# NTSB ERA22LA128: Stinson 108, N6493, Pahokee, FL, February 16, 2022 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Limited · Final report - Date: February 16, 2022, 11:10 local (16:10 UTC) - Place: Pahokee, FL - Coordinates: 26.782932, -80.693092 - Nearby events: https://openairdocs.org/map.md?lat=26.7829&lon=-80.6931&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Nose over/nose down](https://openairdocs.org/ntsb-events/096) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Eastern Region Aviation - Parties: FAA - NTSB case key (mKey): 104656 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA128 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104656/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104656 - Page: https://openairdocs.org/ntsb/ERA22LA128 ## Probable cause The student pilot’s incorrect tail wheel takeoff procedure, and the flight instructor’s lack of remedial action, which resulted in a nose over. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Student/instructed pilot (probable cause); cases with it: [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) - [Takeoff: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) ## Analysis The pilot receiving tail wheel instruction (student pilot) stated that during takeoff, he raised the tail wheel too high, and the propeller contacted the ground. The airplane nosed over and came to rest inverted. The student pilot added that there were no preimpact mechanical malfunctions and the flight instructor confirmed the student pilot’s statement. Examination of the wreckage by a Federal Aviation Administration inspection revealed substantial damage to the wings and vertical stabilizer. ## Aircraft - Registration: N6493 (not matched to a registry record) - Reported make and model: STINSON 108 (3) - Category: Airplane - Serial number: 108-4493 - Year built: 1948 - Airframe hours: 3075.1 - Engines: Franklin 335 165 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 20, 2021 - Destination: Same as departure - Airport: PHK, Palm Beach County Glades, runway 36, 4,100 × 75 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 28; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review May 12, 2021; seat: left; restraint: 3-point; flight hours: 290 total, 7.2 in this make and model, 190 as pilot in command, 11 in the last 90 days, 1.5 in the last 30 days, 0 in the last 24 hours - Flight instructor; age 56; injuries: none; flight instructor, flight engineer, airline transport; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review April 25, 2021; seat: right; restraint: 3-point; flight hours: 20,100 total, 825 in this make and model, 10,000 as pilot in command, 300 in the last 90 days, 95 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 19 knots, gusting 24 - Visibility: 10 statute miles - Temperature: 77 °F, dew point 61 °F - Altimeter: 30.38 inHg - Observed at: KPBI, 32 nm away - METAR: KPBI 161553Z 10019G24KT 10SM SCT031 SCT042 SCT250 25/16 A3038 RMK AO2 SLP286 T02500156 ## Docket (3 files) The files NTSB released with the investigation on May 25, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104656. 6.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13421178&FileExtension=pdf&FileName=6120.1%20Pilot_Operator%20Aircraft%20Accident_Incident%20Report-%20Completed_Redacted-Rel.pdf - Pilots' statements (item 2, PDF, 3 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13420890&FileExtension=pdf&FileName=Pilot%20%26%20CFI%20statements_Redacted-Rel.pdf - Photos (item 3, PDF, 3 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13908800&FileExtension=pdf&FileName=Investigative%20Photo%27s-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.