# NTSB GAA19CA202: Piper PA 12, N92798, Sisters, OR, April 10, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: April 10, 2019, 10:30 local (17:30 UTC) - Place: Sisters, OR - Coordinates: 45.588611, -122.596946 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.5886&lon=-122.5969&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: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report November 6, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99238 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA202 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99238/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99238 - Page: https://openairdocs.org/ntsb/GAA19CA202 ## Probable cause The pilot's failure to maintain pitch control during the landing roll, which resulted in a nose-over. ## 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: [Piper PA-12, 51 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7101202), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-12, 3 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=7101202), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Wind: sudden wind shift](https://openairdocs.org/ntsb-findings/03034010): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Piper PA-12, 5 cases](https://openairdocs.org/ntsb-findings/03034010/cases.md?model=7101202), [All aircraft, 114 cases](https://openairdocs.org/ntsb-findings/03034010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Piper PA-12, 7 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=7101202), [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: [Piper PA-12, 40 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7101202), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-12, 17 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7101202), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Piper PA-12, 36 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7101202), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot in the tailwheel-equipped airplane reported that, during the approach, the wind speed increased and became turbulent. He recalled that, during the landing roll, "I immediately applied a slight amount of forward stick," but when the tailwheel contacted the surface, "the wind suddenly changed to a tailwind," and the airplane nosed over. The airplane sustained substantial damage to the rudder, both wing lift struts, and the engine mounts. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. The nearest METAR, located at an airport 1 mile away from the accident site, reported that, about the time of the accident, the wind was from 290° at 10 knots, visibility was 10 statute miles, and the clouds were broken at 6,500 ft mean sea level and deteriorating. The pilot landed the airplane on runway 20. ## Factual narrative The pilot in the tailwheel-equipped airplane reported that during the approach, the wind velocity increased and became turbulent. He recalled that during the landing roll, "I immediately applied a slight amount of forward stick," but when the tailwheel contacted the surface, "the wind suddenly changed to a tailwind," and the airplane nosed over. The airplane sustained substantial damage to the rudder, both wing lift struts, and the engine mounts. The nearest METAR was located at an airport 1 mile away from the accident site, and reported that about the time of the accident, the wind was from 290° at 10 knots. The visibility was 10 statute miles, and the clouds were broken at 6,500ft MSL and deteriorating. The pilot landed the airplane on runway 20. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N92798](https://openairdocs.org/deregistered/N92798-2021-06-05), registration cancelled 2021-06-05, S/N 12-244, built 1946 (OpenAirDocs) - Reported make and model: Piper PA 12 (No Series) - Registry model: [Piper PA-12](https://openairdocs.org/model/piper-pa-12) (registry code 7101202) (OpenAirDocs) - Registry engine: [Lycoming 0-235 series](https://openairdocs.org/engine/lycoming-0-235-series) (registry code 41505, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 12-244 - Year built: 1946 - Engines: Lycoming O-320 150 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Tailwheel Productions Llc - Registered owner: Tailwheel Productions Llc - Airworthiness certificate: Standard, Other - Departed: S33, Madras, OR - Destination: 65K, Sisters, OR - Airport: 6K5, Sisters Eagle Air, runway 20, 3,560 × 60 ft, grass/turf - Equipment: ADS-B, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 73; injuries: none; commercial, flight instructor; airplane ratings: single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review November 28, 2018; seat: rear; flight hours: 8,000 total, 100 in this make and model - Student pilot; age 88; injuries: minor; airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: with waivers/limitations; last flight review April 17, 2017; seat: front; restraint: 3-point ## Weather - Conditions: Visual (VMC), Day - Wind: 290° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: 5,500 ft broken - Temperature: 50 °F, dew point 41 °F - Altimeter: 30.42 inHg - Observed at: KPDX, 1 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 20190410006379A](https://openairdocs.org/incident/20190410006379A), Apr 10, 2019: Piper PA-12, Sisters, OR, Substantial damage. Pilot was attempting turf/grass strip landing on right side of runway 20, 6K5 Sisters Oregon airport. While on roll out pilot reports dramatic wind change. The… ## Docket (2 files) The files NTSB released with the investigation on July 15, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99238. 4.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40474087&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photos (item 2, .PDF, 2 photos, 313 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40474088&FileExtension=.PDF&FileName=Photos-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.