# NTSB GAA19CA528: Siai-Marchetti SM 1019, N16XC, Lakeport, CA, September 7, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Data collection · Final report - Date: September 7, 2019, 16:00 local (23:00 UTC) - Place: Lakeport, CA - Coordinates: 39.039443, -122.907775 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.0394&lon=-122.9078&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report February 11, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 100217 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA528 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100217/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100217 - Page: https://openairdocs.org/ntsb/GAA19CA528 ## Probable cause The pilot's exceedance of the airplane's critical angle of attack during takeoff in gusting, variable wind conditions, which resulted in a loss of airplane control and subsequent impact with water. ## 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: [Siai-Marchetti SM 1019, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=8121215), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Siai-Marchetti SM 1019, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=8121215), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Wind: gusts](https://openairdocs.org/ntsb-findings/03034045): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Siai-Marchetti SM 1019, 1 case](https://openairdocs.org/ntsb-findings/03034045/cases.md?model=8121215), [All aircraft, 1,199 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md) - [Wind: variable wind](https://openairdocs.org/ntsb-findings/03034025): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Siai-Marchetti SM 1019, 1 case](https://openairdocs.org/ntsb-findings/03034025/cases.md?model=8121215), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/03034025/cases.md) - [Experience/qualifications: total experience](https://openairdocs.org/ntsb-findings/02031015): Personnel issues › Experience/knowledge · Pilot; cases with it: [Siai-Marchetti SM 1019, 1 case](https://openairdocs.org/ntsb-findings/02031015/cases.md?model=8121215), [All aircraft, 126 cases](https://openairdocs.org/ntsb-findings/02031015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Siai-Marchetti SM 1019, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=8121215), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Takeoff: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Siai-Marchetti SM 1019, 2 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=8121215), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Siai-Marchetti SM 1019, 2 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=8121215), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot of the float-equipped airplane reported that, while taking off from a lake, the airplane accelerated, became airborne and that, about 40 ft above the water, he retracted the flaps. The airplane pitched down, and the left wing dropped. He attempted to correct to no avail, and the airplane impacted the water. The airplane sustained substantial damage to the fuselage, empennage, and both wings. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. He added that he believed P factor caused the left roll because the airplane aerodynamically stalled and would not correct despite his attempts to do so. He also stated that he had accrued 5 hours in the airplane make and model, 2 hours of which occurred in the preceding 30 days. The pilot reported that it was a very windy, gusty day and that the wind was variable. An automated weather observation station located 15 miles west of the accident site reported that, about the time of the accident, the wind was from 300° at 14 knots, gusting to 20 knots. The airplane was departing to the south. ## Factual narrative The pilot of the float-equipped airplane reported that, while taking off from a lake, the airplane accelerated, became airborne, and about 40 ft above the water, he retracted the flaps. The airplane pitched down and the left wing dropped. He attempted to correct to no avail and the airplane impacted the water. The pilot reported that he believed P factor caused the left roll because the airplane was aerodynamically stalling and would not correct, despite his attempts. The pilot reported that he had accrued 5 hours in the airplane make and model, 2 hours of which occurred in the preceding 30 days. The airplane sustained substantial damage to the fuselage, empennage and both wings. 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, it was a very windy, gusty day, and the wind varied in direction. An airport's automated weather observation station, located 15 miles west, reported that, about the time of the accident, the wind was from 300° at 14 knots, gusting to 20 knots. The airplane was departing to the south. ## Aircraft - Registration: [N16XC](https://openairdocs.org/deregistered/N16XC-2020-11-13), registration cancelled 2020-11-13, S/N 045, built 1979 (OpenAirDocs) - Reported make and model: SIAI-MARCHETTI SM 1019 - Registry model: [Siai-Marchetti SM 1019](https://openairdocs.org/model/siai-marchetti-sm-1019) (registry code 8121215) (OpenAirDocs) - Registry engine: [Allison 250-B15G](https://openairdocs.org/engine/allison-250-b15g) (registry code 03064, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 045 - Year built: 1979 - Airframe hours: 1639.05 - Engines: Allison 250-B15G turbo prop - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Annual, June 3, 2019 - Departed: Lakeport, CA - Equipment: Stall warning system, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: minor; private; airplane ratings: single-engine land, single-engine sea, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review January 9, 2019; seat: front; restraint: 4-point; flight hours: 7,777 total, 5 in this make and model, 7,777 as pilot in command, 64 in the last 90 days, 27 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 14 knots, gusting 20 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 52 °F - Altimeter: 29.98 inHg - Observed at: KUKI, 15 nm away ## Docket (3 files) The files NTSB released with the investigation on October 30, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100217. 2.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477487&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation (Pilot) (item 2, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477488&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Pilot)-Master.PDF - Accident Photo (item 3, .PDF, 1 photo, 257 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477489&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.