# NTSB GAA18CA319: Cessna 172, N786SA, San Diego, CA, June 3, 2018

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Data collection · Final report
- Date: June 3, 2018, 14:15 local (21:15 UTC)
- Place: San Diego, CA
- Coordinates: 32.812221, -117.131385 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=32.8122&lon=-117.1314&mi=10
- Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping)
- Defining events: [Taxi-into takeoff position: Ground collision](https://openairdocs.org/ntsb-events/200); [Taxi-into takeoff position: Ground collision](https://openairdocs.org/ntsb-events/200)
- Highest injury: Minor injuries
- Injuries: 2 minor, 2 uninjured
- Status: Completed, report November 5, 2018
- Report: Approved by Office Director
- NTSB office: General Aviation Accidents
- Parties: FAA
- NTSB case key (mKey): 97388
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA18CA319
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97388/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97388
- Page: https://openairdocs.org/ntsb/GAA18CA319

## Probable cause (aircraft 2)

The biplane pilot’s failure to see and avoid the stopped airplane.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Pilot of other aircraft (probable cause), aircraft 1; cases with it: [Cessna 172S, 12 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=2072439), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md)
- [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot of other aircraft (probable cause), aircraft 1; cases with it: [Cessna 172S, 11 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=2072439), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md)
- [Physical workspace: visibility](https://openairdocs.org/ntsb-findings/03041020): Environmental issues › Task environment · Effect on personnel, aircraft 1; cases with it: [Cessna 172S, 1 case](https://openairdocs.org/ntsb-findings/03041020/cases.md?model=2072439), [All aircraft, 25 cases](https://openairdocs.org/ntsb-findings/03041020/cases.md)
- [Attention/monitoring: monitoring environment](https://openairdocs.org/ntsb-findings/02021545): Personnel issues › Psychological · Pilot (probable cause), aircraft 2; cases with it: [Great Lakes 2T-1A-2, 3 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md?model=3910101), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/02021545/cases.md)
- [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Pilot (probable cause), aircraft 2; cases with it: [Great Lakes 2T-1A-2, 1 case](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=3910101), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Taxi-into takeoff position: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event), aircraft 1; cases with it: [Cessna 172S, 23 cases](https://openairdocs.org/ntsb-events/200/sequence.md?model=2072439), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md)
- [Taxi-into takeoff position: Ground collision](https://openairdocs.org/ntsb-events/200) (defining event), aircraft 2; cases with it: [Great Lakes 2T-1A-2, 2 cases](https://openairdocs.org/ntsb-events/200/sequence.md?model=3910101), [All aircraft, 618 cases](https://openairdocs.org/ntsb-events/200/sequence.md)

## Analysis (aircraft 2)

The flight instructor, who was on the controls, reported that he and a student taxied for departure. Upon arrival at the departure end of the runway, there were four airplanes ahead of them in a run-up area. He added that the first airplane moved to the hold-short line and that, after he completed the engine run-up, they moved forward to the hold-short line behind the first airplane. The other three airplanes, which were biplanes, remained in the run-up area. After the departure of the first airplane, the instructor told the control tower they were ready for departure, and the tower controller replied to stand by. The tower controller then cleared the three biplanes, which were waiting in the run-up area for takeoff as a flight of three. The second biplane in the flight struck the instructor's airplane's right aileron as it taxied past. The pilot of the tailwheel-equipped biplane reported that he was the second in the flight of three. He added that the flight had been holding in the run-up area at a 45° angle to complete their run-up checks when the tower controller cleared the flight for takeoff. He began to follow the lead airplane, and his airplane struck the airplane stopped at the hold-short line. He reported that he never saw the stopped airplane until after the impact. The instructor's airplane sustained substantial damage to the right aileron. In an interview with the Federal Aviation Administration inspector, the flight instructor reported that he was not aware that the three biplanes were part of a single flight awaiting takeoff clearance. He also reported that he had never flown tailwheel airplanes and was not aware of their limited forward visibility. The flight instructor and biplane pilot reported that there were no preaccident mechanical failures or malfunctions with their respective airplanes that would have precluded normal operation.

## Factual narrative (aircraft 2)

The flight instructor, who was on the controls, reported that he and a student taxied for departure. Upon arrival at the departure end of the runway, there were four airplanes ahead of them in a run-up area. He added that the first airplane moved to the hold short line and that after he completed the engine run-up, they moved forward to the hold short line behind the first airplane. The other three airplanes, which were biplanes, remained in the run-up area. After the departure of the first airplane, the instructor told the control tower they were ready for departure and tower replied to stand by. Tower then cleared the three biplanes, who were waiting in the run-up area, for takeoff as a flight of three. The second biplane in the flight struck the instructor's airplane's right aileron as it taxied past. The pilot of the tailwheel-equipped biplane reported that he was the second in the flight of three. He added that the flight had been holding in the run-up area at a 45° angle to complete their run-up checks when ATC cleared the flight for takeoff. He began to follow the lead airplane and his airplane struck the airplane stopped at the hold short line. He reported that he never saw the stopped airplane until after the impact. The instructional airplane sustained substantial damage to the right aileron. In an interview with the Federal Aviation Administration inspector, the flight instructor reported that he was not aware that the three biplanes were part of a single flight awaiting takeoff clearance. He also reported that he had never flown tailwheel airplanes and was not aware of their limited forward visibility. The flight instructor and biplane pilot reported that there were no preaccident mechanical failures or malfunctions with their respective airplanes that would have precluded normal operation.

## Aircraft 1

- Registration: [N786SA](https://openairdocs.org/aircraft/N786SA), registered now, S/N 172S8830, built 2001 (OpenAirDocs)
- Reported make and model: CESSNA 172 (S)
- Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs)
- Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 172S8830
- Year built: 2001
- Airframe hours: 9388.4
- Engines: LYCOMING IO-360-L2A 180 horsepower reciprocating
- Damage: Substantial damage
- Flight: Instructional, Part 91
- Operator: Westwind School of Aeronautics
- Registered owner: Hatchett, Pete C.
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, May 16, 2018
- Departed: MYF, San Diego, CA
- Destination: DVT, Phoenix, AZ
- Flight plan: VFR
- Airport: MYF, Montgomery-Gibbs Executive
- Equipment: Auto-pilot

## Aircraft 2

- Registration: [N5762B](https://openairdocs.org/aircraft/N5762B), registered now, S/N 0833, built 1980 (OpenAirDocs)
- Reported make and model: GREAT LAKES 2T1A (2)
- Registry model: [Great Lakes 2T-1A-2](https://openairdocs.org/model/great-lakes-2t-1a-2) (registry code 3910101) (OpenAirDocs)
- Registry engine: [Lycoming AEIO-360 series](https://openairdocs.org/engine/lycoming-aeio-360-series) (registry code 41522, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 0833
- Year built: 1980
- Airframe hours: 1421.3
- Engines: Continental 180 horsepower reciprocating
- Damage: No damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Aerobatic
- Last inspection: Annual, May 4, 2018
- Departed: MYF, San Diego, CA
- Airport: MYF, Montgomery-Gibbs Executive
- Equipment: None

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor, aircraft N786SA; age 29; injuries: minor; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review January 5, 2018; seat: right; restraint: 3-point; flight hours: 1,006.7 total, 832.7 in this make and model, 876.9 as pilot in command, 236.1 in the last 90 days, 60.7 in the last 30 days, 3.7 in the last 24 hours
- Pilot, aircraft N786SA; age 28; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review May 8, 2018; seat: left; restraint: 3-point; flight hours: 206.6 total, 78.3 as pilot in command, 30.5 in the last 90 days, 3.2 in the last 30 days
- Pilot, aircraft N5762B; age 52; injuries: minor; flight instructor, commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review January 28, 2017; seat: rear; restraint: 5-point; flight hours: 4,471 total, 76 in this make and model, 3,821 as pilot in command, 12 in the last 90 days, 8 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 300° at 10 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 75 °F, dew point 55 °F
- Altimeter: 29.88 inHg
- Observed at: KMYF

## FAA reports on this event (2)

The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs).

- [Accident 20180603015242A](https://openairdocs.org/incident/20180603015242A), Jun 3, 2018: Cessna 172S, San Diego, CA, Substantial damage. While waiting for takeoff clearance, holding short of rwy 28R at montgomery field (myf), PIC of N786SA taxied to the hold line of runway 28R, remaining on the…
- [Accident 20180603007022A](https://openairdocs.org/incident/20180603007022A), Jun 3, 2018: Great Lakes 2T-1A-2, San Diego, CA, Minor damage. N5762B was the second aircraft in a flight of three biplanes. The flight was parked in the run-up area adjacent to the taxiway at runway 28R, awaiting takeoff…

## Docket (5 files)

The files NTSB released with the investigation on August 28, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97388. 5.3 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 N786SA (item 1, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466116&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20N786SA-Master.PDF
- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 N5762B (item 2, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466117&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20N5762B-Master.PDF
- N5762B Pilot's Statement and Diagram (item 3, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466118&FileExtension=.PDF&FileName=N5762B%20Pilot%27s%20Statement%20and%20Diagram-Master.PDF
- FAA Record of Conversation - Flight Instructor N786SA (item 4, .PDF, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466119&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation%20-%20Flight%20Instructor%20N786SA-Master.PDF
- Accident Photo (item 5, .PDF, 1 photo, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40466120&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.

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