# NTSB BFO95FA045: Cessna 172M, N20819, Eldersburg, MD, April 7, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 7, 1995, 17:30 local (21:30 UTC) - Place: Eldersburg, MD - Coordinates: 39.370994, -76.969047 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.3710&lon=-76.9690&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal, 1 serious - Status: Completed, report September 24, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 8996 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=BFO95FA045 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/8996/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=8996 - Page: https://openairdocs.org/ntsb/BFO95FA045 ## Probable cause THE PILOT'S FAILURE TO MAINTAIN PROPER AIRSPEED. FACTORS IN THE ACCIDENT WERE THE PILOT'S FAILURE TO REMOVE CARBURETOR HEAT DURING THE GO-AROUND AND THE PRESENCE OF A TAILWIND. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, go-around (vfr) - airspeed - not maintained, pilot in command (cause) - carburetor heat - not removed, pilot in command (contributing factor) - weather condition - tailwind (contributing factor) - stall/spin - inadvertent, pilot in command - In flight collision with terrain/water, descent - uncontrolled ## Analysis DURING A GO-AROUND, THE AIRPLANE WAS INADVERTENTLY STALLED. WITNESSES STATED THAT THE AIRPLANE HAD JUST CLEARED POWERLINES WHEN ITS LEFT WING DROPPED DOWN. THE WITNESSES STATED THE AIRPLANE TURNED LEFT AND DESCENDED TO THE GROUND. POSTACCIDENT EXAMINATION OF THE AIRFRAME AND ENGINE REVEALED NO ANOMALIES. THE AIRPLANE'S FLAPS WERE EXTENDED 16 DEGREES. CARBURETOR HEAT WAS APPLIED REDUCING THE AIRPLANE'S CLIMB PERFORMANCE ABOUT 143 FEET PER MINUTE. A NON CERTIFICATED PROPELLER WAS INSTALLED ON THE AIRPLANE REDUCING THE AIRPLANE'S CLIMB PERFORMANCE ABOUT 60 FEET PER MINUTE. A TAILWIND OF ABOUT 5 TO 7 KNOTS WAS PRESENT. AT THE TIME OF THE ACCIDENT, THE AIRPLANE'S GROSS WEIGHT WAS ABOUT 2,149 POUNDS. THE AIRPLANE'S MAXIMUM GROSS WEIGHT WAS 2,300 POUNDS. ## Factual narrative HISTORY OF FLIGHT On April 7, 1995, at 1730 eastern daylight time, a Cessna 172M, N20819, collided with terrain about 200 yards from the end of runway 20 at the Hoby Wolf Airport, Eldersburg, Maryland. The pilot and two passengers were fatally injured. A third passenger received serious injuries. The airplane was destroyed. Visual meteorological conditions prevailed. The personal local flight departed Haysfield (MD24) located near Clarksville, Maryland, about 1710. The flight was conducted under 14 CFR Part 91. The purpose and itinerary of the flight was unknown. A witness located at the Hoby Wolf Airport stated that about 1720 he saw the accident airplane fly over runway 20 at an altitude of about 1,200 to 1,500 feet mean sea level (msl) and then turn right as if the pilot decided to depart the airport area. He stated he did not see the airplane again until it was flying southwest over the "dip" in runway 20. The witness stated, "The aircraft continued up the strip. My immediate thought was it would snag the wires at the end of the strip or go into the top of the trees...the aircraft continued to climb when I expected an immediate nose over or no more than level flight after clearing the wires. As I observed the aircraft it appeared to me at a high angle of attack...at that moment the left wing fell to a vertical position, and it appeared to fall left wing down...." The witness reported that at the time of the accident the wind was coming from the north at about 5 to 7 knots. A witness located in his yard across from the runway stated he saw and heard N20819 flying over runway 20 at about 50 feet above the ground. He stated he watched the airplane because "...by the time they are adjacent to my house, most airplanes have landed." He said when the airplane reached the end of the runway, about 100 to 150 feet above the ground "...the airplane then went into a vigorous climb...kind of leveled off and made a sweeping left hand turn." He stated that during the climb he heard the engine "gurgle" or "sputter" about six to eight times. Another witness located outside her home at the accident site reported, "I heard the engine of a plane which was extremely loud and extremely close. I saw the plane come over our pine trees. It leaned onto its left side. The wing hit the ground and the plane turned so that it was facing back towards me. The nose of the plane impacted the ground...." PERSONNEL INFORMATION The pilot held a Airline Transport Pilot certificate with a multiengine land rating and was type rated in a Cessna 500. He had commercial pilot privileges for airplane single engine land and was type rated in a Dehavilland DH-4 and a Lockheed L-382. The pilot also held a ground instructor certificate with advanced and instrument ratings; a Flight Engineer certificate with a turbojet rating; and a Control Tower Operator certificate for the Teterboro, New Jersey, Air Traffic Control Tower. The pilot's civilian log book was not recovered. The pilot reported a total of 5,000 civilian flight hours on his last application for a Federal Aviation Administration first class medical certificate on December 2, 1993. The pilot received a proficiency check ride in a Cessna 172 from an instructor at Flite-Rentals, Howard County, Maryland, in March 1995. Prior to the check ride, the pilot reported to Flite- Rentals that he received a biennial flight review in August 1993, and had accumulated a total of 6,000 flight hours. According to the owner of the Hoby Wolf airport, the pilot had landed at his airport only once prior to the accident. He stated that the day before the accident, the pilot landed at the airport and made a full stop. The passenger in the front right seat was a student pilot. According to a family member, the student pilot had not flown an airplane for several years. AIRCRAFT INFORMATION According to the airplane's log books, the airplane received a 100 hour inspection on March 30, 1995, about 11 hours prior to the accident. The propeller installed on the accident airplane was a McCauley 1C160/DTM7557. According to Cessna Aircraft Certification records, the airplane was delivered with a McCauley 1C160/DTM7553 propeller installed. According to Cessna flight test data, the use of a McCauley 1C160/DTM7557 would result in a loss of about 60 feet per minute rate of climb. According to Cessna Aircraft personnel calculations, in a climb condition with carburetor heat applied, the airplane's rate of climb would be reduced about 143 feet per minute. (See attached "Rate of Climb Change With Application of Carburetor Heat" for assumed parameters). The airplane's empty weight was 1,419 pounds and its gross maximum weight was 2,300 pounds. At the time of the accident, the airplane's gross weight was about 2,149 pounds. (See attached Gross Weight Calculation sheet for details). AIRPORT INFORMATION Remarks listed under the Hoby Wolf Airport in the Airport/Facility Directory state, "...land on Rwy 20 tkf Rwy 02. Rwy 02-20 has up and down slopes with undulations: Ldg-first 535' has a 3 degree upslope and next 315' has a 2 degree downslope, rest of rwy has 4 1/2' upslope to road." The owner of the airport stated that a standard pattern was in use (left turns only). Trees and powerlines were present at the end of runway 20. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the accident site on April 8, 1995. The examination revealed the airplane came to rest upright on a magnetic heading of about 300 degrees. The engine was displaced downward. The propeller blade tips were curled and bent aft. Control continuity was verified. The left wing remained attached to the fuselage and its tip was crushed upward. The entire left wing was dented and crushed. The left wing flap was found extended 16 degrees. The empennage was intact but the fuselage skin behind the cabin was buckled. The elevator trim tab was found to be 2.5 degrees nose down. The right wing was attached to the fuselage and its leading edge was crushed aft. The right wing flap was found extended 16 degrees. The throttle and mixture controls were full forward. The carburetor heat control in the cabin was pulled to the on position. Also, verification of the carburetor heat control position was confirmed by the heat valve position. The heat valve position was in the on position at the induction air box. The ignition switch was found in the left magneto position. The fuel selector was found in the "BOTH" position. About 20 gallons of 100LL aviation grade fuel was removed from the airplane's fuel system and no fuel contaminates were found. The airplane was removed from the accident site and transported to a storage facility. The engine was examined at the storage facility and no anomalies were noted. MEDICAL AND PATHOLOGICAL INFORMATION The autopsy and toxicology were performed by Dr. Golle at the Baltimore, Maryland, Medical Examiner's Office, on April 7, 1995. ADDITIONAL INFORMATION At 1653, the Baltimore, Maryland, weather observation facility reported an outside air temperature of 71 degrees fahrenheit and a dew point of 28 degrees fahrenheit. According to Carburetor Icing Probability Curves, conditions which are known to be favorable to the formation of induction system icing in typical light aircraft installations were not present. The airplane was released to Nancy Seal, Insurance Agent, Clearview Airport Inc., Westminster, Maryland, on April 10, 1995. ## Aircraft - Registration: [N20819](https://openairdocs.org/deregistered/N20819-2013-04-15), registration cancelled 2013-04-15, S/N 17263846, built 1974 (OpenAirDocs) - Reported make and model: CESSNA 172M - Registry model: [Cessna 172M](https://openairdocs.org/model/cessna-172m) (registry code 2072418) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172-63846 - Airframe hours: 3066 - Engines: LYCOMING O-320-E2D 150 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Jd Kreis Aviation Incorporated, doing business as Flite Rentals - Registered owner: Aviation Investment Resources - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 30, 1995, 11 hours before - Departed: MD24, CLARKSVILLE, MD - Airport: 1W5, Hoby Wolf, runway 20, 1,940 × 60 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; military, airline transport, flight engineer; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 6,000 total ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 6 knots - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 28 °F - Altimeter: 29.00 inHg - Observed at: BWI, 15 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 19950407007319A](https://openairdocs.org/incident/19950407007319A), Apr 7, 1995: Cessna 172M, Eldersburg, MD, Destroyed, 3 fatal. Stalled on a belated downwind landing go around. Factors carb heat on. Gross weight and pilots used to extra power. ## Docket (22 files) The files NTSB released with the investigation on July 6, 1995, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=8996. 2.6 MB in all. - Supplement A (item 1, .PDF, 195 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022956&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 277 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022957&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement K (item 3, .PDF, 317 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022958&FileExtension=.PDF&FileName=Supplement%20K-Master.PDF - Supplement S (item 4, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022959&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Witness Statements (item 5, .PDF, 434 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376719&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Charts of Accident Area (item 6, .PDF, 167 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022961&FileExtension=.PDF&FileName=Charts%20of%20Accident%20Area-Master.PDF - Maps or Charts of Accident Area (item 7, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022962&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area-Master.PDF - Maps or Charts of Accident Area (item 8, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022963&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area-Master.PDF - Reports from Parties to the Investigation (Cessna) (item 9, .PDF, 469 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376720&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20(Cessna)-Redacted.PDF - Lycoming Operator's Manual, Seal Level Power Curve (item 10, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022965&FileExtension=.PDF&FileName=Lycoming%20Operator%27s%20Manual,%20Seal%20Level%20Power%20Curve-Master.PDF - Lycoming Operator's Manual, Seal Level and Altitude Performance (item 11, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022966&FileExtension=.PDF&FileName=Lycoming%20Operator%27s%20Manual,%20Seal%20Level%20and%20Altitude%20Performance-Master.PDF - Weight and balance at time of accident (item 12, .PDF, 27 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022967&FileExtension=.PDF&FileName=Weight%20and%20balance%20at%20time%20of%20accident-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 13, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376721&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.12 (item 14, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376723&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.12-Redacted.PDF - Photo 1: Flight path of N20819 (item 15, .PDF, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022970&FileExtension=.PDF&FileName=Photo%201%3A%20%20Flight%20path%20of%20N20819-Master.PDF - Photo 2: View of wreckage path. Markings on street represent gouges in the pavement. Photo taken by Cessna (item 16, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022971&FileExtension=.PDF&FileName=Photo%202%3A%20%20View%20of%20wreckage%20path.%20%20Markings%20on%20street%20represent%20gouges%20in%20the%20pavement.%20%20Photo%20taken%20by%20Cessna-Master.PDF - Photo 3: Propeller blade. Note curl and chordwise scratches. Photo taken by Cessna (item 17, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022972&FileExtension=.PDF&FileName=Photo%203%3A%20%20Propeller%20blade.%20%20Note%20curl%20and%20chordwise%20scratches.%20%20Photo%20taken%20by%20Cessna-Master.PDF - Photo 4: View of engine and propeller at accident site. Photo taken by Cessna (item 18, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022973&FileExtension=.PDF&FileName=Photo%204%3A%20%20View%20of%20engine%20and%20propeller%20at%20accident%20site.%20%20Photo%20taken%20by%20Cessna-Master.PDF - Photo 5: View of the left side of the airplane. Photo taken by Cessna (item 19, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022974&FileExtension=.PDF&FileName=Photo%205%3A%20%20View%20of%20the%20left%20side%20of%20the%20airplane.%20%20Photo%20taken%20by%20Cessna-Master.PDF - Photo 6: Front view of airplane. Photo taken by Cessna (item 20, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022975&FileExtension=.PDF&FileName=Photo%206%3A%20%20Front%20view%20of%20airplane.%20%20Photo%20taken%20by%20Cessna-Master.PDF - Photo 7: Normal left traffic pattern, as compared to right traffic pattern flown by N20819 (item 21, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022976&FileExtension=.PDF&FileName=Photo%207%3A%20%20Normal%20left%20traffic%20pattern,%20as%20compared%20to%20right%20traffic%20pattern%20flown%20by%20N20819-Master.PDF - Photo 8: View of right side of airplane (item 22, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40022977&FileExtension=.PDF&FileName=Photo%208%3A%20%20View%20of%20right%20side%20of%20airplane-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.