# NTSB WPR16LA167: Siai-Marchetti SF260, N16FD, Fullerton, CA, August 25, 2016 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: August 24, 2016, 18:00 local (Aug 25, 2016, 01:00 UTC) - Place: Fullerton, CA - Coordinates: 33.870555, -117.98166 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.8706&lon=-117.9817&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: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA Long Beach FSDO - NTSB case key (mKey): 93886 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR16LA167 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93886/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93886 - Page: https://openairdocs.org/ntsb/WPR16LA167 ## Probable cause The failure of the pilot to set the flaps to the proper takeoff setting before takeoff, resulting in an aerodynamic stall during takeoff and loss of control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Siai-Marchetti SF260, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=8121208), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Siai-Marchetti SF260, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=8121208), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/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 SF260, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=8121208), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Siai-Marchetti SF260, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=8121208), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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 SF260, 1 case](https://openairdocs.org/ntsb-events/241/sequence.md?model=8121208), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Siai-Marchetti SF260, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=8121208), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis An aerobatic training flight was flown by an airline transport pilot. The preflight, taxi, and initial takeoff roll were uneventful until just after rotation, when the airplane began rolling left. The pilot attempted to correct for the roll to the left by adding full right aileron and rudder, but the airplane continued to roll to the left and impacted the ground off the left side of the runway. After the airplane impacted the ground, it continued to travel across a flight school ramp, striking four airplanes, and impacting a hangar, resulting in substantial damage to the fuselage. A small postaccident fire ensued. Postaccident examination of the airplane and engine revealed no anomalies that would have precluded normal operation. A review of onboard video revealed that, as the airplane was taxiing to the runway hold line, the left flap was in the neutral (or retracted) position. Furthermore, the pilot and the passenger discussed the takeoff, but make no mention of the flap position before takeoff. The airplane operations manual and the Before Take-off checklist state that the takeoff flap setting was 20. However, video evidence shows that the pilot failed to set the flaps to the takeoff setting before takeoff which would have resulted in decreased lift, and an increased stall speed. The pilot was likely unaware of the flap setting as the airplane aerodynamic stalled and the pilot was not able to maintain airplane control. Airport surveillance video depict the airplane on the runway and accelerating. About 3 seconds later, the nose gear and left main gear were clear of the runway, and the airplane banked slightly to the right. About 2 seconds after that, the airplane was airborne and pitched up slightly and was rolling to the left; 1 second later, the left bank increased to about 15° consistent with the airplane at or near an aerodynamic stall. ## Factual narrative On August 24, 2016, about 1800 Pacific daylight time, a Siai-Marchetti SF260 airplane, N16FD, was substantially damaged when it was involved in an accident near Fullerton, California. The airline transport-rated pilot and passenger sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 training flight. The flight was operated by Air Combat USA, as an aerobatic customer training flight. The pilot, who was a current fighter pilot and instructor in the F/A-18A-D with the United States Marine Corps, had about 7.6 hours of flight experience in the accident airplane type, and the flight was intended to familiarize him with the handling qualities of the airplane type with a passenger on board. The passenger, who was an employee of Air Combat USA, had about 60 hours of flight experience, but did not hold a pilot’s certificate. The pilot reported that the preflight, taxi, and initial takeoff roll were all normal. During the takeoff roll, just after rotation, the airplane began to roll left. The pilot attempted to correct for the roll by adding full right aileron and rudder, but the airplane continued to roll to the left and impacted the ground off the left side of the runway. After the airplane impacted the ground, it continued to travel across a flight school ramp, struck a taxiing airplane and three parked airplanes, and impacted a hangar before coming to rest. A small postaccident fire ensued and was quickly extinguished by airport personnel. Postaccident examination of the airframe and engine revealed no anomalies that would preclude normal operation. Four recovered video files were sent to the NTSB Vehicle Recorder Division for analysis. At the start of one video, which was recorded by an onboard video camera system that recorded high-quality audio from the airplane’s intercom and alternately from two cameras: one faced aft towards the pilots and the other faced forward from behind the pilots. The aft-facing camera recorded that, just before the airplane taxied to the hold short line, the left flap was visible and appeared to be in the retracted position. The system then switched to the forward-facing camera as the airplane taxied unto the runway as the second airplane in the formation. The pilot and the passenger discussed the takeoff but make no mention of the flap position. The operator knew before the accident flight that the airplane’s flap gauge was inoperative. Therefore, the flaps were set to the takeoff position by matching them to a fully deflected aileron on the same side of the wing. Using this technique to set the flaps for takeoff in a same type of airplane with a functional flap gauge, the flap setting was observed to be about 17°. The airplane’s operations manual states that the takeoff flap setting is 20°. Furthermore, the manual and the Before Take-off checklist state to set flaps to 20° before takeoff. The other videos were taken from cameras on the airport ramp and captured theaccident airplane’s path. Review of one of the videos revealed that, about 4 seconds after the cameras began recording, the airplane was on the runway and accelerating. About 3 seconds later, the nose gear and left main gear were clear of the runway, and the airplane banked slightly to the right. About 2 seconds after that, the airplane was airborne and pitched up slightly and was rolling to the left; 1 second later, the left bank increased to about 15°. The video ended at 2 seconds after that, with the airplane left of the runway, and in a left bank of about 10-15°. The next video showed the airplane taking off but did not gain altitude after becoming airborne. About 22 seconds after the cameras began recording, the last video captured the airplane passing over parked airplanes, possibly striking one. The accident airplane came to rest 2 seconds after that, followed by a plume of smoke. Another video that was reviewed by the NTSB investigator-in-charge showed the lead airplane taking off followed by the accident airplane taking off. Figure 1: Accident airplane’s takeoff flap position. Figure 2: Exemplar airplane’s flaps set to takeoff position. A Federal Aviation Administration inspector examined and took pictures of an exemplar Siai-Marchetti SF260 airplane and observed the flap position from a rearward angle, which was similar to the angle of the accident airplane’s video camera that faced rearward (see figures 1 and 2). The examination revealed that when the flaps were set to the takeoff flap setting of 20°, the flaps were easily discernable to be partially extended, in the exemplar airplane, which is the same type as the accident airplane. ## Aircraft - Registration: [N16FD](https://openairdocs.org/deregistered/N16FD-2022-03-05), registration cancelled 2022-03-05, S/N 305, built 1977 (OpenAirDocs) - Reported make and model: SIAI-MARCHETTI SF260 (D) - Registry model: [Siai-Marchetti SF260](https://openairdocs.org/model/siai-marchetti-sf260) (registry code 8121208) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 305 - Year built: 1977 - Airframe hours: 9773.1 - Engines: LYCOMING 0-540 SERIES 260 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Other work use, Part 91 - Operator: Air Combat, USA - Registered owner: N16fd Inc - Airworthiness certificate: Standard, Aerobatic - Last inspection: 100 hour, July 5, 2016 - Departed: FUL, Fullerton, CA - Destination: FUL, Fullerton, CA - Airport: FUL, Fullerton Muni, runway 24, 3,121 × 75 ft, asphalt - Equipment: Electronic primary flight display, Stall warning system, Electronic multifunction display, Auto-pilot, Video recording device, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 35; injuries: minor; flight instructor, commercial, military, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1; last flight review May 25, 2016; seat: right; restraint: 4-point; flight hours: 1,777 total, 7.6 in this make and model ## Weather - Conditions: Visual (VMC), Day - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 55 °F - Altimeter: 29.89 inHg - Observed at: KFUL ## 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 20160824014099A](https://openairdocs.org/incident/20160824014099A), Aug 24, 2016: Siai-Marchetti SF260, Fullerton, CA, Destroyed. On takeoff, immediately following rotation, N16FD began rolling left uncontrollably. The pilot was not able to arrest the roll despite him applying full right… ## Docket (12 files) The files NTSB released with the investigation on March 16, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93886. 61.5 MB in all. - Onboard and security video recordings - specialist's factual report (item 1, PDF, 4 pages, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12006808&FileExtension=pdf&FileName=wpr16la167_v4_onboard_protected-Rel.pdf - Onboard and security video recordings - specialist's factual report - attachment 1 (item 2, AVI, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12006289&FileExtension=avi&FileName=08252016b_export-Rel.avi - Onboard and security video recordings - specialist's factual report - attachment 2 (item 3, AVI, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12006210&FileExtension=avi&FileName=08252016c_export-Rel.avi - Onboard and security video recordings - specialist's factual report - attachment 3 (item 4, MP4, 14.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12006886&FileExtension=mp4&FileName=s_w%20ptz-Rel.mp4 - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 5, PDF, 29 pages, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11724354&FileExtension=pdf&FileName=N16FD%20Completed%20NTSB%20Accident%20Reporting%20Form%20final%201_Redacted-Rel.pdf - Pilot statement (item 6, PDF, 4 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11724436&FileExtension=pdf&FileName=Pilot%20Statement_Redacted-Rel.pdf - Witness statement (item 7, PDF, 1 page, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11726012&FileExtension=pdf&FileName=Statement%20of%20CRSimpson%20082516%20crs_Redacted-Rel.pdf - Record of conversation (item 8, PDF, 4 pages, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11725540&FileExtension=pdf&FileName=Record%20of%20Conversation%20WPR16LA167%20Final%201-Rel.pdf - Aircraft operations manual excerpts (item 9, PDF, 3 pages, 421 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11725486&FileExtension=pdf&FileName=F260D-O540-OM%20flight%20Manual%20Excerpts%201-Rel.pdf - Maintenance logbook excerpts (item 10, PDF, 3 pages, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11725373&FileExtension=pdf&FileName=N16FD%20Airframe%20Mx%20Log%20Part%20Excerpts%20Final_Redacted-Rel.pdf - Aircraft time (item 11, PDF, 2 pages, 246 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11724836&FileExtension=pdf&FileName=FW_%20N16FD%20Total%20Time_Redacted-Rel.pdf - Takeoff video (item 12, AVI, 33.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12035120&FileExtension=avi&FileName=08252016a_clip-Rel.avi 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.