# NTSB ATL03FA023: Cessna 150L, N11294, Arecibo, PR, December 6, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 6, 2002, 11:22 local (15:22 UTC) - Place: Arecibo, PR - Coordinates: 18.45111, -66.675552 - Nearby events: https://openairdocs.org/map.md?lat=18.4511&lon=-66.6756&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report November 25, 2003 - Report: Approved by Office Director - Parties: FAA FSDO-21, Cessna Aircraft Company - NTSB case key (mKey): 56178 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL03FA023 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56178/pdf - Page: https://openairdocs.org/ntsb/ATL03FA023 ## Probable cause The pilots failure to follow the normal takeoff checklist (Wing Flaps-Up) and failure to maintain airspeed after takeoff that resulted in an inadvertent stall. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - checklist - not followed, pilot in command (cause) - flaps - improper use of, pilot in command (cause) - airspeed(vso) - not maintained, pilot in command (cause) - stall - inadvertent, pilot in command - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The airplane was observed by witnesses taxiing out for takeoff and on the takeoff roll with the flaps extended. The airplane reached about 300 feet and the flaps were still observed in the down position. The airplane was in a climb attitude and the airspeed was described as slow. The witness looked away and heard a loud noise seconds later coming from the north side of the runway followed by black smoke. Radio contact was not established. The witness drove to the crash site and observed the airplane in a nose down attitude on fire with the tail section on the ground. Examination of the wreckage revealed the flaps were in the full down position. The checklist states flap deflections greater than 10-degrees are not recommended at any time for takeoff. Examination of the airframe, flight controls and engine assembly and accessories revealed no anomalies. ## Factual narrative HISTORY OF FLIGHT On December 6, 2002, at 1122 Atlantic standard time, a Cessna 150L, N11294, registered to a private owner, operating as a 14 CFR Part 91 personal flight, collided with terrain after takeoff from Antonio Nery Juarbe POL Airport, Arecibo, Puerto Rico. Visual meteorological conditions prevailed and no flight plan was filed. There was a postcrash fire and the airplane was destroyed. The private pilot and one passenger were fatally injured. The flight was originating from Arecibo, Puerto Rico at 1120 on December 6, 2002. A witness stated the airplane had been topped off with fuel before departing. The witness also noticed that the flaps appeared to have been fully extended while taxing out of the parking ramp and on the takeoff roll from runway 08. The airplane reached about 300 feet and the flaps were still down. The airplane was in a climb attitude and the airspeed was slow. He looked away and continued his work. Seconds later he heard a loud noise coming from the north side of runway 08. He looked around for the airplane and observed black smoke. He ran to a radio and attempted to contact the pilot, which was unsuccessful. He drove towards the smoke and observed the airplane in a nose down attitude on fire with the tail section separated on the ground. PERSONNEL INFORMATION Review of information on file with the FAA Airman's Certification Division, Oklahoma City, Oklahoma, revealed the pilot was issued a private pilot certificate on October 5, 1976, with ratings for airplane single engine land. The certificate had limitations stating, "passenger carrying prohibited on flights more than 10 miles from the Island of Puerto Rico. Not valid for flights which require the use of English." The pilot logbooks were not located. Family members stated the pilot normally took his pilot logbook with him in the airplane. The pilot held a third class medical issued on August 25, 2001, with the restriction, "must have available glasses for near vision." The pilot reported on his application for the medical certificate that he had accumulated 400 total flight hours. AIRCRAFT INFORMATION Review of aircraft maintenance records revealed the last recorded annual inspection was on June 1, 2002, at 8995.0 hours. The airplane had accumulated about 53 hours since the annual inspection. The engine was overhauled by H.P. Accessory Service on January 17, 1997,and had accumulated 1,079 hours since major overhaul. The airframe had accumulated 9,048 hours. Review of refueling records obtained from the registered owner, revealed 18 gallons of fuel had been purchased from Isla Grande Flying School, San Juan, Puerto Rico, on December 5, 2002. The fuel was transported to Arecibo, and 11 gallons of fuel was added to the airplane before the pilot departed on the accident flight. METEOROLOGICAL INFORMATION The nearest weather reporting facility at the time of the accident was Borinquen, Puerto Rico. The 1050 surface weather observation was: clear, visibility 10 miles, temperature 84 degrees Fahrenheit, dew point temperature 77 degrees Fahrenheit, wind 100-degrees at 10 knots, and altimeter 30.08. WRECKAGE AND IMPACT INFORMATION The wreckage was located in a pasture about 1/4 mile northeast of the departure end of the airport. Examination of the crash site revealed the airplane collided with the terrain on a heading of 328-degrees magnetic. The propeller assembly was separated from the crankshaft flange and both propeller blades sustained torsional twisting and "s" bending. The engine assembly was displaced to the right. The engine compartment, engine cowling, and firewall sustained extensive post crash fire damage. The firewall was wrapped around the accessory section of the engine. The nose gear was crushed aft. The right wing was displaced forward. Accordion crushing was present on the leading edge of the wing extending outboard from the wing root to the wing tip. The right wing tip was shattered. The wing sustained fire damage from the wing root outboard 60 inches to the flap and aileron split. Four feet of the forward main spar was consumed by fire. The right main fuel tank exhibited a bulged appearance and the fuel tank was ruptured. The flap jackscrew was extended 5.85 inches equating to 40-degrees flap extension and the flap was in the full down position. Examination of the flap track revealed no deficiencies. The right wing strut remained attached to the wing and the fuselage attachment fittings. The cabin area was consumed by fire from the firewall aft to the baggage compartment bulkhead. The left and right landing gear was found in a 90-degree nose down attitude. The tail cone was intact and sustained fire damage on the right side 15 inches aft of the baggage bulkhead. The left side of the tail cone sustained fire damage extending aft 4 feet. The upper skin on the left side of the tail cone was crushed aft extending 11 inches. Wrinkling of the tail cone skin was present on both sides of the tail cone adjacent to the leading edges of the left and right stabilizer. The upper and lower surface of the left and right stabilizers were wrinkled. The left and right elevators were not damaged. The leading edge of the vertical fin sustained compression damage where it attaches to the dorsal fin. The rudder sustained downward wrinkling in the vicinity of the rudder counter weight. The left wing was displaced aft. The leading edge of the wing sustained accordion crushing inboard to the forward spar, and extended outboard from the wing root to the wing tip. The left wing tip was shattered. The forward and rear spar was consumed by fire extending outboard 70 inches from the wing root. The left main fuel tank was ruptured and the top of the fuel tank was consumed by fire. The left flap was in the full down position and 35 inches of the inboard flap was consumed by fire. The remaining flap track revealed no deficiencies. The left wing strut was attached to the wing and fuselage attachment fittings. The pitot tube was buried in the ground in a vertical position. There were no separated or disconnected flight control cables. Control continuity was established to the primary and secondary flight controls. The control"Y" assembly, elevator tube, and forward elevator bellcrank were intact, and attached to one another. The aileron chains remained routed around the sprockets on the upper portion of the control"Y" assembly. The engine assembly sustained extensive fire and impact damage. The carburetor, vacuum pump, starter, generator, and left and right magnetos were consumed by post crash fire. The engine assembly could not be rotated by hand. The upper spark plugs from cylinders 1, 2, 3, and 4 were removed. A visual inspection was conducted on all pistons. The No.2 piston dome had melted. The engine was disassembled and there was no evidence of a precrash mechanical failure or malfunction. MEDICAL AND PATHOLOGICAL INFORMATION A Forensic Pathologist from the Instituto De Ciencias Forenses Seccion De Patologia, San Juan, Puerto Rico, conducted a postmortem examination of the pilot on December 7, 2002. The cause of death was severe trauma. The Forensic Toxicology Research Section, Federal Aviation Administration, Oklahoma City, Oklahoma, performed postmortem toxicology of specimens from the pilot. The results were negative for carbon monoxide, cyanide, and ethanol. Ranitidine, a histamine of an unspecified quantity used to treat and prevent the recurrence of ulcers and to treat other conditions where the stomach makes too much acid was present in the urine. A Forensic Pathologist from the Instituto De Ciencias Forenses Seccion De Patologia, San Juan, Puerto Rico, conducted a postmortem examination of the passenger on December 7, 2002. The cause of death was severe trauma. TEST AND RESEARCH The Cessna 150 Owners Manual states on page 1-4 in "Section 1, TAKE-OFF. NORMAL TAKE-OFF. (1) Wing Flaps-Up." ## Aircraft - Registration: [N11294](https://openairdocs.org/deregistered/N11294-2005-06-30), registration cancelled 2005-06-30, S/N 15075304, built 1973 (OpenAirDocs) - Reported make and model: Cessna 150L - Registry model: [Cessna 150L](https://openairdocs.org/model/cessna-150l) (registry code 2071826) (OpenAirDocs) - Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 15075304 - Airframe hours: 9048 - Engines: Continental O-200A 100 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Carmelo B. Beniquez - Registered owner: Jose J. Gonzalez - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 1, 2002, 53 hours before - Departed: ABO, Arecibo, PR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 400 total ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 84 °F, dew point 77 °F - Altimeter: 30.07 inHg - Observed at: TJBQ, 25 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 20021206036149A](https://openairdocs.org/incident/20021206036149A), Dec 6, 2002: Cessna 150L, Arecibo, PR, Destroyed, 2 fatal. (-23) On December 6, 2002, at 1122 atlantic standard time, a Cessna 150L type aircraft, N11294, registered to a private owner, operating as a 14 CFR 91… ## Other investigations on N11294 (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 MIA76DKT69](https://openairdocs.org/ntsb/MIA76DKT69), Apr 25, 1976: Cessna 150 (N11294), Pembrook Pines, FL, substantial damage 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.