# NTSB GAA19CA408: Piper PA 20, N7409K, Hamilton, MT, July 12, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: July 12, 2019, 12:30 local (18:30 UTC) - Place: Hamilton, MT - Coordinates: 46.251388, -114.125556 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.2514&lon=-114.1256&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Minor injuries - Injuries: 1 minor - Status: Completed, report December 2, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99828 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA408 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99828/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99828 - Page: https://openairdocs.org/ntsb/GAA19CA408 ## Probable cause The pilot's loss of directional control due to his unintentional use of brakes instead of the rudder during the landing roll, 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: [Piper PA-20, 1 case](https://openairdocs.org/ntsb-findings/01023242/cases.md?model=7102002), [All aircraft, 297 cases](https://openairdocs.org/ntsb-findings/01023242/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-20, 20 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7102002), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/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: [Piper PA-20, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102002), [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: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-20, 21 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7102002), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-20, 6 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7102002), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Landing: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Piper PA-20, 6 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=7102002), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot of the tailwheel-equipped airplane reported that, upon landing and approaching the taxiway he intended to exit, he lifted his feet from the "rudderbars" to engage the brakes. The airplane abruptly entered a left turn, and he thought he used the right rudder, but he mistakenly used brake pedal. Immediately thereafter, the airplane nosed over. The airplane sustained substantial damage to the right wing lift strut and rudder. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot reported that he believes the accident could have been avoided "if [he] had kept [his] feet on the rudderbars until [the airplane] had exited the runway." ## Factual narrative The pilot of the tailwheel-equipped airplane reported that, upon landing and approaching the taxiway he intended to exit, he lifted his feet from the "rudderbars" to engage the brakes. The airplane abruptly entered into a left turn and he "jabbed at the right rudder," but mistakenly utilized brake pedal. The airplane immediately nosed over. The airplane sustained substantial damage to the right wing lift strut and rudder. 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 the time of the accident, the wind was from 010° at 6 knots. The airplane was landing on runway 34. The pilot reported that he believes the accident could have been avoided "if [he] had kept [his] feet on the rudderbars until [he] had exited the runway." ## Aircraft - Registration: [N7409K](https://openairdocs.org/deregistered/N7409K-2019-10-01), registration cancelled 2019-10-01, S/N 20-318, built 1950 (OpenAirDocs) - Reported make and model: Piper PA 20 (Undesignat) - Registry model: [Piper PA-20](https://openairdocs.org/model/piper-pa-20) (registry code 7102002) (OpenAirDocs) - Registry engine: [Lycoming 0-290 series](https://openairdocs.org/engine/lycoming-0-290-series) (registry code 41506, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 20-318 - Year built: 1950 - Airframe hours: 3433.89 - Engines: Lycoming O-320-A2A 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 13, 2019 - Departed: 6S5, Hamilton, MT - Destination: 6S5, Hamilton, MT - Airport: 6S5, Ravalli County, runway 34, 4,200 × 75 ft, asphalt - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: minor; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review May 5, 2019; seat: left; restraint: 3-point; flight hours: 726 total, 460 in this make and model, 595 as pilot in command, 4 in the last 90 days, 4 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 10° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 55 °F - Altimeter: 30.05 inHg - Observed at: K6S5, 40 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 20190712011349A](https://openairdocs.org/incident/20190712011349A), Jul 12, 2019: Piper PA-20, Hamilton, MT, Substantial damage. Tbd ## Other investigations on N7409K (1) 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. - [NTSB LAX04CA026](https://openairdocs.org/ntsb/LAX04CA026), Oct 25, 2003: Piper PA-20 (N7409K), Petaluma, CA, substantial damage. Probable cause: the pilot's inadequate compensation for a crosswind condition and failure to maintain directional control that resulted in a ground loop. ## Docket (1 files) The files NTSB released with the investigation on September 9, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99828. 234 KB in all. - Accident Photo (item 1, .PDF, 1 photo, 234 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475640&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. --- 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.