# NTSB CEN15FA278: Cessna 172, N5743A, Shreveport, LA, June 19, 2015 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 19, 2015, 17:15 local (22:15 UTC) - Place: Shreveport, LA - Coordinates: 32.538055, -93.746391 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.5381&lon=-93.7464&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: Fatal - Injuries: 1 fatal - Status: Completed, report February 8, 2016 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, Continental Motors, Textron Aviation - NTSB case key (mKey): 91403 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15FA278 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91403/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91403 - Page: https://openairdocs.org/ntsb/CEN15FA278 ## Probable cause The pilot's loss of airplane control during initial climb after takeoff for reasons that could not be determined because an examination of the airframe and engine did not reveal any preimpact anomalies. ## 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: [Cessna 172, 30 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072402), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Cessna 172, 4 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=2072402), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 172, 16 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072402), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172, 36 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072402), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was performing touch-and-go landings at a controlled airport. During the accident takeoff, the airplane was observed in a nose-high attitude. The pilot made an abbreviated radio call indicating that he was returning to the airport. The airplane rolled to the left, nosed over, impacted the ground with its left wing, cartwheeled on its nose, and came to rest upright. An on-scene examination revealed no preimpact flight control anomalies, and the pilot's seat was found pinned in a seat rail's hole, indicating that the loss of control was not the result of inadvertent slippage of the seat. The engine was test run and no anomalies were noted. The airplane was equipped with lap belts, and it did not have (nor was it required to have) shoulder harnesses. The pilot sustained injuries that were consistent with unrestrained upper body impact with the control yoke. No medical issues were identified with the pilot that would have contributed to the accident. ## Factual narrative N5743A was a 1956 model Cessna 172 airplane with serial number 28343. 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, six-cylinder, Continental Motors O-300-B engine, bearing serial number 10976-D-5-B, and marked as producing 145-horsepower at 2,700 rpm. The engine drove a fixed pitch McCauley propeller marked as a model 1A170/DM7651 propeller with serial number 56289. An airplane logbook endorsement showed that the airplane's last annual inspection was completed on May 1, 2014, and that the airplane had a tachometer time of 1,501:14. The airplane's total time could not be determined from logbook entries. According to fueling records, the airplane was fueled with 27.1 gallons of aviation gasoline on December 31, 2014. DTN, located approximately three miles north of downtown Shreveport, Louisiana, was a towered airport, owned by the Shreveport Airport Authority. The airport's field elevation was 179 feet above mean sea level. DTN had two runways: runway 14/32 - 5,018 feet by 150 feet, asphalt, and runway 5/23 - 3,200 feet by 75 feet, asphalt. On June 19, 2015, about 1715 central daylight time, a Cessna 172 airplane, N5743A, impacted terrain during takeoff following a touch and go on runway 23 at the Shreveport Downtown Airport (DTN), near Shreveport, Louisiana. The commercial pilot who was the sole occupant was fatally injured. The airplane sustained substantial wing and fuselage damage. The airplane was registered to and operated by Bag Flying Club Inc. under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual flight rules conditions prevailed for the flight, which did not operate on a flight plan. The local flight originated from DTN at time unknown. The airplane had been observed performing touch and go landings at DTN. An air traffic controller cleared the airplane to perform a touch and go landing on runway 23. During the accident takeoff, the airplane was observed in a nose high attitude. The National Transportation Safety Board investigator in charge listened to a recording of the tower communications and the pilot representing N5743A made an abbreviated radio call indicating that he was returning. The controller subsequently saw the airplane rolled to the left, nosed over, and impacted the ground left wing first. The airplane cartwheeled on its nose and came to rest pointing back towards the departure runway. The controller subsequently made emergency response notifications, and first responders went to the accident site. A liquid consistent with aviation gasoline was found leaking from the left wing, which had partially separated from its fuselage. First responders stopped the fuel tank's leak. The Parish of Caddo Coroner arranged with the Louisiana State University Health Science Center to conduct an autopsy on the pilot and take toxicological samples. The autopsy listed thecause of death as blunt force injuries. The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report. The report was negative for the tests performed. At 1853, the recorded weather at DTN was: Wind 240 at 11 knots; visibility 10 statute miles; sky condition clear; temperature 32 degrees C; dew point 22 degrees C; altimeter 29.94 inches of mercury. The 65-year-old pilot held a Federal Aviation Administration (FAA) commercial pilot certificate with airplane single engine and multi engine land, instrument airplane, and lighter-than-air free balloon ratings. He also held a flight instructor's certificate for single engine airplanes. The pilot held a Second Class Medical Certificate dated July 19, 2013, with a limitation to have glasses available for near vision. On the application for that medical certificate, he indicated that he had accumulated 2,100 hours of total flight time and 5 hours of flight time in last six months before the exam. The certificate showed that the pilot was 74 inches tall. His logbook showed he had recorded that he flew 1,924.8 hours of total flight time and an endorsement, dated March 3, 2015, showed that he acquired the ground training for a flight review. The airplane was equipped with lap belts and it did not have any shoulder harnesses. First responders found the pilot's upper torso, arms, and head were resting on the eyebrow molding over the instrument panel. The pilot sustained injuries that were consistent with unrestrained forward impact with the control yoke. The accident engine was shipped to Continental Motors. The engine's sparkplug wires were damaged and the carburetor had a separated mounting flange. The sparkplug wires were removed and exemplar wires were installed. The carburetor's separated flange was repaired with an adhesive. The engine was fitted with an exemplar carburetor and a test club propeller. The engine was subsequently mounted on a test stand. The engine was operational during the test run. The exemplar carburetor was removed and the repaired carburetor was installed on the engine. The engine was operational during the test run with the repaired carburetor. The engine produced rated rpm and accelerated to full rpm during throttle accelerations from idle. No pre-impact abnormities were noted with the engine during the examination test run. The airplane came to rest upright on an approximate 270 degree heading, about 840 feet and 214 degrees from the intersection of runway 5/23 and 14/32; near taxiways Mike and Quebec. A ground scar started about 65 feet from and 330 degrees from the wreckage. Red colored glass like media was found abeam the scar about 58 feet from the wreckage. Linear depressions nearly perpendicular to the scar were found about 39 and 38 feet from the wreckage. The linear depressions had a transfer of a media consistent with the black and white color paint on the propeller blades. An oval shape depression was observed along the scar between 37and 35 feet from the wreckage. The airplane's fuselage was resting with its nose on the ground and its tail elevated. Both wing inboard leading edges sections were not damaged. The left wing tip leading edge had dirt colored media adhering to it. The rear fuselage, aft of the baggage compartment, was torn on its upper surface and the empennage was buckled downward. The empennage structures were not damaged. The left aileron was buckled about mid-span. The left flap was buckled around the inboard hinge. The inboard end of the left flap had a witness mark consistent with contact of the left flap contour formed on the fuselage. The outboard end of the left flap and inboard end of the left aileron had witness marks consistent with contact by each other. The left wing remained attached to the fuselage at its forward spar and had separated from the fuselage at its rear spar. The left fuel tank vent hose was partially separated and the left fuel tank fuel line was separated. The left aileron bell crank was partially separated from its wing mount. The remaining flight controls were intact. The control column in both pitch and roll and the rudder pedals could not be moved due to airframe structure impinging on them. Control cables were traced from the cockpit controls to each flight control surface and flight control continuity was established. The elevator trim wheel moved and its control cables were intact to its trim actuator. The actuator's extension corresponds to zero degrees of trim and the trailing edge of the trim tab was aligned with the elevator's trailing edge. The flap's actuator bar was moved by hand and both flaps moved. The left and right wing tanks were defueled and the removed fuel totaled about 10 gallons. The fuel tank selector valve handle was found out-of-detent between right tank and OFF positions. The fuel line to the engine fuel line was detached and a jumper hose attached. Low-pressure air was applied to the hose and each fuel tank cap was removed to listen for air. The sound of air was heard coming from the right fuel tank filler neck. As the fuel tank selector valve was subsequently rotated thought its four detent positions air was heard in the expected locations; right filler cap opening, left fuel line separation at left wing root, both locations, and then no location. The line was then attached to the detached engine feed line and air again applied. Air was heard at the fuel line detached from the carburetor. Air was applied to the fuel tank vent and it could be heard at both filler necks. The right fuel tank cap's flapper valve was intact. First responders had removed the pilot's seat back. The pilot's seat rails were buckled. The pilot's seat was pinned in the rail's fifth aft hole, which is consistent with it being selected in reference to the pilot's height. The fifth hole was cracked perpendicular across the hole with respect to the rail. The seat's pin required the use of pliers to retract the pin from the hole. Theengine tachometer indicated it had accumulated 1,529:01 hours of time. The propeller had one blade bowed forward and one blade bowed aft. The blade bowed aft had cord-wise abrasions on its blade back. The engine was able to rotate when its propeller flange was turned by hand. The sound of impulse couplings were heard when the flange was turned. The carburetor separated from the engine at its mounting base with the engine. The carburetor accelerator pump ejected a fluid consistent with the smell of aviation gasoline when it was depressed. The emergency locator transmitter was found in the "on" position and was turned off during the examination of the wreckage. ## Aircraft - Registration: [N5743A](https://openairdocs.org/deregistered/N5743A-2018-03-14), registration cancelled 2018-03-14, S/N 28343, built 1956 (OpenAirDocs) - Reported make and model: CESSNA 172 - Registry model: [Cessna 172](https://openairdocs.org/model/cessna-172) (registry code 2072402) (OpenAirDocs) - Registry engine: [Continental 0-300 series](https://openairdocs.org/engine/continental-0-300-series) (registry code 17022, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28343 - Year built: 1956 - Engines: CONT MOTOR O-300-B 145 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Bag Flying Club Inc - Registered owner: Bag Flying Club Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2014 - Departed: DTN, Shreveport, LA - Destination: DTN, Shreveport, LA - Airport: DTN, Shreveport Downtown, runway 23, 3,200 × 75 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: fatal; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review March 3, 2015; seat: left; restraint: lap only; toxicology performed; flight hours: 2,100 total ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 72 °F - Altimeter: 29.94 inHg - Observed at: KDTN ## 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 20150619010169A](https://openairdocs.org/incident/20150619010169A), Jun 19, 2015: Cessna 172, Shreveport, LA, Destroyed, 1 fatal. Aircraft impacted terrain after takeoff following a touch and go on RUNWAY23 at Shreveport downtown (kdtn). ## Docket (9 files) The files NTSB released with the investigation on December 10, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91403. 9.6 MB in all. - Maintenance Records - Engine Logbook Excerpt (item 1, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434835&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Engine%20Logbook%20Excerpt-Master.PDF - Maintenance Records - Logbook Excerpt (item 2, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434836&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Logbook%20Excerpt-Master.PDF - Miscellaneous Information - Pilot Logbook Excerpt (item 3, .PDF, 802 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434837&FileExtension=.PDF&FileName=Miscellaneous%20Information%20-%20Pilot%20Logbook%20Excerpt-Master.PDF - Wreckage Diagram supplied by Textron Aviation (item 4, .PDF, 442 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434838&FileExtension=.PDF&FileName=Wreckage%20Diagram%20supplied%20by%20Textron%20Aviation-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 5, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434840&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 6, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434841&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Evidence Control Form (item 7, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434842&FileExtension=.PDF&FileName=Evidence%20Control%20Form-Master.PDF - Toxicological Report (item 8, .PDF, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434843&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photos (item 9, .PDF, 14 photos, 6.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434839&FileExtension=.PDF&FileName=Photos-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.