# NTSB CEN14LA406: Cessna 177RG, N468LE, Manistee, MI, August 5, 2014 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: August 5, 2014, 15:10 local (19:10 UTC) - Place: Manistee, MI - Coordinates: 44.272499, -86.246948 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.2725&lon=-86.2469&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Minor injuries - Injuries: 4 minor - Status: Completed, report January 21, 2016 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, Grand Rapids FSDO - NTSB case key (mKey): 89808 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14LA406 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89808/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89808 - Page: https://openairdocs.org/ntsb/CEN14LA406 ## Probable cause The pilot receiving instruction's inability to respond to or compensate for the sudden change in wind direction and speed that the airplane encountered shortly after liftoff, which resulted in a tailwind condition, a corresponding decrease in airspeed, and a reduced climb gradient. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Wind: sudden wind shift](https://openairdocs.org/ntsb-findings/03034010): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-findings/03034010/cases.md?model=2073709), [All aircraft, 114 cases](https://openairdocs.org/ntsb-findings/03034010/cases.md) - [Wind: sudden wind shift](https://openairdocs.org/ntsb-findings/03034010): Environmental issues › Conditions/weather/phenomena · Ability to respond/compensate (probable cause); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-findings/03034010/cases.md?model=2073709), [All aircraft, 114 cases](https://openairdocs.org/ntsb-findings/03034010/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 177RG, 8 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2073709), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=2073709), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=2073709), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Cessna 177RG, 1 case](https://openairdocs.org/ntsb-events/400/sequence.md?model=2073709), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 177RG, 9 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2073709), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 177RG, 22 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073709), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight instructor reported that the departure airport's weather station was inoperative during his preflight check of the weather conditions and, as such, he referenced the airport's windsock to select the runway for takeoff. As the airplane taxied from the ramp area, the windsock indicated a light variable wind primarily from the east. Believing that the wind was light and variable, the flight instructor told his student, a private pilot who was receiving flight instruction, to depart on runway 19 because the intended destination was south of the departure airport. The flight instructor reported that the student used a short-field takeoff procedure for the takeoff. The airplane became airborne with about 1,000 ft of runway remaining; however, during the initial climb, about 5 to 10 ft above the runway, the airplane experienced a sudden loss of airspeed and began to sink back toward the runway. The airplane touched down at the runway departure threshold and continued down an embankment into a tree line. Following the accident, the flight instructor noted that the airport's windsock was indicating a north-to-northwest wind direction with wind gusts reaching 18 to 20 knots. He stated that the apparent wind change had resulted in a tailwind condition during the accident takeoff. Additionally, he reported that there were no mechanical malfunctions or failures with the airplane that would have prevented its normal operation. The reported sudden change in wind direction and speed during initial climb would have resulted in a tailwind condition, a corresponding decrease in airspeed, and a reduced climb gradient. ## Factual narrative On August 5, 2014, about 1510 eastern daylight time, a Cessna model 177RG airplane, N468LE, was substantially damaged during takeoff on runway 19 (2,721 feet by 75 feet, asphalt) at the Manistee County Airport (MBL), Manistee, Michigan. The private pilot, flight instructor, and two passengers sustained minor injuries. The airplane was operated by Great Lakes Air Ventures LLC under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. Day visual meteorological conditions prevailed for the cross-country instructional flight that was en route to Mason County Airport (LDM), Ludington, Michigan.The flight instructor reported that the MBL weather station was inoperative during his preflight check of the weather conditions and, as such, he referenced the airport's windsock to select the runway for takeoff. As the airplane taxied from the ramp area, the windsock indicated a light wind of variable direction that was primarily from the east. Believing that the winds were light-and-variable, the flight instructor told his student, a private pilot who was receiving flight instruction toward a complex airplane endorsement, to depart on runway 19 because the intended destination was south of the departure airport. The flight instructor reported that he calculated the runway length required to clear a 50-foot obstacle was about 1,850 feet at the airplane's maximum gross weight and with a calm wind condition. The student reportedly initially selected the wing flaps to 20 degrees, but the flight instructor noted the incorrect flap setting and told the student to select 10 degrees of wing flaps for the short-field takeoff. The takeoff was initiated from the end of the runway, to maximize available runway length, and by holding the wheel brakes until maximum engine power had been achieved. During the subsequent takeoff roll, the flight instructor noticed that the wing flaps were still incorrectly set at 20 degrees and changed them to 10 degrees for the short-field takeoff. The student called out rotation speed (66 knots) and began to apply aft elevator control input for takeoff. The flight instructor stated that the airplane achieved liftoff around 70 knots with about 1,000 feet of runway remaining. During initial climb, about 5-10 feet above the runway, the airplane experienced a sudden loss of airspeed and began to sink back toward the runway. The airplane touched-down at the runway departure threshold and continued down an embankment into a tree line located about 350 feet from the end of the runway. Following the accident, the flight instructor noted that the airport's windsock was indicating a north-to-northwest wind direction with wind gusts reaching 18-20 knots. He stated that the apparent wind change had resulted in a tailwind condition during the accident takeoff. Additionally, he reported that there were no mechanical malfunctions or failures with the airplane that would have prevented its normal operation during the accidenttakeoff. The fuselage and both wings were substantially damaged during the accident. The automated surface observing system (ASOS) located at the departure airport (MBL) was not operational when the accident occurred. There was an active notice to airman (NOTAM) for the inoperative weather system. However, there was a valid terminal forecast issued for MBL at the time of the accident, which indicated a surface wind of 350 degrees at 7 knots. The next closest aviation weather observing system was located at the intended destination (LDM), which was 19.8 miles south of the MBL. At 1515, the LDM weather station reported: wind 310 degrees at 7 knots; visibility 10 miles; scattered clouds at 3,800 feet above ground level (agl), scattered clouds at 4,500 feet agl, and a broken ceiling at 9,500 feet agl; temperature 24 degrees Celsius, dew point 16 degrees Celsius, and an altimeter setting of 30.07 inches of mercury. ## Aircraft - Registration: [N468LE](https://openairdocs.org/deregistered/N468LE-2017-02-07), registration cancelled 2017-02-07, S/N 177RG0158, built 1971 (OpenAirDocs) - Reported make and model: CESSNA 177RG - Registry model: [Cessna 177RG](https://openairdocs.org/model/cessna-177rg) (registry code 2073709) (OpenAirDocs) - Registry engine: [Lycoming IO-360-A1B6D](https://openairdocs.org/engine/lycoming-io-360-a1b6d) (registry code 41593, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 177RG0158 - Year built: 1971 - Airframe hours: 3531 - Engines: Lycoming IO-360-A1B6D 200 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Great Lakes Air Ventures, LLC - Registered owner: James E. Zook - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 24, 2014, 14 hours before - Departed: MBL, Manistee, MI - Destination: LDM, Ludington, MI - Airport: MBL, Manistee County-Blacker, runway 19, 2,721 × 75 ft, asphalt - Equipment: Handheld GPS, Stall warning system, Electronic flight bag or handheld device, Auto-pilot ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; injuries: minor; private; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; last flight review June 15, 2014; seat: left; restraint: 4-point; flight hours: 131 total, 3 in this make and model, 5 in the last 90 days, 3 in the last 30 days, 2 in the last 24 hours - Flight instructor; age 25; injuries: minor; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review October 9, 2013; seat: right; restraint: 4-point; flight hours: 471 total, 16 in this make and model, 281 as pilot in command, 68 in the last 90 days, 11 in the last 30 days, 2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 9,500 ft broken - Temperature: 75 °F, dew point 61 °F - Altimeter: 30.06 inHg - Observed at: LDM, 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 20140805013159A](https://openairdocs.org/incident/20140805013159A), Aug 5, 2014: Cessna 177RG, Manistee, MI, Destroyed. On August 05, 2014, approximately 15:10 eastern daylight time, a Cessna CE-177 cardinal aircraft, N468LE, impacted terrain after departing runway 18 at… ## Docket (5 files) The files NTSB released with the investigation on December 7, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89808. 3.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434608&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Flight Instructor Statement (Scott Mason) (item 2, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434609&FileExtension=.PDF&FileName=Flight%20Instructor%20Statement%20(Scott%20Mason)-Master.PDF - Pilot-Receiving-Instruction Statement (Chad Paalman) (item 3, .PDF, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434610&FileExtension=.PDF&FileName=Pilot-Receiving-Instruction%20Statement%20(Chad%20Paalman)-Master.PDF - Email Correspondence with FAA Inspector Thomas Kozura (item 4, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434611&FileExtension=.PDF&FileName=Email%20Correspondence%20with%20FAA%20Inspector%20Thomas%20Kozura-Master.PDF - NTSB Weather Summary (item 5, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434612&FileExtension=.PDF&FileName=NTSB%20Weather%20Summary-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.