# NTSB CEN19LA225: Cessna T188, N2863J, Knox, IN, July 14, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: July 13, 2019, 19:24 local (Jul 14, 2019, 00:24 UTC) - Place: Knox, IN - Coordinates: 41.294166, -86.622497 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.2942&lon=-86.6225&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA Flight Standards - NTSB case key (mKey): 99838 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA225 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99838/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99838 - Page: https://openairdocs.org/ntsb/CEN19LA225 ## Probable cause The pilot's exceedance of the airplane's critical angle of attack, which resulted in an aerodynamic stall and loss of airplane control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Cessna T188C, 4 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2073012), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna T188C, 4 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2073012), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/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 T188C, 8 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2073012), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Cessna T188C, 4 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2073012), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cessna T188C, 5 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2073012), [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 T188C, 13 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2073012), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was practicing agricultural application passes along the operator's airstrip. A witness reported that the pilot's initial passes were completed without incident, although the pilot "seemed to be slightly aggressive in the turns." After landing, the pilot mentioned turning at an airspeed of 60 mph, and the witness informed him to never fly below 80 mph. The pilot took off and completed three more practice passes. After the pilot's final pass, he executed a "very steep field exit" and held the airplane in a nose-up attitude longer than required to clear the obstacles. He entered a left 270° turn and, after rolling wings-level, the airplane entered an "extremely slow" climb before abruptly rolling into a steep left bank that continued until impact. The pilot reported that the did not recall any of the events leading to the accident. A postaccident examination revealed damage to the forward fuselage, both wings and the empennage. The examination did not reveal any anomalies consistent with a preimpact failure or malfunction. It is likely that the pilot exceeded the airplane's critical angle of attack while maneuvering, which resulted in an aerodynamic stall at an altitude that precluded recovery. ## Factual narrative On July 14, 2019, about 1924 central daylight time, a Cessna T188C airplane, N2863J, was substantially damaged when it impacted terrain near Knox, Indiana. The pilot sustained serious injuries. The airplane was registered to and operated by AAA Spraying Solutions, LLC dba Bluebird Ag, as a Title 14 Code of Federal Regulations Part 91 aerial application training flight. Visual meteorological conditions prevailed, and the flight was not operated on a flight plan. The local flight originated from the operator's airstrip about 1900. The pilot reported that he did not have any memory of the events leading up to, or of any portion of, the accident flight. He had not completed any agricultural application work within the previous 2 years and was reestablishing his currency at the time of the accident. The operator stated that the pilot was practicing by spraying water along the operator's airstrip. The pilot completed several takeoffs and landings, and then sprayed 40 gallons of water over the runway. After landing, the pilot commented that the airplane had gotten down to 60 mph in the turns. The pilot was informed that the minimum airspeed in turns was 80 mph. An additional 80 gallons of water were loaded onto the airplane for another practice flight. The pilot conducted a couple more passes over the runway and appeared to be returning for another pass, when the airplane pitched up to clear a group of trees before entering a left turn. The airplane appeared to get "very slow in the turn." The witness "heard the engine go to full power" as the left turn continued. The wings leveled momentarily before the airplane entered a second left turn that "just kept getting steeper." The airplane impacted the ground with a 60° to 70° bank angle. A second witness, who was an agricultural application pilot and familiar with the accident airplane, reported that the initial passes with 40 gallons of water were completed without incident; although, the pilot "seemed to be slightly aggressive in the turns." After the pilot landed, the airplane was loaded with 80 gallons of water. While the airplane was being loaded, the pilot "mentioned something about turning at 60 mph indicated" airspeed. The witness stressed to the pilot his own comfort level of never flying below 80 mph indicated airspeed. The pilot took off and completed three more practice passes. His final pass was from west to east, and he executed a "very steep field exit." The pilot held the airplane in a nose up attitude longer than required to clear the obstacles. The pilot then executed a left 270° turn. The engine sounded as if it was making full power after the pilot rolled wings level. The pilot appeared to begin lowering the nose, but then seemed to begin pulling up before the airplane had regained sufficient energy. The airplane entered an "extremely slow climb;" wings level before abruptly rolling into a 60° plus left bank which continued until it descended behind trees immediately before impact. Thewitness noted that he was close enough to see the control surfaces and they appeared to be responding to pilot inputs during that final turn. A postaccident examination conducted by a Federal Aviation Administration inspector revealed damage to the forward fuselage, both wings and the empennage. The inspector did not report any anomalies consistent with a preimpact failure or malfunction. The airplane owner's manual noted aerodynamic stall airspeeds of 73 mph at a 0° angle of bank (wings level) and 103 mph at a 60° angle of bank when operating at 4,400 lbs gross weight with wing flaps retracted. The manual added that the airplane stall characteristics are conventional, and the stall warning should sound 5 to 10 mph above the stall speed in all configurations. ## Aircraft - Registration: [N2863J](https://openairdocs.org/deregistered/N2863J-2020-12-05), registration cancelled 2020-12-05, S/N T18803538T, built 1979 (OpenAirDocs) - Reported make and model: Cessna T188 (C) - Registry model: [Cessna T188C](https://openairdocs.org/model/cessna-t188c) (registry code 2073012) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: T18803538T - Year built: 1979 - Airframe hours: 7871 - Engines: Continental TSIO-520T 310 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: AAA Spraying Solutions LLC - Registered owner: AAA Spraying Solutions LLC - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, June 27, 2019, 29 hours before - Departed: PVT, Knox, IN - Destination: PVT, Knox, IN - Airport: IG05, Wheeler, runway 26, 2,600 × 200 ft, grass/turf - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; injuries: serious; commercial; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; last flight review March 1, 2019; seat: single; restraint: 5-point; flight hours: 460 total, 165 in this make and model, 3 in the last 90 days, 3 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 68 °F - Altimeter: 30.10 inHg - Observed at: VPZ, 20 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 20190714022889A](https://openairdocs.org/incident/20190714022889A), Jul 14, 2019: Cessna T188C, Knox, IN, Substantial damage. Three witness statements agree that the pilot was practicing spray passes over the runway. Last pass was from west to east. Pilot pulled up abruptly and… ## Docket (5 files) The files NTSB released with the investigation on September 26, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99838. 2.9 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476292&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 54 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476293&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - Conversation Summary - Operator (item 3, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476294&FileExtension=.PDF&FileName=Conversation%20Summary%20-%20Operator-Master.PDF - Witness Statements (item 4, .PDF, 435 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476295&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - FAA Inspector Statement (item 5, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40476296&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-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.