# NTSB GAA18CA022: Aviat A1, N337AM, Williamsport, PA, October 22, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: October 22, 2017, 09:29 local (13:29 UTC) - Place: Williamsport, PA - Coordinates: 41.239166, -76.930557 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.2392&lon=-76.9306&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Abnormal runway contact](https://openairdocs.org/ntsb-events/090) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report January 11, 2018 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 96237 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA18CA022 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96237/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96237 - Page: https://openairdocs.org/ntsb/GAA18CA022 ## Probable cause The pilot’s failure to verify that the parking brake was disengaged before landing, which resulted in a runway excursion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: master cylinder/brake valve](https://openairdocs.org/ntsb-findings/01023243): Aircraft › Aircraft systems · Unintentional use/operation (probable cause); cases with it: [Aviat A-1B, 1 case](https://openairdocs.org/ntsb-findings/01023243/cases.md?model=2210406), [All aircraft, 21 cases](https://openairdocs.org/ntsb-findings/01023243/cases.md) - [Attention/monitoring: task monitoring/vigilance](https://openairdocs.org/ntsb-findings/02021520): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Aviat A-1B, 2 cases](https://openairdocs.org/ntsb-findings/02021520/cases.md?model=2210406), [All aircraft, 330 cases](https://openairdocs.org/ntsb-findings/02021520/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aviat A-1B, 33 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2210406), [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: [Aviat A-1B, 2 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=2210406), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Abnormal runway contact](https://openairdocs.org/ntsb-events/090) (defining event); cases with it: [Aviat A-1B, 9 cases](https://openairdocs.org/ntsb-events/090/sequence.md?model=2210406), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Aviat A-1B, 24 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2210406), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Aviat A-1B, 2 cases](https://openairdocs.org/ntsb-events/094/sequence.md?model=2210406), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) - [Landing: Dragged wing/rotor/float/other](https://openairdocs.org/ntsb-events/093); cases with it: [Aviat A-1B, 6 cases](https://openairdocs.org/ntsb-events/093/sequence.md?model=2210406), [All aircraft, 319 cases](https://openairdocs.org/ntsb-events/093/sequence.md) ## Analysis The pilot of the tundra-tired, tailwheel-equipped airplane reported that, during touchdown, he saw that the left emergency brake was partially engaged. He added that the left wheel was locked and that the airplane exited the left side of the runway. Subsequently, the right landing gear collapsed, and the right wing tip struck the ground. He added that, before the previous takeoff from a grass airstrip, he had performed his preflight checklist, which was normal. But, "upon reflection," he realized that he had changed his normal routine by shutting down the engine, setting the parking brakes, and exiting the airplane after completing the checklist. After re-entering the airplane, he only did a "visual left to right flow check." He then pressed and released the brakes and applied power holding the left rudder and brake down to turn the airplane in the direction of the departure and then departed after a "very short ground roll downhill." He further added that, by immediately turning left during the takeoff roll, he "may not have released enough pressure on the parking brake to turn it completely off." He believed that, due to the combination of the large smooth tire, wet grass, and downslope hill, he was unable to determine that the emergency parking brake was engaged. The airplane sustained substantial damage to the fuselage and right wing. ## Factual narrative The pilot of the tundra tire, tailwheel-equipped airplane reported that, during the landing touchdown, he discovered that the left emergency brake was partially engaged. He added that, the left wheel was locked and the airplane exited the left side of the runway. Subsequently, the right landing gear collapsed and the right wingtip struck the ground. He added that, before the previous takeoff, from a grass airstrip, he had performed his preflight checklist, which was normal. But, "upon reflection", he realized that he had changed his normal routine by shutting down the engine, setting the parking brakes and exiting the airplane after completing the checklist. After re-entering the airplane, he only did a "visual left to right flow check". He then, pressed and released the brakes and applied power holding the left rudder and brake down to turn the airplane in the direction of the departure, and departed after a "very short ground roll downhill". He further added, that by taking an immediate turn to the left, during the takeoff roll, he "may not have released enough pressure on the parking brake to turn it completely off." He believed that, due to the combination of the large smooth tire, wet grass and downslope hill he was unable to determine that the emergency parking brake was engaged. The airplane sustained substantial damage to the fuselage and right wing. The pilot did report that the left parking brake did not disengage. ## Aircraft - Registration: [N337AM](https://openairdocs.org/aircraft/N337AM), registered now, S/N 2337, built 2006 (OpenAirDocs) - Reported make and model: AVIAT AIRCRAFT INC A1 (B) - Registry model: [Aviat A-1B](https://openairdocs.org/model/aviat-a-1b) (registry code 2210406) (OpenAirDocs) - Registry engine: [Lycoming O-360-A1P](https://openairdocs.org/engine/lycoming-o-360-a1p) (registry code 42259, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2337 - Year built: 2006 - Airframe hours: 1295 - Engines: LYCOMING O-360-A1P 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 18, 2017 - Departed: Reedsville, PA - Destination: IPT, Williamsport, PA - Airport: IPT, Williamsport Rgnl, runway 09, 6,825 × 150 ft, asphalt - Equipment: Satellite tracking device, Stall warning system, Electronic flight bag or handheld device, Handheld GPS, Onboard weather ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review May 26, 2016; seat: front; restraint: 5-point; flight hours: 3,264 total, 610 in this make and model, 3,264 as pilot in command, 64 in the last 90 days, 18.5 in the last 30 days, 4.5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Temperature: 48 °F, dew point 45 °F - Altimeter: 30.38 inHg - Observed at: KIPT ## 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 20171022014979A](https://openairdocs.org/incident/20171022014979A), Oct 22, 2017: Aviat Aircraft Inc A-1B, Montoursville, PA, Substantial damage. While landing at ipt the left wheel brake remained locked resulting in loss of control and subsequent ground loop. ## Docket (3 files) The files NTSB released with the investigation on December 8, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96237. 1.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 875 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458632&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photo (item 2, .PDF, 464 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458633&FileExtension=.PDF&FileName=Accident%20Photo-Master.PDF - Pilot's Statement (item 3, .PDF, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458634&FileExtension=.PDF&FileName=Pilot%27s%20Statement-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.