# NTSB CEN19LA263: Cessna 172, N8928B, New Carlisle, OH, August 11, 2019 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: August 11, 2019, 07:42 local (11:42 UTC) - Place: New Carlisle, OH - Coordinates: 39.929721, -84.022781 - Nearby events: https://openairdocs.org/map.md?lat=39.9297&lon=-84.0228&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Minor injuries - Injuries: 3 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 100034 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19LA263 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100034/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100034 - Page: https://openairdocs.org/ntsb/CEN19LA263 ## Probable cause The pilot’s excessive use of pitch control during rotation, which resulted in the airplane exceeding its critical angle of attack and entering an aerodynamic stall shortly after liftoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Cessna 172, 1 case](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=2072402), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/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: [Cessna 172, 8 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2072402), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/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 172, 30 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072402), [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. - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 172, 16 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072402), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cessna 172, 8 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2072402), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172, 36 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072402), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was conducting a personal flight when during takeoff he was too aggressive as he pulled aft on the control stick to rotate, which resulted in a higher-than-normal pitch attitude after liftoff. About 15 seconds after liftoff, he felt the airplane shudder as it began to descend. He decreased airplane pitch to increase airspeed, but the airplane continued to descend. He made an immediate landing in a plant nursery about 0.5 mile from the departure end of runway. The airplane’s nose landing gear collided with a hoop support in the plant nursery before the airplane impacted terrain. The airplane sustained substantial damage to the fuselage, both wings, and the empennage. The pilot reported that there were no mechanical malfunctions or failures that would have precluded normal operation of the airplane. A witness reported seeing the airplane taxi to the approach end of the runway and stop momentarily before it continued the takeoff roll with the flaps retracted. He saw the airplane pitch up very sharply about 330-500 ft from the departure end of the runway. The airplane’s pitch attitude was high enough for him to see the top surface of both wings and the horizontal stabilizers. The airplane climbed about 2-3 airplane lengths in the nose-high pitch attitude before it pitched down to a nose-level attitude. The airplane’s tail yawed briefly left and right before the right wing dropped and the airplane descended behind a tree line. Although the airplane was about 5 lbs over maximum gross weight, it likely still had adequate takeoff performance to achieve a normal takeoff with the runway length available. It is likely the pilot used excessive aft pitch control during rotation, which resulted in the airplane exceeding its critical angle of attack and entering an aerodynamic stall shortly after liftoff. ## Factual narrative Weight and Balance During an interview, the pilot provided a weight and balance calculation that he completed after the accident. According to the pilot’s weight and balance data, the airplane weighed about 2,205 lbs at the time of the accident and had a center of gravity located 41.83 inches aft of the datum. According to the FAA-approved Type Certificate Data Sheet and the Cessna 172 Owner’s Manual, the airplane’s maximum takeoff weight was 2,200 lbs. Takeoff Performance The pilot stated that he did not calculate the runway length required for takeoff. The asphalt runway used for the takeoff was 2,000 ft long, and the airport elevation was 895 ft mean sea level. The surface wind was calm and the outside temperature was 17°C at an airport about 6.5 miles south of the accident site. According to the Cessna 172 Owner’s Manual, the runway length required for a normal liftoff and to clear a 50 ft obstacle was 725 ft and 1,650 ft, respectively, at sea level with a calm wind, 15°C outside temperature, and the airplane at maximum takeoff weight. The runway length required for normal liftoff and to clear a 50 ft obstacle was 880 ft and 2,000 ft, respectively, at 2,500 ft mean sea level with a calm wind, 10°C outside temperature, and the airplane at maximum takeoff weight. On August 11, 2019, about 0742 eastern daylight time, a Cessna 172 airplane, N8928B, was substantially damaged when it was involved in an accident near New Carlisle, Ohio. The pilot and two passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he completed a normal preflight inspection of the airplane using the checklist. He estimated that the airplane had about 35 gallons of fuel onboard before the flight. The pilot did not observe any anomalies with the airplane or its engine during the before takeoff engine runup, which included verifying proper flight control movement and proper function of each magneto and the carburetor heat. The flaps were fully retracted during the takeoff. The pilot made a rolling takeoff on runway 27 and after the airplane accelerated to 70 mph he rotated for liftoff near the departure end of the runway. The pilot stated that he was too aggressive when he pulled aft on the control stick during rotation, which resulted in a higher-than-normal pitch attitude after liftoff. About 15 seconds after liftoff, he felt the airplane shudder as it began to descend. He decreased airplane pitch to increase airspeed, but the airplane continued to descend. He made an immediate landing in a plant nursery about 0.5 mile from the departure end of runway 27. The airplane’s nose landing gear collided with a hoop support in the plant nursery before the airplane impacted terrain. The pilot reported that there were no mechanical malfunctions or failures that would have precluded normal operation of the airplane. A witness, who also was a flight instructor, reported seeing the airplanetaxi to the approach end of runway 27 and stop momentarily before it continued the takeoff roll with the flaps retracted. He saw the airplane pitch up very sharply about 2 to 3 runway lights (330-500 ft) from the departure end of runway 27. The airplane’s pitch attitude was high enough for him to see the top surface of both wings and the horizontal stabilizers. The airplane climbed about 2-3 airplane lengths in the nose-high pitch attitude before it pitched down to a nose-level attitude. The airplane’s tail yawed briefly left and right before the right wing dropped and the airplane descended behind a tree line. The airplane came to rest upright in a plant nursery. The airplane sustained substantial damage to the fuselage, both wings, and the empennage. There was fuel leaking at the accident site from the damaged fuel tanks; however, fuel samples recovered on the day of the accident did not have any evidence of contamination. The engine remained partially attached to the firewall, and the propeller remained attached to the crankshaft flange. The propeller blades exhibited chordwise scratches and burnishing, a S-shape spanwise bend, and minor leading-edge damage. One blade tip had separated during impact. Engine control cable continuity could not be verified due to impact damage. The carburetor heat control cable separated from the airbox during impact. Internal engine and valve train continuity was confirmed as the crankshaft was rotated. Compression and suction were noted on all four cylinders in conjunction with crankshaft rotation. There were no leaks during a pressure test of each cylinder with the associated piston at top-dead-center while on the compression stroke. A borescope inspection of each cylinder did not reveal any anomalies with the cylinders, pistons, valves, valve seats, or lower spark plugs. The upper spark plugs were removed and exhibited features consistent with normal engine operation. Both magnetos remained attached to the engine crankcase and provided spark on all posts while the engine crankshaft was rotated. The magneto-to-engine timing was correct. The carburetor separated from the engine crankcase during impact. The carburetor bowl did not contain residual fuel, and there was no evidence of water or particulate contamination in the bowl. Disassembly of the carburetor did not reveal any anomalies with the venturi, accelerator pump, composite floats, or needle valve. The postaccident examination did not reveal any anomalies that would have precluded normal engine operation during the flight. ## Aircraft - Registration: [N8928B](https://openairdocs.org/deregistered/N8928B-2020-01-06), registration cancelled 2020-01-06, S/N 36628, built 1958 (OpenAirDocs) - Reported make and model: Cessna 172 - Registry model: [Cessna 172](https://openairdocs.org/model/cessna-172) (registry code 2072402) (OpenAirDocs) - Registry engine: [Continental 0-300 series](https://openairdocs.org/engine/continental-0-300-series) (registry code 17022, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 36628 - Year built: 1958 - Airframe hours: 4962 - Engines: Continental O-300-A 145 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Wright Flyers Club - Registered owner: Wright Flyers Club - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 24, 2019, 28 hours before - Departed: 3OH0, New Carlisle, OH - Destination: AFJ, Washington, PA - Flight plan: VFR - Airport: 3OH0, Andy Barnhart Memorial Airport, runway 27, 2,000 × 30 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: minor; private; airplane ratings: single-engine land; medical: basicmed; last flight review January 6, 2019; seat: left; restraint: lap only; flight hours: 147 total, 132 in this make and model, 98 as pilot in command, 19 in the last 90 days, 1 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 57 °F - Altimeter: 30.09 inHg - Observed at: FFO, 7 nm away - METAR: METAR KFFO 111156Z AUTO 00000KT 10SM CLR 17/14 A3009 RMK AO2 SLP188 T01720141 10172 20146 52008= ## 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 20190811013829A](https://openairdocs.org/incident/20190811013829A), Aug 11, 2019: Cessna 172, New Carlisle, OH, Destroyed. On Sunday, August 11, 2019, at approximately 0737 EDT, a Cessna skyhawk CE-172 aircraft, registration n-number N8928B, was involved in an accident when it… ## Docket (10 files) The files NTSB released with the investigation on August 26, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100034. 10.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14168464&FileExtension=pdf&FileName=01%20-%20Pilot%20Report_Redacted-Rel.pdf - Memorandum of conversation (nathan mcbride) (item 2, PDF, 1 page, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14168811&FileExtension=pdf&FileName=02%20-%20Memorandum%20of%20Conversation%20(Nathan%20McBride)-Rel.pdf - Witness statement (item 3, PDF, 2 pages, 293 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14168313&FileExtension=pdf&FileName=03%20-%20Witness%20Statement_Redacted-Rel.pdf - FAA record of visit with nathan mcbride (item 4, PDF, 2 pages, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14168791&FileExtension=pdf&FileName=04%20-%20FAA%20Record%20of%20Visit%20with%20Nathan%20McBride-Rel.pdf - Memorandum of conversation (robert craig) (item 5, PDF, 1 page, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14168474&FileExtension=pdf&FileName=05%20-%20Memorandum%20of%20Conversation%20(Robert%20Craig)-Rel.pdf - Maintenance logbooks (excerpts) (item 6, PDF, 2 pages, 272 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14168133&FileExtension=pdf&FileName=06%20-%20Maintenance%20Logbooks%20(Excerpts)_Redacted-Rel.pdf - Cessna 172 owner manual (excerpts) (item 7, PDF, 9 pages, 5.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14168323&FileExtension=pdf&FileName=07%20-%20Cessna%20172%20Owner%20Manual%20(Excerpts)-Rel.pdf - Weight and balance documentation (item 8, PDF, 5 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14168801&FileExtension=pdf&FileName=08%20-%20Weight%20and%20Balance%20Documentation_Redacted-Rel.pdf - Weather data (item 9, PDF, 1 page, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14168484&FileExtension=pdf&FileName=09%20-%20Weather%20Data-Rel.pdf - Photos (item 10, PDF, 2 pages, 2 photos, 488 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14169009&FileExtension=pdf&FileName=10%20-%20Photos-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. --- 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.