# NTSB CEN19FA325: Cessna A185, Conroe, TX, September 21, 2019

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Field · Final report
- Date: September 21, 2019, 18:25 local (23:25 UTC)
- Place: Conroe, TX
- Coordinates: 30.344722, -95.405281
- Nearby events: https://openairdocs.org/map.md?lat=30.3447&lon=-95.4053&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Fuel contamination](https://openairdocs.org/ntsb-events/193)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Central Region
- Parties: FAA, Textron Aviation, Continental Motors
- NTSB case key (mKey): 100303
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA325
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100303/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100303
- Page: https://openairdocs.org/ntsb/CEN19FA325

## Probable cause

A partial loss of engine power due to fuel contamination with water, and the pilot’s failure to maintain control of the airplane during an attempted return to the airport shortly after takeoff, which resulted in an aerodynamic stall.

## Findings

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

- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Fluids: fuel](https://openairdocs.org/ntsb-findings/01071010): Aircraft › Fluids/misc hardware · Fluid condition (probable cause); cases with it: [All aircraft, 1,695 cases](https://openairdocs.org/ntsb-findings/01071010/cases.md)
- [Fluids: water](https://openairdocs.org/ntsb-findings/01071030): Aircraft › Fluids/misc hardware · Related operating info (probable cause); cases with it: [All aircraft, 13 cases](https://openairdocs.org/ntsb-findings/01071030/cases.md)
- [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Takeoff: Fuel contamination](https://openairdocs.org/ntsb-events/193) (defining event); cases with it: [All aircraft, 225 cases](https://openairdocs.org/ntsb-events/193/sequence.md)
- [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Maneuvering: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342); cases with it: [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The pilot and pilot-rated passenger had just departed and planned to depart the airport area. During the initial takeoff climb, the pilot-rated passenger reported to air traffic control that she had a “fuel issue/problem” and was going to return to the airport. A witness stated that the engine made a loud "pop pop" sound followed by a decrease in engine power. A few seconds later, the witness heard the engine power increase again. According to the air traffic controller, the airplane’s left bank continued to increase, and he cleared the airplane to land on any runway. The airplane subsequently impacted terrain in a nose-low attitude. Postaccident examination of the airplane revealed that the left wing contained about one gallon of fuel and about 6 oz of water. The source of the water could not be determined. No other anomalies were noted with the airframe. Examination and a functional test of the engine did not reveal any anomalies that would have precluded normal operation. It is likely that the engine lost power shortly after takeoff due to the water contamination found in the fuel tank. It is also likely that during the steep bank turn towards the airport, the pilot allowed the airplane to exceed the critical angle of attack which resulted in an aerodynamic stall and subsequent impact with the ground. Based on the toxicology results, it is likely that the pilot had taken the sedating prescription medication clonazepam. Clonazepam is used to treat seizure disorder and panic disorder. The inactive metabolite was detected in blood and urine suggesting the use of the medication occurred several days before the accident. Given the lack of the active compound it is unlikely the pilot’s use of clonazepam contribute to this accident. Ethanol was detected in the pilot’s blood, but not in his urine. It is likely that the identified ethanol was from sources other than ingestion and did not contribute to this accident.

## Aircraft

- Registration: C-GOZJ (not matched to a registry record)
- Reported make and model: Cessna A185 (F)
- Category: Airplane
- Serial number: 18502526
- Year built: 1974
- Airframe hours: 2454.4
- Engines: Continental Motors IO-520-D30B 285 horsepower reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, March 29, 2019
- Airport: CXO, Conroe-North Houston Rgnl, runway 14, 7,501 × 150 ft, concrete
- Equipment: Unknown

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 61; injuries: fatal; private; airplane ratings: single-engine land, single-engine sea; medical: class 3, with waivers/limitations; last flight review May 16, 2016; seat: left; restraint: 5-point; toxicology performed; flight hours: 705.1 total, 218.1 in this make and model, 648.3 as pilot in command
- Pilot; age 41; injuries: fatal; private; airplane ratings: single-engine sea, single-engine land; medical: class 3, without waivers/limitations; seat: right; restraint: 5-point; toxicology performed; flight hours: 119.6 total, 36.7 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 130° at 8 knots
- Visibility: 10 statute miles
- Lowest ceiling: none
- Temperature: 82 °F, dew point 72 °F
- Altimeter: 30.01 inHg
- Observed at: KCXO, 1 nm away

## Docket (15 files)

The files NTSB released with the investigation on September 21, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100303. 23.1 MB in all.

- Photograph of accident site (item 1, PDF, 1 page, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12397698&FileExtension=pdf&FileName=photos%20for%20docket-Rel.pdf
- Air traffic controller witness interview (item 2, PDF, 2 pages, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12396941&FileExtension=pdf&FileName=CEN19FA325%20ATC%20Controller%20Witness%20Interview-Rel.pdf
- FBO witness statement (item 3, PDF, 1 page, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12397678&FileExtension=pdf&FileName=Witness%20statement%20Conroe%20Bradley%20Painter_Redacted-Rel.pdf
- Memorandum of record for wreckage exam (item 4, PDF, 3 pages, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12397650&FileExtension=pdf&FileName=CEN19FA325%20Memorandum%20of%20Record%20for%20Wreckage%20Exam-Rel.pdf
- Fueling records from FBO (highlighted transactions are from credit cards used by pilot) (item 5, PDF, 60 pages, 10.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12397709&FileExtension=pdf&FileName=Fueling%20records%20from%20GAS-Rel.pdf
- FBO fueling inspection records for July 2019 (item 6, PDF, 1 page, 494 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12397660&FileExtension=pdf&FileName=GAS%20Fuel%20Inspection%20Record%20for%20July%202019_Redacted-Rel.pdf
- Engine data monitor factual report (item 7, PDF, 2 pages, 248 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12397826&FileExtension=pdf&FileName=JPI%20Factual%20Report%20CEN19FA325-Rel.pdf
- Attachment 1 to engine data monitor factual report (item 8, PDF, 1 page, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12397763&FileExtension=pdf&FileName=Attachment%201%20-%20Tabular%20Data%20(CEN19FA325)-Rel.pdf
- Engine monitor data from July 4, 2019 (item 9, PDF, 1 page, 240 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12398069&FileExtension=pdf&FileName=Graph%20of%20flight%20on%207-4-19-Rel.pdf
- Engine monitor data from July 7, 2019 (item 10, PDF, 1 page, 270 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12397688&FileExtension=pdf&FileName=Graph%20of%20flight%20on%207-7-19-Rel.pdf
- Engine monitor data from September 14, 2019 (item 11, PDF, 1 page, 259 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12397836&FileExtension=pdf&FileName=Graph%20of%20flight%20on%209-14-19-Rel.pdf
- Engine run report (item 12, PDF, 8 pages, 878 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12396568&FileExtension=pdf&FileName=19-100%20C-GOZJ%20Engine%20Run%20Report_Redacted-Rel.pdf
- Pilot's toxicology (item 13, PDF, 1 page, 446 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12397753&FileExtension=pdf&FileName=Tox%20Dennison%20fro%20Docket_Redacted-Rel.pdf
- Pilot-rated passenger toxicology (item 14, PDF, 1 page, 376 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12398059&FileExtension=pdf&FileName=Tox%20Arnold%20for%20Docket_Redacted-Rel.pdf
- Maintenance records excerpts (item 15, PDF, 11 pages, 8.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12704608&FileExtension=pdf&FileName=CEN19FA325%20-%20Maintenance%20Excerpts_Redacted-Rel.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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