# NTSB CEN12LA059: Cessna 172M, N13584, Sturgis, SD, November 11, 2011 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: November 11, 2011, 09:05 local (16:05 UTC) - Place: Sturgis, SD - Coordinates: 44.418056, -103.375274 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.4181&lon=-103.3753&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: Fatal - Injuries: 1 fatal - Status: Completed, report November 7, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Cessna, Lycoming, Federal Aviation Administration - NTSB case key (mKey): 82281 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12LA059 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82281/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82281 - Page: https://openairdocs.org/ntsb/CEN12LA059 ## Probable cause The student pilot’s failure to maintain control of the airplane during takeoff with extended flaps. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Wing structure: trailing edge flaps](https://openairdocs.org/ntsb-findings/01035753): Aircraft › Aircraft structures · Incorrect use/operation (probable cause); cases with it: [Cessna 172M, 2 cases](https://openairdocs.org/ntsb-findings/01035753/cases.md?model=2072418), [All aircraft, 33 cases](https://openairdocs.org/ntsb-findings/01035753/cases.md) - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 172M, 9 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=2072418), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Student/instructed pilot (probable cause); cases with it: [Cessna 172M, 19 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=2072418), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Experience/qualifications: total experience](https://openairdocs.org/ntsb-findings/02031015): Personnel issues › Experience/knowledge · Student/instructed pilot; cases with it: [Cessna 172M, 3 cases](https://openairdocs.org/ntsb-findings/02031015/cases.md?model=2072418), [All aircraft, 126 cases](https://openairdocs.org/ntsb-findings/02031015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna 172M, 13 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2072418), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Cessna 172M, 16 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2072418), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis The flight instructor stated that during the student pilot’s second solo landing, the airplane’s flaps were not retracted before the next takeoff. After takeoff, the airplane pitched up to a 60-degree nose-up attitude. According to the flight instructor, the airplane’s engine sounded like it was developing full power. The airplane entered a half-turn spin and impacted the terrain vertically. Postaccident examination showed that the flaps were extended and revealed no evidence of preimpact mechanical malfunction or anomaly that would have precluded normal operation. Toxicology tests detected acetaminophen and diphenhydramine in the pilot's urine. Although diphenhydramine can cause drowsiness, the investigation could not determine whether it contributed to the accident. ## Factual narrative HISTORY OF FLIGHT On November 11, 2011, about 0905 mountain standard time, N13584, a Cessna 172M, operated by Bear Butte Flying Club, piloted by a student pilot, sustained substantial damage on impact with terrain following a loss of control during climbout from runway 29 (5,100 feet by 60 feet, dry/concrete) at the Sturgis Municipal Airport (49B), near Sturgis, South Dakota. The instructional flight was operating under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident. No flight plan was on file. The pilot sustained fatal injuries. The local flight originated from 49B about 0800 and was taking off at the time of the accident. The student pilot’s certified flight instructor (CFI) stated that during the student pilot’s second solo landing, the airplane was stopped on the runway and the airplane’s flaps were not raised before the next takeoff. The airplane was observed after takeoff to rotate up to 60 degrees pitch up. According to the CFI, the airplane’s engine sounded like it was developing full power. The airplane was observed in a half-turn spin prior to when it impacted terrain vertically. PERSONNEL INFORMATION The pilot held a student pilot certificate. He held a Third Class Medical Certificate dated September 29, 2011. A limitation on his medical certificate indicated that he must wear corrective lenses to exercise the rights of his certificate. His logbook endorsements indicated that he had accumulated 9.6 hours of total flight time of which 0.4 hours of flight time was as pilot-in-command. AIRCRAFT INFORMATION N13584 was a 1973 Cessna model 172M airplane with serial number 17262858. The airplane was a high wing, all-metal, single-engine, four-place monoplane. It had a fixed tricycle landing gear configuration, and was powered by a naturally aspirated four-cylinder, Lycoming O-320-E2D engine, bearing serial number L-36653-27A, and marked as producing 150-horsepower. A review of Federal Aviation Administration (FAA) airworthiness documents revealed that the engine was converted to 160-horsepower using the SA2375SW and SE3692SW supplemental type certificates. The airplane had its most recent annual inspection performed on July 15, 2011. At the time of that annual inspection, the airplane accumulated 6,546 hours of total time and the airplane’s engine accumulated 1,180 hours of time since a major overhaul. METEOROLOGICAL INFORMATION At 0855, the recorded weather at the Ellsworth Air Force Base, near Rapid City, South Dakota, was: Wind 240 degrees at five knots; visibility 10 statute miles; sky condition clear; temperature 11 degrees C; dew point -10 degrees C; altimeter 29.76 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane came to rest on the grass south of runway 29. FAA inspectors, assisted by safety representatives from the airplane manufacturer and engine manufacturer, conducted an on-scene postaccident examination of the wreckage. Flight control continuity wasestablished except for separations consistent with overload and damage consistent with impact crushing. Control continuity was established to the engine. The engine exhibited a thumb compression at all cylinders when its crankshaft was rotated. The tachometer indicated 6,570.3 hours. The flap jackscrew was observed and its thread extension of 4.6 inches indicated that the flaps were extended about 30 degrees. No airplane or engine preimpact anomalies were detected. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot at the Clinical Laboratory of the Black Hills. That autopsy indicated the pilot’s cause of death was due to blunt trauma injuries sustained in an airplane crash. The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report. That report indicated: 19.72 (ug/ml, ug/g) Acetaminophen detected in Urine Diphenhydramine detected in Urine Diphenhydramine NOT detected in Blood The FAA Forensic Toxicology's WebDrugs website description of Acetaminophen, in part, stated: Acetaminophen is a common over the counter analgesic/antipyretic (Tylenol). It is available in many oral dosage forms and in combination with various decongestants and/or antihistamines. It is also available by prescription in combination with various opiate derivatives. Large doses of acetaminophen can produce hepatotoxicity. People who use moderate amounts of ethanol on a regular basis have a greater risk of acetaminophen-induced hepatotoxicity. The FAA Forensic Toxicology's WebDrugs website description of Diphenhydramine indicated it was a common over the counter antihistamine used in the treatment of the common cold and hay fever. ADDITIONAL INFORMATION N13584 was involved in a previous accident listed in the NTSB database as report number CHI01LA051. That report, in part, indicated that the elevator trim tab and the cockpit trim indicator were not consistent with each other. It was reported that when the pilot aligned the indicator for a takeoff setting, the actual trim surface was in a full nose down position. A postaccident review of the maintenance records subsequent to this accident found no history of unresolved airworthiness issues. ## Aircraft - Registration: [N13584](https://openairdocs.org/deregistered/N13584-2017-10-06), registration cancelled 2017-10-06, S/N 17262858, built 1973 (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: 17262858 - Airframe hours: 6570.3 - Engines: LYCOMING O-320-E2D 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Bear Butte Flying Club - Registered owner: Bear Butte Flying Club - Last inspection: Annual, July 15, 2011, 24 hours before - Departed: 49B, Sturgis, SD - Destination: 49B, Sturgis, SD - Airport: 49B, Sturgis Municipal Airport, runway 29, 5,100 × 60 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; student; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 10 total, 10 in this make and model, 1 as pilot in command, 6 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 52 °F, dew point 14 °F - Altimeter: 29.76 inHg - Observed at: RCA, 20 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 20111111026409A](https://openairdocs.org/incident/20111111026409A), Nov 11, 2011: Cessna 172M, Sturgis, SD, Destroyed, 1 fatal. On November 11, 2011 at about 0906 MST, the student pilot was making his second solo flight from the Sturgis, SD airport. He was making a stop and go landing… ## Other investigations on N13584 (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 CHI01LA051](https://openairdocs.org/ntsb/CHI01LA051), Dec 19, 2000: Cessna 172M (N13584), Sturgis, SD, substantial damage. Probable cause: The pilot failed to maintain control of the airplane during takeoff and he discontinued an aborted takeoff once initiated. Factors associated with the accident were the inaccurate elevator trim… ## Docket (11 files) The files NTSB released with the investigation on September 21, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82281. 2.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374715&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statement (item 2, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374716&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Witness Statement (item 3, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374717&FileExtension=.PDF&FileName=Witness%20Statement-Redacted.PDF - Miscellaneous - Pilot Logbook Excerpts (item 4, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374722&FileExtension=.PDF&FileName=Miscellaneous%20-%20Pilot%20Logbook%20Excerpts-Redacted.PDF - Miscellaneous - Airplane Annual Inspection Excerpts (item 5, .PDF, 261 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374734&FileExtension=.PDF&FileName=Miscellaneous%20-%20Airplane%20Annual%20Inspection%20Excerpts-Redacted.PDF - Miscellaneous - Communication Summary (item 6, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375778&FileExtension=.PDF&FileName=Miscellaneous%20-%20Communication%20Summary-Master.PDF - Statement of Party Representatives to NTSB Investigation - Lycoming (item 7, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374775&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Lycoming-Redacted.PDF - Statement of Party Representatives to NTSB Investigation - Cessna (item 8, .PDF, 131 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375623&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Cessna-Redacted.PDF - Toxicological Report (item 9, .PDF, 329 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374725&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Miscellaneous - FAA Forensic Toxicology's WebDrugs website Descriptions (item 10, .PDF, 26 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40374738&FileExtension=.PDF&FileName=Miscellaneous%20-%20FAA%20Forensic%20Toxicology%27s%20WebDrugs%20website%20Descriptions-Master.PDF - Miscellaneous - CHI01LA051 (item 11, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40375634&FileExtension=.PDF&FileName=Miscellaneous%20-%20CHI01LA051-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.