CEN19FA307

NTSB accident investigation · Cessna 140 · Lakeview, SD · September 8, 2019

Accident · FatalClass 3 · FieldFinal report
Date
September 8, 2019, 00:00 local (05:00 UTC)
Place
Lakeview, SD
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N73000Cessna 140
Defining event
Enroute: Loss of control in flight
Weather
Visual (VMC) · Dusk
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Continental Motors, Textron Aviation, FAA Rapid City FSDO
FAA report
20190908012769A
Case key
100213

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

On this page

Probable cause

The student pilot’s failure to maintain control of the airplane, which resulted in the exceedance of the airplane’s critical angle-of-attack, an aerodynamic stall, and subsequent impact with terrain, and the student pilot’s non-compliance and lack of experience.

Findings · 6

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Student/instructed pilotCessna 140: 56 casesAll aircraft: 9,295 casesProbable cause
Attention/monitoring: monitoring equip/instrumentsPersonnel issues › Psychological · Student/instructed pilotCessna 140: 1 caseAll aircraft: 142 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededCessna 140: 4 casesAll aircraft: 990 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedCessna 140: 4 casesAll aircraft: 2,247 casesProbable cause
Experience/qualifications: qualification/certificationPersonnel issues › Experience/knowledge · Student/instructed pilotCessna 140: 1 caseAll aircraft: 280 casesProbable cause
Experience/qualifications: total experiencePersonnel issues › Experience/knowledge · Student/instructed pilotCessna 140: 1 caseAll aircraft: 126 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 student pilot was conducting a low-level aerial observation flight with his son to determine the level of water in towers on farms nearby. The time of the student pilot’s departure from his private airstrip and the time of the accident could not be determined. The amount of fuel in the airplane at takeoff was undetermined. After contact from concerned family members, law enforcement located the wreckage the next day about 825 ft from the approach end of the pilot's airstrip. Postaccident examination of the airframe and engine revealed no preimpact anomalies that would have precluded normal operation. Airplane wreckage and impact signatures were consistent with the airplane being configured for landing. Propeller signatures indicated little or no rotation at the time of impact. The impact damage was consistent with a loss of control in flight, followed by the exceedance of the airplane's critical angle of attack and an aerodynamic stall. The reason for the loss of control in flight could not be determined. The student pilot was taught to fly by his grandfather. It is possible the student pilot was teaching his son to fly; however, it was undetermined if that was occurring during the accident flight. The pilot held a student pilot certificate and therefore was prohibited by regulation from carrying a passenger. Additionally, the student pilot's endorsement for flight operations was expired, and he did not hold an endorsement for the accident airplane make and model.

Factual narrative

The amount of fuel in the airplane before the flight departed was undetermined. The airframe and engine were modified to use automotive fuel (referred to as MOGAS) in accordance with FAA supplemental type certificates. The airplane was not equipped with a carburetor temperature system or a stall warning indicator, nor was it required to be. A review of the airplane's maintenance records revealed no evidence of any uncorrected mechanical discrepancies with the airframe and engine. The student pilot's private airstrip, which was about 65 ft wide and 1,850 ft long, consisted of grass and dirt. The airstrip was about 5.5 miles southwest of Lakeview and was oriented about 350° and about 170° (runway 35-17, respectively). It was undetermined if the airstrip had runway lighting. On September 8, 2019, at an undetermined time, a Cessna 140 airplane, N73000, sustained substantial damage when it was involved in an accident near Lakeview, South Dakota. The student pilot and passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 aerial observation flight. Local law enforcement reported that according to family members, the purpose of the flight was for the student pilot and his son to fly around the local area for the aerial observation of various large water towers stationed on farms on the Rosebud Indian Reservation. It was unknown what time the airplane departed for the flight from the student pilot's private airstrip. The student pilot would normally fly the airplane low, over the water towers, and look down into the water towers to determine the water level. He would then report the water level to the farmers. It was unknown if the pilot was compensated by the farmers for performing the aerial observation work. After not hearing from the student pilot and his son for several hours, concerned family members contacted local law enforcement officers, who then initiated a search for the missing airplane. The wreckage was located about 0800 central daylight time on September 9, 2019, as shown in the figure. Figure. View of the airplane looking to the south. The student pilot's private airstrip is shown in the upper right corner of the photograph near the trees. The Sanford Health Pathology Clinic, Sioux Falls, South Dakota, conducted an autopsy of the pilot. The cause of the death was attributed to multiple blunt force injuries. The FAA's Forensic Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology tests on specimens from the pilot; testing was negative for carbon monoxide and ethanol. A review of weather data from 1652 to 2152 from the Miller Field Airport (VTN), Valentine, Nebraska, showed temperatures between 16°C (60.8°F) and 19°C (66.2°F), along with dew points between 11°C (51.8°F) and 12°C (53.6°F). The reported conditions for those times indicated a probability of serious icing at either cruise or glide power settings per the carburetor icing probability graph from the FAASpecial Airworthiness Information Bulletin CE-09-35 Carburetor Icing Prevention. FAA Special Airworthiness Information Bulletin CE-09-35 Carburetor Icing Prevention informs pilots of the potential hazards associated with carburetor icing. This document does not include information about the probability of carburetor icing occurring with MOGAS. The FAA reported it has not published any information or disclaimers for the public about MOGAS and the formation of carburetor icing. A review of the Federal Aviation Administration (FAA) electronic airmen registry for the student pilot revealed that he held a student pilot certificate. The limitation listed on the student pilot certificate states, "carrying passengers is prohibited." Title 14 CFR 61.89 discusses the limitations for student pilots and states that a student pilot may not act as a pilot-in-command of an aircraft that is carrying a passenger. It was undetermined if the passenger was manipulating the flight controls during the flight. A review of the student pilot's logbook showed that he started logging flight time in August 2007 and that the last logged flight was in November 2015. The student pilot had received an endorsement to conduct solo flights in a Cessna 150 airplane. The endorsement was dated October 29, 2015, and expired in July 2016. No further endorsements were found. No solo flight endorsements were found listed for a Cessna 140. Title 14 CFR 61.87(n) discusses the limitations for student pilots operating an aircraft in solo flight and states the following: A student pilot may not operate an aircraft in solo flight unless that student pilot has received an endorsement in the student's logbook for the specific make and model aircraft to be flown by an authorized instructor who gave the training within the 90 days preceding the date of the flight. The flight instructor who provided the initial solo endorsement for the student pilot described the student pilot as a "safe pilot" except that he flew with his son and wasn’t supposed to as a student pilot. The flight instructor reported that the student pilot was taught to fly by his grandfather, who was not a certificated pilot. He further reported that the student pilot knew he was not supposed to fly with passengers as a student pilot. The airplane came to rest on a heading of 24° and at an elevation of 2,910 ft above mean sea level on grass. The airplane was about 825 ft to the northwest of the approach end of runway 17 at the student pilot's private airstrip. The airplane sustained substantial damage to both wings, the fuselage, and the empennage. Evidence was consistent with the airplane impacting terrain in a near-vertical, nose-down, left-wing-low attitude. The tail was bent slightly up and over the fuselage. The left- and right-wing leading edges sustained significant impact compression damage. All components of the airframe and engine were located at the accident site. Flight control continuity was established for theairframe. Control continuity was established for the engine. A flap impact-related witness mark was observed on the right side of the fuselage indicating the flaps were extended at the time of impact. Due to impact damage, the position of the carburetor heat control at the time of the accident was not determined. The two wing fuel tanks were breached from the accident sequence, and the fuel level at the time of impact was undetermined. A small amount of fuel was obtained from both fuel tanks. The fuel had unknown debris in it and was a slight yellow color. The propeller remained attached to the engine. One propeller blade remained relatively straight and exhibited paint burnishing with diagonal scratches on the cambered side. The other propeller blade was bent aft around the engine cowling at approximately midspan and did not exhibit rotational impact signatures. The examination revealed no preimpact mechanical malfunctions or failures with the airframe and engine that would have precluded normal operation.

Aircraft

Registration
N73000
Reported as
Cessna 140 (Undesignat)
Category
Airplane
Serial number
10205
Built
1946
Airframe hours
2,093.67
Engine
Continental Motors C-85-12, 85 horsepower, reciprocating
Damage
Substantial damage
Flight
Aerial observation · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 7, 2019 · 4 hours before
Departed
None · Lakeview, SD
Destination
None · Lakeview, SD
Airport
None · Private Airstrip
Equipment
None

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
39
Injuries
Fatal
Certificate
Student
Medical
Class 3
Last flight review
October 29, 2015
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
40 total · 20 in this make and model · 20 as pilot in command

Weather

Conditions
Visual (VMC) · Dusk
Wind
50° at 6 knots
Visibility
10 statute miles
Lowest ceiling
2,200 ft broken
Temperature
61 °F, dew point 52 °F
Altimeter
29.97 inHg
Observed at
KVTN, 15 nm away

Docket · 21

The files NTSB released with the investigation on August 26, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 90.6 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.