# NTSB WPR12FA280: Aviat A-1C-180, N63WY, Kooskia, ID, June 28, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 28, 2012, 15:00 local (21:00 UTC) - Place: Kooskia, ID - Coordinates: 46.130554, -114.92694 - Nearby events: https://openairdocs.org/map.md?lat=46.1306&lon=-114.9269&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal, 1 uninjured - Status: Completed, report December 5, 2013 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Lycoming Engines - NTSB case key (mKey): 84129 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12FA280 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84129/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84129 - Page: https://openairdocs.org/ntsb/WPR12FA280 ## Probable cause The pilot's decision to attempt a takeoff with a gusty tailwind, which resulted in his loss of airplane control during the initial climb and an aerodynamic stall/spin. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Aviat A-1C-180, 3 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2210410), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Aviat A-1C-180, 20 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2210410), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Effect on equipment; cases with it: [Aviat A-1C-180, 3 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=2210410), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Aviat A-1C-180, 4 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=2210410), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Aviat A-1C-180, 6 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2210410), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Aviat A-1C-180, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=2210410), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Aviat A-1C-180, 12 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2210410), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The passenger reported that the pilot wanted "to beat" an approaching storm and that immediately after taking off and during the initial climb, the airplane rolled violently to the right; it then rolled back to the left, and the nose dropped before impact with terrain. A witness reported observing two men rushing to pack up their airplane while the weather at the airfield was deteriorating due to an incoming thunderstorm. He reported seeing the airplane make an uphill intersection takeoff with a strong gusting tailwind. The witness added that the airplane appeared unstable during the takeoff. A second witness reported that a thunderstorm was within one mile of the airfield and that the windsock was fully erect and moving around erratically, adding that the wind "was knocking the aircraft all over." The passenger stated that he thought the airplane was about tree top level when it encountered the violent wind condition and that the engine was running normally before the accident. A postaccident examination of the airframe and engine revealed no mechanical malfunctions or failures that would have precluded normal operation. The pilot's decision to attempt a downwind takeoff in gusting wind conditions, coupled with a thunderstorm in close proximity to the airfield, most likely resulted in his loss of airplane control and subsequent impact with terrain. ## Factual narrative HISTORY OF FLIGHT On June 28, 2012, about 1500 mountain daylight time, an AVIAT Aircraft Inc. A-1C-180 airplane, N63WY, was substantially damaged following a loss of control and impact with terrain during takeoff initial climb at the Moose Creek United States Forest Service Airport (1U1), near Kooskia, Idaho. The certified private pilot received fatal injuries, and the sole passenger was not injured. Visual meteorological conditions prevailed for the local flight, which was being operated in accordance with 14 Code of Federal Regulations Part 91, and a flight plan was not filed. The flight was destined for the Coeur d'Alene-Pappy Boyington Field (COE), Coeur d'Alene, Idaho. In a statement submitted to the National Transportation Safety Board investigator-in-charge (IIC) by local law enforcement personnel, as well as in a personal interview with the IIC, the rear-seated passenger who survived the accident reported that the pilot loaded the airplane with the intent of departing ahead of an incoming storm. The passenger stated that the pilot wanted "to beat" the approaching weather. The passenger reported that the takeoff was a little steep, and that soon after taking off and climbing, the airplane rolled violently to the right, and then back to the left, followed by the nose of the airplane dropping prior to impact with terrain. The passenger stated that he thought the airplane was about tree-top level when the airplane entered the violent wind condition. The passenger added that he thought the airplane seemed to be running [normally] prior to the crash. One witness to the accident reported that he observed two men rushing to pack up their airplane while the weather at the airfield was deteriorating due to an incoming thunderstorm. The witness further reported that he saw two men get into the accident airplane, start the engine and taxi to the runway intersection and proceeded to takeoff uphill on runway 01 with a strong gusting tailwind. The witness opined that due to the weather and winds at the time, no one should have not been flying in or out of Moose Creek at that time. The witness added that the airplane seemed unstable during the takeoff sequence. A second witness reported that a storm cell with gusty winds, thunder and lightning and light rain was within a mile of the airport, and that the windsock was full erect and moving around erratically. The witness stated that she and other witnesses observed the pilot and passenger of the accident airplane "hurry to pack [the] aircraft and get out." She added that the airplane then taxied to the runway intersection and took off on runway 01. The witness added that other pilots had reported that they had heard the propeller cycle and mag checks being done while the airplane was taxiing. The witness opined that the accident airplane didn't travel more than 10 feet [during the climb]. "The wind was knocking the aircraft all over." PERSONNEL INFORMATION The pilot, age 48, held a private pilotcertificate for single-engine land and instrument airplane. He also held a third-class airman medical certificate dated June 22, 2011, with the limitation, "must have available glasses for near vision." A review of the pilot's personal logbook revealed that he had accumulated a total of 681 hours as of June 21, 2012. This included a total time in make and model of 49 hours, with about 36 hours as pilot in command and 7 hours of dual instruction in the accident airplane. The review also indicated that the pilot had flown a total of 21 hours, 16 hours, and 8 hours in the last 90, 60 and 30 days respectively, all in the accident airplane. The pilot's most recent flight review was performed on September 19, 2011. AIRCRAFT INFORMATION The two-seat, high-wing, fixed-gear airplane, serial number (S/N) 3133, was manufactured in 2011. It was powered by a Lycoming O-360-A1P engine, serial number L-41826-36E, rated at 180 horse power. A review of the airplane's maintenance records revealed that on July 7, 2011, a Flight Resource LLC 3 blade MTV-9-B/198-52 propeller was installed in accordance with Supplemental Type Certificate (STC) #SA02870Ch and Aviat Aircraft Inc. Production Certificate #704NM. The airplane was originally flight tested on August 4, 2011, and subsequently issued its Standard Airworthiness Certificate on August 11, 2011. On August 16, 2011, Micro Vortex Generators were installed on the airplane in accordance with STC #SA00668SE, and on September 29, 2011, at a total airframe time of 31.4 hours, an M-20 air-oil separator was installed in accordance with STC #SA02033AT. METEROROLOGICAL INFORMATION There was no weather reporting facility located at the Moose Creek United States Forest Service Airport (1U1). The closest weather reporting stations were located at Missoula, Montana, Salmon, Idaho, and Lewiston, Idaho, each of which reported the following conditions within about 30 minutes of the time of the accident: At 1453, the weather reporting station located at the Missoula International Airport, Missoula, Montana, about 60 nautical miles (nm) north-northeast of the accident site, reported wind calm, visibility 10 miles, sky clear, temperature 26 degrees Celsius (C), dew point -2 degrees C, and an altimeter setting of 29.97 inches of mercury. At 1535, the weather reporting station located at the Salmon Airport, Salmon, Idaho, about 70 nm southeast of the accident site, reported wind 340 degrees at 5 knots, visibility 10 miles, sky clear, temperature 30 degrees C, dew point 2 degrees C, and an altimeter setting of 29.86 inches of mercury. At 1456, the weather reporting station located at the Lewiston-Nez Perce County Airport, Lewiston, Idaho, about 88nm west of the accident site, reported wind variable at 4 knots, visibility 10 miles, sky clear, temperature 28 degrees C, dew point 12 degrees C, and an altimeter setting of 29.85 inches of mercury. WRECKAGE AND IMPACT INFORMATION From information provided by the recovery team, the airplaneimpacted airport terrain on the west side of the runway and came to rest in an upright position facing the direction from which it had departed. The entire airplane was consumed by the post-crash fire. The initial impact point was estimated to be about 50 feet south of where the airplane came to rest. All components necessary for flight were accounted for at the accident site. Both wings remained attached to the fuselage. The rudder, vertical stabilizer, horizontal stabilizer and both left and right elevators remained attached to the fuselage. The engine was observed to have remained attached to the respective engine mounts at all attach points. Both propeller blades remained secured in their respective propeller hubs, with both blades broken off about 10 inches outboard of their respective hubs. The forward and aft cockpit areas were both destroyed by the post-crash fire damage. MEDICAL AND PATHOLOGICAL INFORMATION On July 2, 2012, an autopsy was performed on the pilot at the Idaho County Coroner's Office, Grangeville, Idaho. The results of the autopsy revealed that the cause of death was due to "complications of an aircraft accident." The FAA Civil Aerospace Medical Institute (CAMI) conducted forensic toxicology examinations on specimens from the pilot, and reported that no carbon monoxide or ethanol were detected in the blood, 1.65 (ug/ml) cyanide detected in the blood, and no drugs detected in the blood. TESTS AND RESEARCH Airframe The airframe was examined subsequent to the removal of the wreckage. The cabin/cockpit area was destroyed by extreme thermal distress. All flight instruments were destroyed with no instrumentation data able to be recovered. The rudder, elevator, vertical stabilizer and horizontal stabilizer each remained attached to their respective empennage attach points. Each component was consumed by post-crash fire and each sustained only minimal impact damage. The fuselage aft of the cabin/cockpit area was consumed by fire and had sustained impact damage. The right wing sustained fire and impact damage. The fuel tank was breached and melted. The forward wing strut remained attached at both wing and fuselage attach points, and was observed bent and twisted. The lower wing strut remained attached to both wing and fuselage attach points, had sustained thermal and impact damaged, and was observed bent and twisted. The right aileron had sustained fire and impact damage, with control cable continuity confirmed to the cockpit/cabin area. The wing spar was observed bent at mid-span and had sustained fire and impact damage. The right wing flap was not observed. The left wing sustained fire and impact damage. The fuel tank was observed breached and melted. The entire span of the wing had sustained thermal and impact damage. The wing struts were not observed. The left aileron sustained fire and impact damage, with control cable continuity confirmed from the cabin/cockpit area outboard to the aileron connections. Engine The engine wasexamined subsequent to the removal of the wreckage. The engine was removed from the firewall and hung from an engine hoist for the examination. The propeller hub was observed attached to the crankshaft with all three wood composite blades fractured and partially separated. The carburetor was found separated from the oil sump. The carburetor inlet screen was found contaminated with a melted substance. The inlet screen and fuel feed hose was retained by the NTSB for further analysis. The valve covers and the top sparkplugs were removed. The spark plugs appeared normal as compared to the Champion Aviation Check a Plug Chart AV-27. The cylinders were borescope inspected and no anomalies noted. The crankshaft was rotated by hand and thumb compression was established on all cylinders. Engine drive train continuity was established to the accessory section. Both magnetos were found deformed by heat, and would not rotate. The oil pickup screen was found free of debris. The vacuum pump drive assembly was damaged by heat and would not rotate. No evidence of a preempt mechanical malfunction was noted during the examination of the recovered engine. A detailed engine report is contained within the public docket. Fuel inlet screen and fuel inlet hose The airplane's fuel inlet screen and fuel inlet hose were shipped to the NTSB Materials Laboratory in Washington, D.C., in order to have debris found in the screen and fuel line analyzed. The NTSB chemist reported that a black-colored particulate was removed from the inlet screen. Debris from interior of the fuel inlet hose was a red-brown material, slightly oily in texture. The debris from the inlet line consisted of black flakes and granules similar to the one removed from the screen, as well as a small amount of white and red colored flakes. Subsequent to samples being collected and analyzed, the chemist reported that a spectral library search found no strong matches for any of the materials. (Refer to Material Laboratory Factual Report No. 13-041, which is located in the docket.) ## Aircraft - Registration: [N63WY](https://openairdocs.org/deregistered/N63WY-2016-11-08), registration cancelled 2016-11-08, S/N 3133, built 2011 (OpenAirDocs) - Reported make and model: AVIAT A-1C-180 - Registry model: [Aviat A-1C-180](https://openairdocs.org/model/aviat-a-1c-180) (registry code 2210410) (OpenAirDocs) - Registry engine: [Lycoming O-360-A1P](https://openairdocs.org/engine/lycoming-o-360-a1p) (registry code 42259, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 3133 - Airframe hours: 72 - Engines: Lycoming O-360 180 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Jahn Ashtiani - Registered owner: Steelhead Aviation LLC - Airworthiness certificate: Standard, Normal - Last inspection: Condition, May 9, 2012, 10 hours before - Departed: 1U1, Kooskia, ID - Destination: COE, Coeur d'Alene, ID - Airport: 1U1, Moose Creek USFS Airport, runway 01, 4,100 × 250 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review September 19, 2011; seat: front; toxicology performed; flight hours: 681 total, 49 in this make and model, 580 as pilot in command, 21 in the last 90 days, 8 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 28 °F - Altimeter: 29.96 inHg - Observed at: MSO, 58 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 20120628013489A](https://openairdocs.org/incident/20120628013489A), Jun 28, 2012: Aviat Aircraft Inc A-1C-180, Grangeville, ID, Destroyed, 1 fatal. Pilot departed uphill on runway 01 with gusty high tailwind conditions and thunderstorms in the vicinity. The aircraft climbed to tree level and then the pilot… ## Docket (18 files) The files NTSB released with the investigation on September 11, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84129. 39.9 MB in all. - Materials Laboratory 15 - Factual Report 13-041 (2 Embedded Images) (item 1, .PDF, 2 photos, 311 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40395044&FileExtension=.PDF&FileName=Materials%20Laboratory%2015%20-%20Factual%20Report%2013-041%20(2%20Embedded%20Images)-Master.PDF - Witness Statements (item 2, .PDF, 354 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399338&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Accident Site Map (item 3, .PDF, 470 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399305&FileExtension=.PDF&FileName=Accident%20Site%20Map-Master.PDF - Weather Data (item 4, .PDF, 315 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399363&FileExtension=.PDF&FileName=Weather%20Data-Master.PDF - Sheriff's Report (item 5, .PDF, 503 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399369&FileExtension=.PDF&FileName=Sheriff%27s%20Report-Redacted.PDF - Excerpts from Lycoming Engines Final Report (item 6, .PDF, 291 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400694&FileExtension=.PDF&FileName=Excerpts%20from%20Lycoming%20Engines%20Final%20Report-Master.PDF - Permission from Lycoming Engines to use Excerpted Data from Final Report (item 7, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399371&FileExtension=.PDF&FileName=Permission%20from%20Lycoming%20Engines%20to%20use%20Excerpted%20Data%20from%20Final%20Report-Redacted.PDF - Excerpts from Maintenance Records (item 8, .PDF, 11.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399372&FileExtension=.PDF&FileName=Excerpts%20from%20Maintenance%20Records-Redacted.PDF - Excerpts from Pilot's Logbook (item 9, .PDF, 22.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399321&FileExtension=.PDF&FileName=Excerpts%20from%20Pilot%27s%20Logbook-Redacted.PDF - Record of Conversation (Anthony Dipaola - Passenger) (item 10, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375898&FileExtension=.PDF&FileName=Record%20of%20Conversation%20(Anthony%20Dipaola%20-%20Passenger)-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 11, .PDF, 830 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399365&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 253 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399326&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 13, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399337&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 1 - view of accident site looking south (item 14, .PDF, 318 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399339&FileExtension=.PDF&FileName=Photo%201%20-%20view%20of%20accident%20site%20looking%20south-Master.PDF - Photo 2 - view of accident site looking southeast (item 15, .PDF, 490 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399340&FileExtension=.PDF&FileName=Photo%202%20-%20view%20of%20accident%20site%20looking%20southeast-Master.PDF - Photo 3 - view of accident site looking east (item 16, .PDF, 479 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399341&FileExtension=.PDF&FileName=Photo%203%20-%20view%20of%20accident%20site%20looking%20east-Master.PDF - Photo 4 - view of accident site looking northeast (item 17, .PDF, 364 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399342&FileExtension=.PDF&FileName=Photo%204%20-%20view%20of%20accident%20site%20looking%20northeast-Master.PDF - Photo 5 - view of accident site looking west (item 18, .PDF, 509 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399343&FileExtension=.PDF&FileName=Photo%205%20-%20view%20of%20accident%20site%20looking%20west-Master.PDF From the NTSB's public API. 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