# NTSB CEN17LA025: Cessna 182Q, N97878, Buffalo, WY, October 23, 2016 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: October 23, 2016, 10:10 local (16:10 UTC) - Place: Buffalo, WY - Coordinates: 44.385555, -106.620552 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.3856&lon=-106.6206&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report May 1, 2017 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Continental Motors, Inc., Textron Aviation, Federal Aviation Administration - NTSB case key (mKey): 94267 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN17LA025 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94267/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94267 - Page: https://openairdocs.org/ntsb/CEN17LA025 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: tE flap control system](https://openairdocs.org/ntsb-findings/01022750): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Cessna 182Q, 2 cases](https://openairdocs.org/ntsb-findings/01022750/cases.md?model=2072732), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022750/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 182Q, 6 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2072732), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/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 on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna 182Q, 13 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2072732), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 182Q, 28 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072732), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N97878-2019-03-09), registration cancelled 2019-03-09, S/N 18267238, built 1979 (OpenAirDocs) - Reported make and model: CESSNA 182Q (Q) - Registry model: [Cessna 182Q](https://openairdocs.org/model/cessna-182q) (registry code 2072732) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18267238 - Year built: 1979 - Airframe hours: 3486 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: serious; 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 ## 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 20161023021389A](https://openairdocs.org/incident/20161023021389A), Oct 23, 2016: Cessna 182Q, Buffalo, WY, Substantial damage. [privacy data omitted] Failed to follow published check list for short field takeoff. ## Docket (7 files) The files NTSB released with the investigation on March 16, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94267. 6.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450000&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - STC Checklist (item 2, .PDF, 193 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450001&FileExtension=.PDF&FileName=STC%20Checklist-Master.PDF - JPI Engine Data - Accident Flight (item 3, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450002&FileExtension=.PDF&FileName=JPI%20Engine%20Data%20-%20Accident%20Flight-Master.PDF - Excerpts of Aircraft Records (item 4, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450003&FileExtension=.PDF&FileName=Excerpts%20of%20Aircraft%20Records-Master.PDF - CMI Engine Test Report (item 5, .PDF, 19 photos, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450004&FileExtension=.PDF&FileName=CMI%20Engine%20Test%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation - Textron (item 6, .PDF, 462 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450005&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Textron-Master.PDF - Statement of Party Representatives to NTSB Investigation - CMI (item 7, .PDF, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40450006&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20CMI-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.