# NTSB GAA19CA300: Vans RV6, N787TL, Rose Hill, KS, June 1, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: June 1, 2019, 18:30 local (23:30 UTC) - Place: Rose Hill, KS - Coordinates: 37.562778, -97.064163 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.5628&lon=-97.0642&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report November 6, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99526 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA300 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99526/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99526 - Page: https://openairdocs.org/ntsb/GAA19CA300 ## Probable cause The pilot's unintentional engagement of the brakes before landing, which resulted in a nose-over. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Unintentional use/operation (probable cause); cases with it: [Evans Charles E VANS ACFT RV-6, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=05615YV), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Evans Charles E VANS ACFT RV-6, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=05615YV), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Evans Charles E VANS ACFT RV-6, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=05615YV), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [Evans Charles E VANS ACFT RV-6, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=05615YV), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot of the tailwheel-equipped airplane reported that, while landing on a grass runway, the airplane nosed over. The pilot acknowledged that he likely landed with the brake pedals depressed. He checked the wheels, and they moved freely. The airplane sustained substantial damage to the fuselage, both wings, and the vertical stabilizer. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The airport's automated weather observation station reported that, about 10 minutes before the accident, the wind was from 210° at 8 knots. The pilot was landing the airplane on runway 19. ## Factual narrative The pilot of the tailwheel-equipped airplane reported that, while landing on a grass runway, the airplane nosed over. The pilot acknowledged that he likely landed with the brake pedals depressed. He checked the wheels and they moved freely. The airplane sustained substantial damage to the fuselage, both wings and the vertical stabilizer. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The automated weather observation station located on the airport reported that, about 10 minutes before the accident, the wind was from 210° at 8 knots. The airplane was landing runway 19. ## Aircraft - Registration: [N787TL](https://openairdocs.org/deregistered/N787TL-2020-08-07), registration cancelled 2020-08-07, S/N 25819 (OpenAirDocs) - Reported make and model: Vans RV6 - Registry model: [Evans Charles E VANS ACFT RV-6](https://openairdocs.org/model/evans-charles-e-vans-acft-rv-6) (registry code 05615YV) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 25819 - Year built: 2006 - Airframe hours: 657.9 - Engines: Superior Air Parts 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, June 1, 2019 - Departed: 4KS7, Douglass, KS - Destination: 4KS7, Douglass, KS - Airport: 4KS7, Butler Airpark, runway 19, 2,687 × 40 ft, grass/turf - Equipment: Satellite tracking device, Onboard weather, Handheld GPS, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: minor; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review September 30, 2017; seat: left; restraint: 4-point; flight hours: 463 total, 70 in this make and model, 368 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 59 °F - Altimeter: 29.87 inHg - Observed at: KIAB, 10 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 20190601005569A](https://openairdocs.org/incident/20190601005569A), Jun 1, 2019: Evans Charles E VANS ACFT RV-6, Rose Hill, KS, Substantial damage. Pilot landed aircraft on runway 19, a 2687 foot turf runway, while simultaneously applying the toe brakes. The aircraft subsequently skidded between 50 and 100… ## Docket (3 files) The files NTSB released with the investigation on June 26, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99526. 1.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 832 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473761&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (item 2, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473762&FileExtension=.PDF&FileName=Record%20of%20Conversation-Master.PDF - Accident Photos (item 3, .PDF, 2 photos, 642 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40473763&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.