheduled/routine maintenance](https://openairdocs.org/ntsb-findings/02062010): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Aviat A-1B, 1 case](https://openairdocs.org/ntsb-findings/02062010/cases.md?model=2210406), [All aircraft, 320 cases](https://openairdocs.org/ntsb-findings/02062010/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aviat A-1B, 1 case](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=2210406), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aviat A-1B, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2210406), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/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: [Aviat A-1B, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=2210406), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Landing-flare/touchdown: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Aviat A-1B, 9 cases](https://openairdocs.org/ntsb-events/090/sequence.md?model=2210406), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Landing-flare/touchdown: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [Aviat A-1B, 19 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2210406), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot was performing a repositioning flight following the completion of an annual inspection. After departing from a runway in his amphibious airplane, he observed a large, open area on a nearby lake and decided to perform a touch-and-go landing. Upon touchdown, the airplane flipped over and came to rest inverted, resulting in substantial damage to the fuselage and wings. Due to his injuries, the pilot had no recollection of the accident. An inspector with the Federal Aviation Administration reported that, during wreckage recovery from the lake, all four landing gear wheels were in the extended positions, and the landing gear handle was in the “Down Land” position. He also noted that the pilot tube was covered in black electrical tape, blocking airflow through the tube. A pitot/static discrepancy was found during the annual inspection and the repair was deferred. The airplane was equipped with a backup landing gear position advisory system that would provide an audible message confirming the position of the gear prior to landing; however, the audible component would not work properly if the pilot tube was obstructed. ## Aircraft - Registration: [N480F](https://openairdocs.org/deregistered/N480F-2022-12-12), registration cancelled 2022-12-12, S/N 2357, built 2006 (OpenAirDocs) - Reported make and model: AVIAT A1 (B) - Registry model: [Aviat A-1B](https://openairdocs.org/model/aviat-a-1b) (registry code 2210406) (OpenAirDocs) - Registry engine: [Lycoming O-360-A1P](https://openairdocs.org/engine/lycoming-o-360-a1p) (registry code 42259, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2357 - Year built: 2007 - Airframe hours: 420 - Engines: Lycoming O-360-A1P 180 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 22, 2021, 0 hours before - Departed: 14A, Mooresville, NC - Destination: Same as departure - Airport: NONE, Lake - Equipment: Stall warning system, Electronic flight bag or handheld device, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: minor; airline transport; airplane ratings: multi-engine land, single-engine sea, single-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review December 28, 2019; seat: front; restraint: 4-point; flight hours: 25,000 total, 75 in this make and model, 20,000 as pilot in command, 30 in the last 90 days, 10 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 48 °F, dew point 5 °F - Altimeter: 30.18 inHg - Observed at: SVH, 10 nm away ## Docket (5 files) The files NTSB released with the investigation on July 13, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=102560. 10.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12063768&FileExtension=pdf&FileName=1%206120_Redacted-Rel.pdf - NTSB memorandum for record FAA statement (item 2, PDF, 1 page, 320 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12064341&FileExtension=pdf&FileName=2%20NTSB%20Memorandum%20for%20Record%20508%20FAA%20Statement-Rel.pdf - FAA written statement (item 3, PDF, 1 page, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12064494&FileExtension=pdf&FileName=2a%20FAA%20Written%20Statement-Rel.pdf - Photo array (item 4, PDF, 6 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12063875&FileExtension=pdf&FileName=3%20Photo%20Array-Rel.pdf - Amphibious landing gear position indicating system installation manual (item 5, PDF, 15 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12064239&FileExtension=pdf&FileName=5%209600%20Install%20Package%20Excerpts_Redacted-Rel.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.