# NTSB WPR19LA006: Vans RV6, N451JP, Cape Girardeau, MO, October 9, 2018 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 2 · Limited · Final report - Date: October 9, 2018, 10:50 local (15:50 UTC) - Place: Cape Girardeau, MO - Coordinates: 37.225276, -89.570831 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.2253&lon=-89.5708&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 2 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Federal Aviation Administration - NTSB case key (mKey): 98450 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19LA006 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98450/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98450 - Page: https://openairdocs.org/ntsb/WPR19LA006 ## Probable cause The pilot's improper landing flare in gusting crosswind conditions, his failure to conduct a go-around, and his failure to maintain directional control, which resulted in a runway departure and nose-over. ## 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: [Lowell C Peterson RV-6A, 1 case](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=056305P), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Lowell C Peterson RV-6A, 1 case](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=056305P), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Wind: crosswind](https://openairdocs.org/ntsb-findings/03034040): Environmental issues › Conditions/weather/phenomena · Ability to respond/compensate (probable cause); cases with it: [Lowell C Peterson RV-6A, 1 case](https://openairdocs.org/ntsb-findings/03034040/cases.md?model=056305P), [All aircraft, 1,008 cases](https://openairdocs.org/ntsb-findings/03034040/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: [Lowell C Peterson RV-6A, 1 case](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=056305P), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Performance/control parameters: landing flare](https://openairdocs.org/ntsb-findings/01062041): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Lowell C Peterson RV-6A, 1 case](https://openairdocs.org/ntsb-findings/01062041/cases.md?model=056305P), [All aircraft, 1,285 cases](https://openairdocs.org/ntsb-findings/01062041/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: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Lowell C Peterson RV-6A, 1 case](https://openairdocs.org/ntsb-events/230/sequence.md?model=056305P), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Lowell C Peterson RV-6A, 1 case](https://openairdocs.org/ntsb-events/470/sequence.md?model=056305P), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Lowell C Peterson RV-6A, 1 case](https://openairdocs.org/ntsb-events/300/sequence.md?model=056305P), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Landing-landing roll: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Lowell C Peterson RV-6A, 1 case](https://openairdocs.org/ntsb-events/096/sequence.md?model=056305P), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The pilot and passenger were landing in gusting crosswind conditions following a local flight. The passenger stated that the airplane touched down on the right side of the runway, bounced several times, departed the right side of the runway, and subsequently nosed over; a witness on the ground also watched the airplane bounce, depart the runway surface, and nose over in the grass. Weather observations indicated a left crosswind component between 9 and 15 knots about the time of the accident. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation, and the accident is consistent with the pilot's failure to attain a proper landing flare in gusting crosswind conditions, which resulted in the bounced landing, during which he failed to conduct a go-around. Subsequently, he did not maintain directional control, which resulted in the runway departure and nose-over. ## Factual narrative The FAA Airplane Flying Handbook, Chapter 8, Approaches and Landings, states: When the airplane contacts the ground with a sharp impact as the result of an improper attitude or an excessive rate of sink, it tends to bounce back in the air... Extreme caution and alertness must be exercised any time a bounce occurs, but particularly when there is a crosswind… When one main wheel of the airplane strikes the runway, the other wheel touches down immediately afterwards, and the wings become level. Then with no crosswind correction as the airplane bounces, the wind causes the airplane to roll with the wind, thus exposing even more surface to the crosswind and drifting the airplane more rapidly.…When a bounce is severe, the safest procedure is to execute a go-around immediately. Guidance provided by the kit manufacturer regarding flight test procedures stated that "If you should accidently hit hard enough to cause a sharp bounce back into the air, apply power and make a go-around for another landing attempt." It further stated that "It is probably better to start over rather than to salvage a bad landing out of an abnormal condition (bouncing back into the air at an unusual attitude or speed)." According to the kit manufacturer, due to the differences in each airplane built, the Pilot's Operating Handbook (POH) is the responsibility of the aircraft's builder/owner, and data such as reference speeds and crosswind limitations should be compiled from flight tests of each specific airplane. On October 9, 2018, about 1050 central daylight time, an experimental amateur-built Vans Aircraft Inc. RV-6A, N451JP, sustained substantial damage when it was involved in an accident in Cape Girardeau, Missouri. The pilot was fatally injured, and the pilot-rated passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. According to a witness located at the airport, the airplane landed "a little long," then bounced "hard" upon touchdown, before bouncing two more times. Immediately following the third bounce, the nose landing gear folded back, and the airplane nosed over. The passenger stated that the pilot mentioned that he was going to land "a little faster" and not use flaps due to the wind. The passenger further stated that the pilot had trouble straightening the airplane when it touched down the first time. The airplane touched down on the right side of the runway, bounced "pretty high," then landed in a right crab before it "shot off the right side of the runway" and subsequently nosed over. The airplane came to rest about 1,750 ft from the approach end of runway 20 and about 25 ft off to the right side of the runway. The witness statements were consistent with onboard GPS data and an airport surveillance video. An autopsy of the pilot was not performed due to his organ donor status. Toxicology testing performed at the FAA's Forensic Sciences Laboratory was negative for ethanol andtested-for drugs. The recorded weather conditions at Cape Girardeau Regional Airport (CGI), Cape Girardeau, Missouri, at 1050 included wind from 150° at 12 knots with gusts to 20 knots. Based on this observation, the crosswind component for landing on runway 20 was between about 9 knots and 15 knots, depending on the gust factor. The pilot held an experimental aircraft builder repairman certificate. The pilot had completed the requirements of BasicMed. All flight control surfaces remained attached to the airplane. Flight control continuity was established from the cockpit to all flight control surfaces. The elevator trim was observed in the neutral position and operated normally. The aileron trim was in the neutral position. The aileron trim operated normally with no anomalies noted. Examination of the brakes and tires revealed no anomalies. The engine and all associated engine components and accessories were present. The crankshaft was manually rotated at the propeller and rotational continuity was established throughout the engine, accessory section, and valve train. During crankshaft rotation, thumb compression and suction were attained on all cylinders. A borescope inspection of the cylinders revealed normal operating signatures. The engine was run at various power settings with no anomalies noted. ## Aircraft - Registration: [N451JP](https://openairdocs.org/deregistered/N451JP-2022-12-03), registration cancelled 2022-12-03, S/N 23435, built 2011 (OpenAirDocs) - Reported make and model: Vans RV6 (A) - Registry model: [Lowell C Peterson RV-6A](https://openairdocs.org/model/lowell-c-peterson-rv-6a) (registry code 056305P) (OpenAirDocs) - Registry engine: [Lycoming O-320-H2AD](https://openairdocs.org/engine/lycoming-o-320-h2ad) (registry code 42131, reciprocating) (OpenAirDocs) - Category: Airplane, amateur-built - Serial number: 23435 - Year built: 2011 - Airframe hours: 183.4 - Engines: Lycoming O-320-H2AD 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Special, Experimental (Special) - Last inspection: Condition, November 10, 2017 - Departed: CGI, Cape Girardeau, MO - Destination: CGI, Cape Girardeau, MO - Airport: CGI, Cape Girardeau Rgnl, runway 20, 3,997 × 100 ft, concrete - Equipment: Electronic multifunction display, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 74; injuries: fatal; private; airplane ratings: single-engine land; medical: basicmed, unknown; last flight review June 23, 2018; seat: left; restraint: 4-point; toxicology performed; flight hours: 230 total - Pilot-rated passenger; age 84; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: basicmed; seat: right; restraint: 4-point; flight hours: 988 total ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 12 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 66 °F - Altimeter: 29.97 inHg - Observed at: KCGI ## 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 20181009019649A](https://openairdocs.org/incident/20181009019649A), Oct 9, 2018: Lowell C Peterson RV-6A, Cape Girardeau, MO, Substantial damage, 1 fatal. Winds were 150@16 gusting 24 knots. Runway used by accident aircraft was 20. Aircraft approached the airport from the northwest. After a normal approach and… ## Docket (14 files) The files NTSB released with the investigation on December 2, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98450. 10.2 MB in all. - Meteorology (item 1, PDF, 4 pages, 424 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9744260&FileExtension=pdf&FileName=CGI%20WX_Redacted-Rel.pdf - Airport diagram (item 2, PDF, 1 page, 67 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9742443&FileExtension=pdf&FileName=GCI%20Airport%20Diagram-Rel.pdf - Passenger statement (item 3, PDF, 1 page, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9744151&FileExtension=pdf&FileName=Passenger%20Statement_Redacted-Rel.pdf - Record of converation (item 4, PDF, 1 page, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9741750&FileExtension=pdf&FileName=Record%20of%20Conversation%20WPR18LA006%20Witness-Rel.pdf - Record of email (item 5, PDF, 1 page, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9749780&FileExtension=pdf&FileName=Record%20of%20Email%20WPR19LA006-Rel.pdf - Accident flight data (landing) (item 6, PDF, 1 page, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11579118&FileExtension=pdf&FileName=Accident%20Flight%20Data%20(Landing)-Rel.pdf - Airframe and engine examination report (item 7, PDF, 5 pages, 557 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9750078&FileExtension=pdf&FileName=WPR19LA006%20Airframe%20and%20Engine%20Examination-Rel.pdf - FAA airplane flying handbook excerpts (item 8, PDF, 3 pages, 701 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9748425&FileExtension=pdf&FileName=Airplane%20Flying%20Handbook%20(FAA-H-8083-3B)%20Excerpts-Rel.pdf - RV-6A POH excerpts (item 9, PDF, 2 pages, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9744723&FileExtension=pdf&FileName=RV-6%20POH%20Example%20Excerpts%20Final-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11577966&FileExtension=pdf&FileName=WPR19LA006_WreakageReleaseForm_Redacted-Rel.pdf - Toxicological report (item 11, PDF, 1 page, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9743694&FileExtension=pdf&FileName=2018_199_001%20Final_Redacted-Rel.pdf - Accident sequence pictures (item 12, PDF, 1 page, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9743307&FileExtension=pdf&FileName=Accident%20Sequence%20Pictures-Rel.pdf - Accident pictures (item 13, PDF, 2 pages, 309 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9742434&FileExtension=pdf&FileName=Accident%20Pictures-Rel.pdf - Accident video (provided by FAA) (item 14, WMV, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11571766&FileExtension=wmv&FileName=10-9-18%20Accident%20Video-Rel.wmv 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.