CEN17LA025

NTSB accident investigation · Cessna 182Q · Buffalo, WY · October 23, 2016

Accident · Serious injuriesLimited investigationFinal report
Date
October 23, 2016, 10:10 local (16:10 UTC)
Place
Buffalo, WY
Injuries
1 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N97878Cessna 182Q
Defining event
Takeoff: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed · report May 1, 2017
Report
Approved by Office Director
NTSB office
Central Region
Parties
Continental Motors, Inc., Textron Aviation, Federal Aviation Administration
FAA report
20161023021389A
Case key
94267

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 set the proper flap position before the short field takeoff, which resulted in a runway excursion and impact with terrain.

Findings · 2

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.

Flight control system: tE flap control systemAircraft › Aircraft systems · Incorrect use/operationCessna 182Q: 2 casesAll aircraft: 74 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotCessna 182Q: 6 casesAll aircraft: 1,391 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 reported that, before taking off from the 1,200-ft-long grass/gravel private airstrip, he performed an engine run-up and set the flaps to 20 degrees. He applied full engine throttle and accelerated to 45 knots airspeed for rotation/takeoff. After applying back pressure to the yoke for takeoff, the airplane would not lift off the runway. The airplane "passed the point of no return," and the pilot continued the takeoff. The airplane impacted a metal post near the end of the runway, traveled down an embankment, impacted terrain, cartwheeled, and came to rest inverted. The pilot reported that all engine instruments were in the "green" during the takeoff roll. An engine test run revealed no anomalies that would have precluded the engine's ability to produce rated horsepower. Examination of the airframe revealed the flaps were in the fully retracted or 0° position. According to the supplemental type certificate pilot's checklist, the flaps should be set at 20° for a short field takeoff. The improper flap setting reduced the airplane's lift and resulted in a longer takeoff roll.

Factual narrative

On October 23, 2016, at 1010 mountain daylight time, a Cessna 182Q single-engine airplane, N97878, impacted terrain following a loss of control during takeoff from a private airstrip near Buffalo, Wyoming. The private pilot, who was the sole occupant, sustained serious injuries, and the airplane sustained substantial damage to the fuselage. The airplane was registered to Garland Air LLC, Buffalo, Wyoming, and operated by a private individual as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed at the time of the accident and a flight plan was not filed. The flight was originating at the time of the accident. Prior to takeoff from the 1,200-foot grass/gravel private airstrip, the pilot reported that he performed an engine run-up and set the flaps to 20 degrees. He applied full engine throttle and advanced to 45 knots airspeed for rotation/takeoff. After applying back pressure to the yoke for takeoff, the airplane would not lift off the runway. The airplane "passed the point of no return" and the pilot kept waiting for the airplane to lift off the runway. Near the end of the left side of the runway, the airplane impacted a metal post, went down an embankment, impacted terrain, cartwheeled, and came to rest inverted. Witnesses to the accident assisted the pilot in exiting the airplane. According to local authorities, the pilot stated that all engine instruments were in the "green" during the takeoff roll. Examination of the airplane by a Federal Aviation Administration inspector revealed the fuselage, both wings, and empennage were buckled and bent. The propeller assembly separated from the engine crankshaft and came to rest in the debris field. The engine remained partially attached to the airframe and was crushed aft into the fuselage. The airplane was recovered for further examination. On November 8, 2016, at the facilities of Beegles Aircraft Services, Greeley, Colorado, the airplane was examined under the supervision of the NTSB investigator-in-charge (IIC). Examination of the airframe revealed the flaps were in the fully retracted or 0-degree position, as confirmed by the flap actuator position. Flight control continuity was established from the cockpit flight controls to the flight control surfaces. Damage, consistent with the impact sequence, was noted on the following engine components: right rear wye pipe separated and missing, front induction balance tube, no. 2 cylinder rocker box cover, propeller governor, right front and rear engine mounts, muffler, lower alternator mount, and exhaust risers/collectors. The engine was manually rotated and thumb compression was confirmed on all six cylinders. Spark was produced at all upper sparkplug ignition leads. The propeller spinner displayed rotational type marks. One propeller blade exhibited rearward twisting and bent about 18 inches outboard of blade root, one blade exhibited rearward twisting and bent about 12 inches outboard of blade root,and one blade was twisted about 180 degrees and was loose in the propeller hub. The blade displayed leading edge and cambered surface gouging. The engine was removed and shipped to the manufacturer for a functional test. A review of the maintenance records showed the most recent annual inspection was completed on February 15, 2016. On July 9, 2016, a high-left canard was installed in accordance with supplemental type certificate (STC) SA485SW. The STC SA485SW pilot checklist indicated the flaps should be set to 20 degrees extended for short field takeoffs. In addition, a Continental Motors, Inc. (CMI) IO-550D-13B engine, and a McCauley propeller were installed in accordance with STC SA3825SW. At the time of the accident, the engine had accumulated 44.7 hours since factory remanufacture. The airplane was equipped with a JPI engine data monitoring (EDM-700) unit. The unit was downloaded at a local Greeley, Colorado, avionics facility. The EDM-700 unit data contained several "flights" of data. The accident flight data was captured on the unit. The accident flight data parameters were consistent with other previous flight data parameters. On January 10 and 11, 2017, at the facilities of CMI, Mobile, Alabama, the engine was examined and a functional test of the engine was performed under the supervision of the NTSB IIC. After replacing some components that were damaged in the accident, the engine was placed in a test cell for a functional test. The engine was test run for 30 minutes at various power settings with no anomalies noted that would have precluded the engine's ability to produce rated horsepower.

Aircraft

Registration
N97878
Reported as
Cessna 182Q (Q)
Category
Airplane
Serial number
18267238
Built
1979
Airframe hours
3,486
Engine
Cont Motor IO-550D-13B, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Garland Air LLC
Registered owner
Garland Air LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 15, 2016 · 53 hours before
Departed
PVT · Buffalo, WY
Destination
GCC · Gillette, WY
Equipment
Stall warning system

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
64
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
August 11, 2015
Seat
Left
Restraint
3-point
Flight hours
4,400 total · 2,000 in this make and model · 4,400 as pilot in command · 80 in the last 90 days · 20 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 14 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
45 °F, dew point 36 °F
Altimeter
30.17 inHg
Observed at
BYG, 5 nm away

Docket · 7

The files NTSB released with the investigation on March 16, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.8 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.