CEN15LA109

NTSB accident investigation · Cessna 182R · Santa Fe, NM · January 15, 2015

Accident · No injuriesLimited investigationFinal report
Date
January 15, 2015, 10:02 local (17:02 UTC)
Place
Santa Fe, NM
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N9611HCessna 182R
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report April 26, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA Albuquerque FSDO
FAA report
20150115001419A
Case key
90619

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot’s failure to remove ice from the airplane’s surfaces before departure, which resulted in the airplane’s inability to attain sufficient airspeed shortly after takeoff, the subsequent exceedance of the airplane’s critical angle-of-attack, and an aerodynamic stall.

Findings · 7

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: lack of actionPersonnel issues › Action/decision · PilotCessna 182R: 2 casesAll aircraft: 792 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 182R: 11 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 182R: 1 caseAll aircraft: 990 casesProbable cause
Aircraft capability: climb capabilityAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleCessna 182R: 1 caseAll aircraft: 183 casesProbable cause
Temp/humidity/pressure: conducive to structural icingEnvironmental issues › Conditions/weather/phenomena · Decision related to conditionCessna 182R: 1 caseAll aircraft: 103 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Attain/maintain not possibleCessna 182R: 3 casesAll aircraft: 1,681 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot was conducting a personal cross-country flight. The pilot reported that, during takeoff with 0 flaps, he accelerated the airplane to about 60 knots and that it subsequently lifted off. About 50 to 100 ft above ground level, the airplane entered an uncommanded steep left bank; the pilot used aileron and rudder inputs and briefly regained control of the airplane before it again banked hard left, pitched down, and impacted terrain. The airplane came to rest upright about 500 ft left of the runway and about 3,000 ft from the beginning of the takeoff roll. The uncommanded bank and pitch down is indicative of an aerodynamic stall. A witness at the airport reported that all of the aircraft, which included the accident airplane, that had been parked overnight on the ramp had frost or ice on them. He added that, before departure, the pilot did not remove any of the frost or ice from the airplane's wings, tail, or fuselage. Photographs of the airplane taken about 45 minutes after the accident showed 1/8- to 1/4-inch-thick rough, mixed rime ice adhering to the wing. The pilot's failure to remove the ice from the airplane's surfaces before departure degraded its takeoff performance and prevented it from attaining sufficient speed to remain airborne and resulted in an aerodynamic stall.

Factual narrative

On January 15, 2015, about 1002 mountain standard time, a Cessna 182R, single engine airplane N9611H, was substantially damaged after impacting terrain during initial climb from Santa Fe Municipal Airport (SAF), Santa Fe, New Mexico. The pilot and passenger were not injured. The airplane was registered to and operated by a private individual. Day visual meteorological conditions (VMC) prevailed at the time of the accident and a flight plan had not been filed for the 14 Code of Federal Regulations Part 91 personal flight. At the time of the accident the airplane was departing SAF and was destined for Cedar City Regional Airport (CDS), Cedar City, Utah. During takeoff with zero flaps the pilot accelerated to about 60 knots and the airplane lifted off. About 50 to 100 feet above ground level the airplane entered an uncommanded steep bank to the left and the pilot used aileron and rudder to briefly regain control before the airplane again banked hard to the left pitched down and impacted terrain. The airplane came to rest upright about 500 feet left of the runway and about 3,000 feet from the start of the takeoff. There was no postimpact fuel spill and both occupants exited without assistance. Witnesses at the airport reported that all aircraft that had been parked overnight on the ramp had frost or ice on them. They estimated the thickness of the frost or ice as about 1/8 inch or less. Witnesses also reported that before departing the pilot used a credit card to remove frost or ice from only the windshield, however he did not remove any of the frost or ice from the wings or tail or fuselage of his airplane. Photographs of the airplane taken about 45 minutes after the accident, showed rough mixed rime ice adhering to the top of the wing, and on the upper part of the metal portions of the leading edges of the wing. The thickest rough portions of the ice appeared to be about 1/8 inch to as much as 1/4 inch thick. The pilot reported no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. A postaccident examination of the airplane showed substantial damage to the left aileron, the firewall, and the lower forward fuselage. The nose gear attach bracket had damage that sheared the rivets off the firewall and wrinkled the firewall. At 0953 the automated weather observing system at SAF, reported wind from 360 degrees at 11 knots, visibility of 10 miles, clear of clouds, temperature 0 degrees Celsius (C), dew point minus 3 degrees C, with an altimeter setting of 30.42 inches of Mercury. ADDITIONAL INFORMATION: The Pilot's Operating Handbook (POH) and FAA Approved Airplane Flight Manual (AFM) for the Cessna 182R states that the pilot should lift the nose wheel at 50 knots and, for a takeoff with zero flaps, climb out at 80 knots. The POH/AFM also states that the power off stall speed at a maximum gross weight of 3,100 pounds with zero flaps is about 50 knots. 14 Code of Federal Regulations Part 91.527(a) states: "No pilot may take off an airplane that has frost, ice, or snow adhering to any… wing". FAA 00-6A - Aviation Weather for Pilots and Flight Operations Personnel, Chapter 10 states: Aircraft icing is one of the major weather hazards to aviation (and) is a cumulative hazard. It reduces aircraft efficiency by increasing weight, reducing lift, decreasing thrust, and increasing drag … each effect tends to either slow the aircraft or force it downward (and) that even a small amount of frost … may prevent an aircraft from becoming airborne at normal takeoff speed (or that) after becoming airborne, could have insufficient margin of airspeed above stall so that moderate gusts or turning flight could produce incipient or complete stalling".

Aircraft

Registration
N9611H
Reported as
Cessna 182R
Category
Airplane
Serial number
18267972
Built
1981
Airframe hours
10,771
Engine
Cont Motor O-470-U, 230 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2013 · 15 hours before
Departed
SAF · Santa Fe, NM
Destination
CDC · Cedar City, UT
Airport
SAF · Santa Fe Muni, runway 02, 8,366 × 150 ft, asphalt
Equipment
Electronic primary flight display, Electronic multifunction display, Auto-pilot, Stall warning system, Onboard weather

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
71
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
September 25, 2014
Seat
Left
Restraint
3-point
Flight hours
120 total · 14 in this make and model · 72 as pilot in command · 37 in the last 90 days · 12 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
360° at 11 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
32 °F, dew point 27 °F
Altimeter
30.42 inHg
Observed at
KSAF

Docket · 4

The files NTSB released with the investigation on March 7, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.