# NTSB GAA19CA217: Vans Vans RV-12, N277E, Wall, SD, April 14, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: April 14, 2019, 09:30 local (15:30 UTC) - Place: Wall, SD - Coordinates: 43.999443, -102.254722 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.9994&lon=-102.2547&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: 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): 99300 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA217 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99300/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99300 - Page: https://openairdocs.org/ntsb/GAA19CA217 ## Probable cause The pilot's improper decision to depart from a slush-covered runway, which resulted in a loss of directional control, a runway excursion, and a subsequent nose-over. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Forrest Foster VANS RV-12, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=05632YV), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Runway/land/takeoff/taxi surface: snow/slush/ice covered surface](https://openairdocs.org/ntsb-findings/03023015): Environmental issues › Physical environment · Decision related to condition (probable cause); cases with it: [Forrest Foster VANS RV-12, 1 case](https://openairdocs.org/ntsb-findings/03023015/cases.md?model=05632YV), [All aircraft, 219 cases](https://openairdocs.org/ntsb-findings/03023015/cases.md) - [Runway/land/takeoff/taxi surface: snow/slush/ice covered surface](https://openairdocs.org/ntsb-findings/03023015): Environmental issues › Physical environment · Effect on operation; cases with it: [Forrest Foster VANS RV-12, 1 case](https://openairdocs.org/ntsb-findings/03023015/cases.md?model=05632YV), [All aircraft, 219 cases](https://openairdocs.org/ntsb-findings/03023015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Forrest Foster VANS RV-12, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=05632YV), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Forrest Foster VANS RV-12, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=05632YV), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Forrest Foster VANS RV-12, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=05632YV), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Takeoff: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Forrest Foster VANS RV-12, 1 case](https://openairdocs.org/ntsb-events/094/sequence.md?model=05632YV), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) - [Takeoff: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Forrest Foster VANS RV-12, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=05632YV), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot reported that, during takeoff from a snow- and slush-covered runway, he decided to stay on the right half of the runway. He added that, as the airplane began to rotate and the nose landing gear lifted off the runway, the left main landing gear encountered some slush. The airplane veered left about 15° and exited the runway to the left, the nose landing gear collapsed, and the airplane then nosed over. The airplane sustained substantial damage to the fuselage and both wings. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Factual narrative The pilot reported that, during takeoff on a snow and slush covered runway, he decided to stay on the right half of the runway. He added that, as the airplane began to rotate and the nose landing gear was off the runway, the left main landing gear encountered some slush. The airplane veered to the left about 15°, exited the runway to the left, and the nose landing gear collapsed. The airplane sustained substantial damage to the fuselage and both wings. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N277E](https://openairdocs.org/deregistered/N277E-2020-07-10), registration cancelled 2020-07-10, S/N 120206, built 2014 (OpenAirDocs) - Reported make and model: Vans VANS RV-12 (No Series) - Registry model: [Forrest Foster VANS RV-12](https://openairdocs.org/model/forrest-foster-vans-rv-12) (registry code 05632YV) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 120206 - Year built: 2014 - Airframe hours: 1062 - Engines: Rotax 912ULS 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, June 12, 2018 - Departed: RAP, Rapid City, SD - Destination: 6V4, Wall, SD - Airport: 6V4, Wall Muni, runway 30, 3,499 × 60 ft, asphalt - Equipment: Electronic primary flight display, Satellite tracking device, Stall warning system, ADS-B, Angle of attack indicator, Auto-pilot, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: none; sport pilot; airplane ratings: single-engine land; medical: sport pilot; last flight review January 9, 2018; seat: left; flight hours: 195.3 total, 190.8 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 130° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 32 °F, dew point 27 °F - Altimeter: 29.71 inHg - Observed at: KPHP, 28 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 20190414002779A](https://openairdocs.org/incident/20190414002779A), Apr 14, 2019: Forrest Foster VANS RV-12, Wall, SD, Substantial damage. Pilot and passenger landed in Wall and ate breakfast then taxied for takeoff and as they were rotating the nose gear was off the ground and the left main gear… ## Docket (3 files) The files NTSB released with the investigation on May 13, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99300. 4.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472813&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - Pilot (item 2, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472814&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Pilot-Master.PDF - Accident Photos (item 3, .PDF, 3 photos, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472815&FileExtension=.PDF&FileName=Accident%20Photos-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.