# NTSB CEN15LA109: Cessna 182R, N9611H, Santa Fe, NM, January 15, 2015

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Limited investigation · Final report
- Date: January 15, 2015, 10:02 local (17:02 UTC)
- Place: Santa Fe, NM
- Coordinates: 35.615554, -106.091667 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=35.6156&lon=-106.0917&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report April 26, 2016
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: FAA Albuquerque FSDO
- NTSB case key (mKey): 90619
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15LA109
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90619/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90619
- Page: https://openairdocs.org/ntsb/CEN15LA109

## 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

NTSB's coded findings; those marked are part of the probable cause.

- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 182R, 2 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2072731), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 182R, 5 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2072731), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 182R, 11 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072731), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 182R, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2072731), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md)
- [Aircraft capability: climb capability](https://openairdocs.org/ntsb-findings/01061010): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Cessna 182R, 1 case](https://openairdocs.org/ntsb-findings/01061010/cases.md?model=2072731), [All aircraft, 183 cases](https://openairdocs.org/ntsb-findings/01061010/cases.md)
- [Temp/humidity/pressure: conducive to structural icing](https://openairdocs.org/ntsb-findings/03031025): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Cessna 182R, 1 case](https://openairdocs.org/ntsb-findings/03031025/cases.md?model=2072731), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/03031025/cases.md)
- [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Cessna 182R, 3 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2072731), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/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: Aircraft inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Cessna 182R, 2 cases](https://openairdocs.org/ntsb-events/050/sequence.md?model=2072731), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md)
- [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 182R, 4 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072731), [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 182R, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072731), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## 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](https://openairdocs.org/aircraft/N9611H), registered now, S/N 18267972, built 1981 (OpenAirDocs)
- Reported make and model: CESSNA 182R
- Registry model: [Cessna 182R](https://openairdocs.org/model/cessna-182r) (registry code 2072731) (OpenAirDocs)
- Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 18267972
- Year built: 1981
- Airframe hours: 10771
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 71; injuries: none; 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

## 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 20150115001419A](https://openairdocs.org/incident/20150115001419A), Jan 15, 2015: Cessna 182R, Santa Fe, NM, Substantial damage. On January 15. 2015 at 10:02 MST, a Cessna 182, N9611H departed the runway on takeoff at Santa Fe municipal airport, Santa Fe, new Mexico while on a personal…

## Docket (4 files)

The files NTSB released with the investigation on March 7, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90619. 2.0 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 878 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437341&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Summary of Findings (item 2, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437344&FileExtension=.PDF&FileName=Summary%20of%20Findings-Master.PDF
- Weather Summary (item 3, .PDF, 19 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437345&FileExtension=.PDF&FileName=Weather%20Summary-Master.PDF
- Photos (item 4, .PDF, 3 photos, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40437347&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.

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