# NTSB GAA17CA013: Cessna A185, N4924E, San Antonio, TX, October 7, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: October 7, 2016, 13:30 local (18:30 UTC) - Place: San Antonio, TX - Coordinates: 29.537776, -98.474166 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.5378&lon=-98.4742&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report January 18, 2017 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 94176 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA17CA013 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94176/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94176 - Page: https://openairdocs.org/ntsb/GAA17CA013 ## Probable cause The pilot's failure to recognize the tailwind condition and maintain directional control during the landing roll, which resulted in a runway excursion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna A185F, 71 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072821), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [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 A185F, 56 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2072821), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Decision related to condition; cases with it: [Cessna A185F, 5 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=2072821), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) - [Wind: variable wind](https://openairdocs.org/ntsb-findings/03034025): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Cessna A185F, 1 case](https://openairdocs.org/ntsb-findings/03034025/cases.md?model=2072821), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/03034025/cases.md) - [Info processing/decision: expectation/assumption](https://openairdocs.org/ntsb-findings/02041525): Personnel issues › Action/decision · Pilot; cases with it: [Cessna A185F, 1 case](https://openairdocs.org/ntsb-findings/02041525/cases.md?model=2072821), [All aircraft, 51 cases](https://openairdocs.org/ntsb-findings/02041525/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · ATC personnel; cases with it: [Cessna A185F, 13 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2072821), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Cessna A185F, 14 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=2072821), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna A185F, 75 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2072821), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Cessna A185F, 34 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2072821), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna A185F, 36 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072821), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot of a tailwheel equipped airplane reported that, while landing at a tower controlled airport, he performed a wheel landing and as the tail settled to the runway, in a "fraction of a second" the airplane was "sideways on the runway." He further reported that the airplane skidded off the runway to the right, the right main landing gear collapsed, and the right wing impacted the terrain. The right wing sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The automated weather observing system at the accident airport, about two minutes before the accident, recorded the wind at 360 degrees true at 11 knots. In addition, a wind shift and frontal passage was recorded about 3 minutes before the accident. The pilot reported that he landed on runway 12 left. The pilot submitted an additional statement, which in part stated: "1) Tower assigned a runway with a known quartering tail wind, up to 18 knots. 2) As pilot in command, I did not process the wind call out prior to landing." According to the Federal Aviation Administration Chart Supplement, within the final approach path, a wind sock was located to the left of the runway. The flight was flown under day visual meteorological conditions, the airplane entered the pattern on a left downwind, and would have likely been visible to the pilot. However, the pilot reported that he did not observe the wind sock. According to an Air Traffic Control transcript of tower and ground communications, the accident occurred about 3 minutes and 8 seconds after the accident airplane's initial contact with the tower, when the accident airplane reported, 3 miles east inbound. The tower responded to the initial call with, wind 010 at 18, cleared to land 12 left. About 40 seconds later, a ground controller held a taxiing jet stating in part: "hold out right there, we're not sure what we're going to be doing with the airport right now, [wind] 360 at 16, that's a pretty strong tailwind for you guys." About 30 seconds later, tower directed the accident airplane to enter left downwind for 12 left and provided the landing clearance a second time for runway 12 left. About 20 seconds later, a second airplane reported inbound and 8 seconds later was directed by tower to enter left downwind for 12 left. The airplane subsequently repeated the instruction and the tower reported wind 360 at 15. About 25 seconds later, the second airplane requested to land runway 30 right instead of runway 12 left. The tower subsequently directed this second airplane to enter a left downwind for runway 30 left, while the accident airplane continued and landed on runway 12 left. According to 14 CFR Part 91.3 titled, "Responsibility and authority of the pilot in command," sub bullet (a) states, "The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft." ## Factual narrative The pilot of a tailwheel equipped airplane reported that, while landing at a tower controlled airport, he performed a wheel landing and as the tail settled to the runway, in a "fraction of a second" the airplane was "sideways on the runway." He further reported that the airplane skidded off the runway to the right, the right main landing gear collapsed, and the right wing impacted the terrain. The right wing sustained substantial damage. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The automated weather observing system at the accident airport, about two minutes before the accident, recorded the wind at 360 degrees true at 11 knots. In addition, a wind shift and frontal passage was recorded about 3 minutes before the accident. The pilot reported that he landed on runway 12 left. The pilot submitted an additional statement, which in part stated: "1) Tower assigned a runway with a known quartering tail wind, up to 18 knots. 2) As pilot in command, I did not process the wind call out prior to landing." According to the Federal Aviation Administration Chart Supplement, within the final approach path, a wind sock was located to the left of the runway. The flight was flown under day visual meteorological conditions, the airplane entered the pattern on a left downwind, and would have likely been visible to the pilot. However, the pilot reported that he did not observe the wind sock. According to an Air Traffic Control transcript of tower and ground communications, the accident occurred about 3 minutes and 8 seconds after the accident airplane's initial contact with the tower, when the accident airplane reported, 3 miles east inbound. The tower responded to the initial call with, wind 010 at 18, cleared to land 12 left. About 40 seconds later, a ground controller held a taxiing jet stating in part: "hold out right there, we're not sure what we're going to be doing with the airport right now, [wind] 360 at 16, that's a pretty strong tailwind for you guys." About 30 seconds later, tower directed the accident airplane to enter left downwind for 12 left and provided the landing clearance a second time for runway 12 left. About 20 seconds later, a second airplane reported inbound and 8 seconds later was directed by tower to enter left downwind for 12 left. The airplane subsequently repeated the instruction and the tower reported wind 360 at 15. About 25 seconds later, the second airplane requested to land runway 30 right instead of runway 12 left. The tower subsequently directed this second airplane to enter a left downwind for runway 30 left, while the accident airplane continued and landed on runway 12 left. According to 14 CFR Part 91.3 titled, "Responsibility and authority of the pilot in command," sub bullet (a) states, "The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft." ## Aircraft - Registration: [N4924E](https://openairdocs.org/aircraft/N4924E), registered now, S/N 18503909, built 1979 (OpenAirDocs) - Reported make and model: CESSNA A185 (F) - Registry model: [Cessna A185F](https://openairdocs.org/model/cessna-a185f) (registry code 2072821) (OpenAirDocs) - Registry engine: [Continental IO-520-D](https://openairdocs.org/engine/continental-io-520-d) (registry code 17236, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18503909 - Year built: 1979 - Airframe hours: 2442 - Engines: Continental IO-550-D 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 4, 2015 - Departed: CXO, HOUSTON, TX - Destination: SAT, San Antonio, TX - Airport: SAT, San Antonio Intl, runway 12L, 5,519 × 100 ft, asphalt - Equipment: Stall warning system, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: none; private, commercial, airline transport; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review August 17, 2016; seat: left; restraint: 4-point; flight hours: 4,500 total, 4,000 in this make and model, 4,500 as pilot in command, 35.4 in the last 90 days, 2.2 in the last 30 days, 1.2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: 11,000 ft broken - Temperature: 82 °F, dew point 72 °F - Altimeter: 30.04 inHg - Observed at: KSAT ## 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 20161007016559A](https://openairdocs.org/incident/20161007016559A), Oct 7, 2016: Cessna A185F, San Antonio, TX, Substantial damage. ^Stephen ratcliff^ flew his Cessna A-185-F from conroe to San Antonio. On his way to the airport, a frontal passage was reported by San Antonio international… ## Other investigations on N4924E (1) 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. - [NTSB ANC84LA001](https://openairdocs.org/ntsb/ANC84LA001), Jan 6, 1983: Cessna 185 (N4924E), Togiak, AK, substantial damage ## Docket (5 files) The files NTSB released with the investigation on December 1, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94176. 2.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446927&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=40446928&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Pilot)-Master.PDF - FAA Chart Supplement KSAT (item 3, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446929&FileExtension=.PDF&FileName=FAA%20Chart%20Supplement%20KSAT-Master.PDF - Accident Photo (Courtesy of FAA) (item 4, .PDF, 1 photo, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446930&FileExtension=.PDF&FileName=Accident%20Photo%20(Courtesy%20of%20FAA)-Master.PDF - ATC Audio Transcript NTSB (item 5, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446931&FileExtension=.PDF&FileName=ATC%20Audio%20Transcript%20NTSB-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.