# NTSB GAA16CA465: Cessna TR182, N738GK, South Lake Tahoe, CA, September 5, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: September 5, 2016, 13:30 local (20:30 UTC) - Place: South Lake Tahoe, CA - Coordinates: 38.898612, -119.993888 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.8986&lon=-119.9939&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-aborted after touchdown: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 5, 2016 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 93954 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA465 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93954/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93954 - Page: https://openairdocs.org/ntsb/GAA16CA465 ## Probable cause The pilot's failure to maintain directional control during an attempted go-around, which resulted in a runway excursion and a nose over. Contributing to the accident was the pilot's failure to remove the carburetor heat during the attempted go-around in high density altitude conditions. ## 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: [Cessna TR182, 3 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2072735), [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: [Cessna TR182, 9 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072735), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna TR182, 7 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=2072735), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Effect on equipment (probable cause); cases with it: [Cessna TR182, 1 case](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=2072735), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) - [Power plant: air intake](https://openairdocs.org/ntsb-findings/01057160): Aircraft › Aircraft power plant · Incorrect use/operation (probable cause); cases with it: [Cessna TR182, 1 case](https://openairdocs.org/ntsb-findings/01057160/cases.md?model=2072735), [All aircraft, 50 cases](https://openairdocs.org/ntsb-findings/01057160/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Cessna TR182, 3 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=2072735), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/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: [Cessna TR182, 2 cases](https://openairdocs.org/ntsb-events/380/sequence.md?model=2072735), [All aircraft, 400 cases](https://openairdocs.org/ntsb-events/380/sequence.md) - [Approach-VFR go-around: Loss of lift](https://openairdocs.org/ntsb-events/500); cases with it: [Cessna TR182, 1 case](https://openairdocs.org/ntsb-events/500/sequence.md?model=2072735), [All aircraft, 252 cases](https://openairdocs.org/ntsb-events/500/sequence.md) - [Landing-aborted after touchdown: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna TR182, 4 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2072735), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-aborted after touchdown: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Cessna TR182, 5 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2072735), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-aborted after touchdown: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna TR182, 2 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2072735), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) - [Landing-aborted after touchdown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna TR182, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072735), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that during landing the airplane floated half way down the runway, so she decided to perform a go-around. During the go-around, the pilot reported that airplane would not climb initially and one wheel touched down on the runway, which "threw the airplane off kilter." Subsequently, the airplane did start to climb, but the flight path was over the grass to the right of the runway, so she forced the airplane down in the grass ahead. During the touchdown, the nose gear collapsed and the airplane nosed over. During a postaccident interview with the National Transportation Safety Board investigator-in-charge, the pilot reported that during the go-around, she retracted the flaps to 20 degrees, but she forgot to remove the carburetor heat because she normally flies fuel-injected airplanes. The fuselage, both wings, and vertical stabilizer sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot's operating handbook for the accident airplane states in part: Balked Landing 1. Power – FULL THROTTLE and 2400 RPM [revolutions per minute]. 2. Carburetor Heat – COLD. 3. Wing Flaps – RETRACT to 20 degrees. 4. Climb Speed – 75 KIAS [knots indicated airspeed]. 5. Wing Flaps – RETRACT slowly after reach 75 KIAS. 6. Cowl Flaps – OPEN. About the time of the accident, at the accident airport, an automated weather observing system reported the wind to be variable at 6 knots, a temperature of 66 degrees Fahrenheit(19 Celsius), and a dew point of 26 degrees Fahrenheit (-3 Celsius). The airport's elevation was 6,268 feet above mean sea level (MSL) and the density altitude was 8,108 feet above MSL. ## Factual narrative The pilot reported that during landing the airplane floated half way down the runway, so she decided to perform a go-around. During the go-around, the pilot reported that airplane would not climb initially and one wheel touched down on the runway, which "threw the airplane off kilter." Subsequently, the airplane did start to climb, but the flight path was over the grass to the right of the runway, so she forced the airplane down in the grass ahead. During the touchdown, the nose gear collapsed and the airplane nosed over. During a postaccident interview with the National Transportation Safety Board investigator-in-charge, the pilot reported that during the go-around, she retracted the flaps to 20 degrees, but she forgot to remove the carburetor heat because she normally flies fuel-injected airplanes. The fuselage, both wings, and vertical stabilizer sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The pilot's operating handbook for the accident airplane states in part: Balked Landing 1. Power – FULL THROTTLE and 2400 RPM [revolutions per minute]. 2. Carburetor Heat – COLD. 3. Wing Flaps – RETRACT to 20 degrees. 4. Climb Speed – 75 KIAS [knots indicated airspeed]. 5. Wing Flaps – RETRACT slowly after reach 75 KIAS. 6. Cowl Flaps – OPEN. About the time of the accident, at the accident airport, an automated weather observing system reported the wind to be variable at 6 knots, a temperature of 66 degrees Fahrenheit(19 Celsius), and a dew point of 26 degrees Fahrenheit (-3 Celsius). The airport's elevation was 6,268 feet above mean sea level (MSL) and the density altitude was 8,108 feet above MSL. According to the Federal Aviation Administration Koch Chart, an airplane would have experienced a 66% decrease to the normal rate of climb. The high density altitude and the pilot's failure to remove the carburetor heat likely contributed to the airplane touching down momentarily on the runway during the go-around. ## Aircraft - Registration: [N738GK](https://openairdocs.org/deregistered/N738GK-2018-05-31), registration cancelled 2018-05-31, S/N R18200925 (OpenAirDocs) - Reported make and model: CESSNA TR182 - Registry model: [Cessna TR182](https://openairdocs.org/model/cessna-tr182) (registry code 2072735) (OpenAirDocs) - Category: Airplane - Serial number: R18200925 - Year built: 1979 - Airframe hours: 4486.8 - Engines: Lycoming O-540-J3C5D 235 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: West Air Aviation - Registered owner: Unique Equipment Leasing LLC - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 22, 2016 - Departed: BIH, BISHOP, CA - Destination: TVL, South Lake Tahoe, CA - Airport: TVL, Lake Tahoe, runway 18, 8,541 × 100 ft, asphalt - Equipment: Stall warning system, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: none; private; airplane ratings: single-engine land; medical: class 2, without waivers/limitations; last flight review December 23, 2015; seat: left; restraint: 3-point; flight hours: 245 total, 22 in this make and model, 118 as pilot in command, 31 in the last 90 days, 2 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 27 °F - Altimeter: 30.01 inHg - Observed at: KTVL ## 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 20160905014979A](https://openairdocs.org/incident/20160905014979A), Sep 5, 2016: Cessna TR182, South Lake Taho, CA, Substantial damage. Cessna 182 N738GK flew from kvgt-kbih-ktvl. The pilot attempted to land on runway 18. Pilot noted after crossing the approach end of the runway the aircraft… ## Docket (5 files) The files NTSB released with the investigation on November 2, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93954. 3.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446048&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (Pilot) (item 2, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446049&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Pilot)-Master.PDF - NTSB_Airplane Performance_Density Altitude Conditions (item 3, .PDF, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446050&FileExtension=.PDF&FileName=NTSB_Airplane%20Performance_Density%20Altitude%20Conditions-Master.PDF - Cessna_182RG_Pilots Operating Handbook_Balked Landing (item 4, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446051&FileExtension=.PDF&FileName=Cessna_182RG_Pilots%20Operating%20Handbook_Balked%20Landing-Master.PDF - Accident Photo (item 5, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446052&FileExtension=.PDF&FileName=Accident%20Photo-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.