# NTSB ERA21LA299: Vans RV6, N464DM, Ocracoke, NC, July 25, 2021 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 4 · Limited · Final report - Date: July 25, 2021, 13:16 local (17:16 UTC) - Place: Ocracoke, NC - Coordinates: 35.104009, -75.961741 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.1040&lon=-75.9617&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: Serious injuries - Injuries: 2 serious - 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): 103548 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21LA299 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103548/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103548 - Page: https://openairdocs.org/ntsb/ERA21LA299 ## Probable cause The pilot's failure to perform a go-around during the unstabilized approach, which resulted in the airplane landing too far down the runway, and a subsequent runway excursion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot; cases with it: [Millsap Dennis RV-6A, 1 case](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=05607ON), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Wind: gusts](https://openairdocs.org/ntsb-findings/03034045): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Millsap Dennis RV-6A, 1 case](https://openairdocs.org/ntsb-findings/03034045/cases.md?model=05607ON), [All aircraft, 1,199 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Millsap Dennis RV-6A, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05607ON), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Millsap Dennis RV-6A, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=05607ON), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-flare/touchdown: Landing area overshoot](https://openairdocs.org/ntsb-events/380); cases with it: [Millsap Dennis RV-6A, 1 case](https://openairdocs.org/ntsb-events/380/sequence.md?model=05607ON), [All aircraft, 400 cases](https://openairdocs.org/ntsb-events/380/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Millsap Dennis RV-6A, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=05607ON), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [Millsap Dennis RV-6A, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=05607ON), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot reported that windspeed at the nearest weather reporting facility was 14-16 knots, and the windsock at the accident airport indicated a 90° crosswind. He stated that his approach was “too high and fast”, and he crossed the runway threshold about 70 ft above ground level (AGL) at a speed of 90 mph. About ½ way down the runway, the airplane was about 30 ft AGL at a speed of about 45 mph, and “oscillating 20° either side of center.” The pilot believed he could “straighten the flight path and touch down in time to stop” before the end of the runway. However, a gust of wind “would not allow the aircraft to slow” and it ran off the end of the runway about 20 mph, nosed over, and sustained substantial damage to the vertical and horizontal stabilizers, the rudder, and the left wing. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N464DM](https://openairdocs.org/aircraft/N464DM), registered now, S/N 60329, built 2002 (OpenAirDocs) - Reported make and model: VANS RV6 (A) - Registry model: [Millsap Dennis RV-6A](https://openairdocs.org/model/millsap-dennis-rv-6a) (registry code 05607ON) (OpenAirDocs) - Registry engine: [Lycoming O-360-A1A](https://openairdocs.org/engine/lycoming-o-360-a1a) (registry code 41594, 4 cycle) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 60329 - Year built: 2002 - Airframe hours: 1161 - Engines: Lycoming O-360-A1A 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, June 13, 2021, 3 hours before - Departed: MCZ, Williamston, NC - Destination: Same as departure - Airport: W95, Ocracoke Island, runway 06, 2,998 × 60 ft, asphalt - Equipment: Auto-pilot, Angle of attack indicator, ADS-B, Handheld GPS, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 78; injuries: serious; private; airplane ratings: single-engine land; medical: basicmed, with waivers/limitations; last flight review July 24, 2020; seat: left; restraint: 4-point; flight hours: 879 total, 353 in this make and model, 8 in the last 90 days, 3 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 70 °F - Altimeter: 30.07 inHg - Observed at: HSE, 18 nm away - METAR: KHSE 251651Z AUTO 18009KT 10SM CLR 30/21 A3007 RMK AO2 SLP181 T03000211 ## 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 20210725011839A](https://openairdocs.org/incident/20210725011839A), Jul 25, 2021: Millsap Dennis RV-6A, Ocracoke, NC, Substantial damage. Pilot landed on runway 6 at Ocracoke Island Airport, W95. The pilot was not able to get the aircraft stopped before the end up the runway and ended up going… ## Docket (5 files) The files NTSB released with the investigation on April 29, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103548. 11.4 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 7.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12679020&FileExtension=pdf&FileName=01-01%206120%20National%20Transportation%20Safety%20Board%20Pilot%20Operator%20Aircraft%20Accident%20Incident%20Report_print_Redacted-Rel.pdf - Memorandum for record - NTSB conversation with pilot (item 2, PDF, 1 page, 204 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12549871&FileExtension=pdf&FileName=01-05%20%20MFR%20-%20NTSB%20Converation%20with%20Pilot-Rel.pdf - Record of FAA interview with pilot (item 3, PDF, 2 pages, 331 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12550647&FileExtension=pdf&FileName=01-03%20FAA%20Interview%20With%20Pilot_print-Rel.pdf - Memorandum for record - conversation with FAA inspector (item 4, PDF, 1 page, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12550985&FileExtension=pdf&FileName=01-02%20Memorandum%20For%20Record%20-%20Conversation%20with%20FAA%20Inspector-Rel.pdf - Investigative photographs (item 5, PDF, 4 pages, 4 photos, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12551024&FileExtension=pdf&FileName=06-01-%20photo%20array_ERA21LA299-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.