# NTSB GAA19CA324: David Shotwell Murphy, N235DS, South Lake Tahoe, CA, June 9, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: June 9, 2019, 12:15 local (19:15 UTC) - Place: South Lake Tahoe, CA - Coordinates: 38.89389, -119.995277 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.8939&lon=-119.9953&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report April 13, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99581 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA324 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99581/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99581 - Page: https://openairdocs.org/ntsb/GAA19CA324 ## Probable cause The pilot's failure to properly tighten his seat belt, which allowed him to slide forward in his seat and resulted in his inadvertent application of excessive brake application during the landing roll and a subsequent noseover. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Equipment/furnishings](https://openairdocs.org/ntsb-findings/01022500): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Shotwell David MURPHY SR 3500, 1 case](https://openairdocs.org/ntsb-findings/01022500/cases.md?model=05615XJ), [All aircraft, 12 cases](https://openairdocs.org/ntsb-findings/01022500/cases.md) - [Landing gear system: brake](https://openairdocs.org/ntsb-findings/01023242): Aircraft › Aircraft systems · Unintentional use/operation (probable cause); cases with it: [Shotwell David MURPHY SR 3500, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=05615XJ), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Shotwell David MURPHY SR 3500, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=05615XJ), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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: [Shotwell David MURPHY SR 3500, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=05615XJ), [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-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [Shotwell David MURPHY SR 3500, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=05615XJ), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot reported that, during the landing roll, the airplane's ground speed was about 30 knots when he applied the brakes lightly, and the tailwheel lifted off the ground. His seatbelt, which was not tightened, allowed him to slide forward in his seat, and he inadvertently applied more brake pressure, which resulted in the airplane nosing over. The airplane sustained substantial damage to the right-wing lift strut and the rudder. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Factual narrative The pilot in the tailwheel-equipped airplane reported that, during the landing roll, the airplane's ground speed was about 30 knots when he applied the brakes lightly, and the tailwheel lifted off the ground. His seatbelt which was not tightened, allowed him to slide forward in his seat and he inadvertently applied more brake pressure and the airplane nosed over. The airplane sustained substantial damage to the right wing lift strut and the rudder. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N235DS](https://openairdocs.org/deregistered/N235DS-2020-03-17), registration cancelled 2020-03-17, S/N 096SR, built 2000 (OpenAirDocs) - Reported make and model: DAVID SHOTWELL MURPHY (SR 3500) - Registry model: [Shotwell David MURPHY SR 3500](https://openairdocs.org/model/shotwell-david-murphy-sr-3500) (registry code 05615XJ) (OpenAirDocs) - Registry engine: [Amateur-built UNKNOWN ENG](https://openairdocs.org/engine/amateur-built-unknown-eng) (registry code 99999) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 096SR - Year built: 2000 - Airframe hours: 255 - Engines: Vedeneyev M-14P 360 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, August 8, 2018 - Departed: TVL, South Lake Taho, CA - Destination: TVL, South Lake Taho, CA - Airport: TVL, South Lake Tahoe, runway 18, 8,541 × 100 ft, asphalt - Equipment: Stall warning system, Angle of attack indicator, Auto-pilot, Electronic multifunction display, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review September 5, 2017; seat: rear; flight hours: 30,033 total, 11 in this make and model, 25,002 as pilot in command, 11 in the last 90 days, 11 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Temperature: 64 °F, dew point 43 °F - Altimeter: 29.73 inHg - Observed at: KTVL ## 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 20190609006339A](https://openairdocs.org/incident/20190609006339A), Jun 9, 2019: Shotwell David MURPHY SR 3500, South Lake Taho, CA, Substantial damage. During a first solo subsequent to a tail wheel endorsement, the pilot landed and was exiting the runway using the high speed taxiway. When brakes were applied,… ## Docket (2 files) The files NTSB released with the investigation on September 5, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99581. 3.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475549&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photo (item 2, .PDF, 1 photo, 398 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475550&FileExtension=.PDF&FileName=Photo-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.