# NTSB GAA16CA485: Dormaier Monte R Baby Great Lakes, N110MD, Mazama, WA, September 3, 2016 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: September 3, 2016, 10:56 local (17:56 UTC) - Place: Mazama, WA - Coordinates: 48.649723, -120.501945 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=48.6497&lon=-120.5019&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report January 18, 2017 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 94009 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA485 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94009/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94009 - Page: https://openairdocs.org/ntsb/GAA16CA485 ## Probable cause The pilot’s failure to maintain directional control during the takeoff roll, 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: [Dormaier Monte R BABY GREAT LAKES, 1 case](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=3910266), [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: [Dormaier Monte R BABY GREAT LAKES, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=3910266), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Object/animal/substance: pole](https://openairdocs.org/ntsb-findings/03022010): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Dormaier Monte R BABY GREAT LAKES, 1 case](https://openairdocs.org/ntsb-findings/03022010/cases.md?model=3910266), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/03022010/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Dormaier Monte R BABY GREAT LAKES, 1 case](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=3910266), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Dormaier Monte R BABY GREAT LAKES, 1 case](https://openairdocs.org/ntsb-events/060/sequence.md?model=3910266), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Dormaier Monte R BABY GREAT LAKES, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=3910266), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Dormaier Monte R BABY GREAT LAKES, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=3910266), [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: [Dormaier Monte R BABY GREAT LAKES, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=3910266), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The Federal Aviation Administration (FAA) Aviation Safety Inspector that responded to the accident site reported that the pilot of the experimental, amateur built, tailwheel landing gear-equipped bi-plane reported to the inspector, that during the takeoff roll the bi-plane drifted off the left side of the turf and gravel runway. The pilot reported that after he had completed his engine run-up and all indications were normal, he lightly applied power and began his takeoff roll from a concrete pad at the approach end of the runway. He reported to the inspector that the bi-plane began to drift to the left and he did not feel as though he had rudder authority, so he added more power with the intent to increase the airflow over the rudder, but the torque from the added power exacerbated the loss of control. The bi-plane drifted further left, exited the runway, and struck a post that supported a satellite dish and subsequently struck a tree. The bi-plane sustained substantial damage to the four wings and the fuselage. The pilot reported to the inspector that in hindsight it would have been better to abort the takeoff. The FAA Inspector reported that during the airplane examination he did not find any evidence of aircraft system or component failure prior to the impact. The NTSB Investigator-in-charge attempted to contact the pilot on multiple occasions to no avail. The pilot did not submit the NTSB Form 6120.1. ## Factual narrative The Federal Aviation Administration (FAA) Aviation Safety Inspector that responded to the accident sight reported that the pilot of the experimental, amateur built, tailwheel landing gear-equipped bi-plane reported to the inspector, that during the takeoff roll the bi-plane drifted off the left side of the turf and gravel runway. The pilot reported that after he had completed his engine run-up and all indications were normal, he lightly applied power and began his takeoff roll from a concrete pad at the approach end of the runway. He reported to the inspector that the bi-plane began to drift to the left and he did not feel as though he had rudder authority, so he added more power with the intent to increase the airflow over the rudder, but the torque from the added power exacerbated the loss of control. The bi-plane drifted further left, exited the runway, and struck a post that supported a satellite dish and subsequently struck a tree. The bi-plane sustained substantial damage to the four wings and the fuselage. The pilot reported to the inspector that in hindsight it would have been better to abort the takeoff. The FAA Inspector reported that during the airplane examination he did not find any evidence of aircraft system or component failure prior to the impact. The NTSB Investigator-in-charge attempted to contact the pilot on multiple occasions to no avail. The pilot did not submit the NTSB Form 6120.1. ## Aircraft - Registration: [N110MD](https://openairdocs.org/deregistered/N110MD-2018-03-08), registration cancelled 2018-03-08, S/N 7704-A-637-B, built 1980 (OpenAirDocs) - Reported make and model: DORMAIER MONTE R BABY GREAT LAKES (NO SERIES) - Registry model: [Dormaier Monte R BABY GREAT LAKES](https://openairdocs.org/model/dormaier-monte-r-baby-great-lakes) (registry code 3910266) (OpenAirDocs) - Registry engine: [Continental A&C65 series](https://openairdocs.org/engine/continental-a-c65-series) (registry code 17003, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 7704-A-637-B - Year built: 1980 - Engines: Lycoming O-235-C 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, July 3, 1997 - Departed: W12, Mazama, WA - Destination: W12, Mazama, WA - Airport: W12, Lost River Resort, runway 11, 3,150 × 85 ft, gravel - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 89; injuries: minor; commercial, flight instructor; airplane ratings: multi-engine land, multi-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review February 12, 2010; seat: single; restraint: 4-point; flight hours: 6,000 total, 124 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: 7,500 ft broken - Temperature: 63 °F, dew point 41 °F - Altimeter: 29.97 inHg - Observed at: KOMK, 41 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 20160903016799A](https://openairdocs.org/incident/20160903016799A), Sep 3, 2016: Dormaier Monte R BABY GREAT LAKES, Mazama, WA, Substantial damage. Pilot initiated takeoff roll by slowly increasing engine power. During takeoff roll the airplane drifted left. Pilot stated there was insufficient rudder… ## Docket (2 files) The files NTSB released with the investigation on December 16, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94009. 390 KB in all. - Memorandum for Record- FAA Statement (item 1, .PDF, 148 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447679&FileExtension=.PDF&FileName=Memorandum%20for%20Record-%20FAA%20Statement-Master.PDF - Photo (item 2, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40447678&FileExtension=.PDF&FileName=Photo-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.