# NTSB CHI02FA113: Cessna 172RG, N5388R, Marthasville, MO, April 23, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: April 23, 2002, 15:10 local (20:10 UTC) - Place: Marthasville, MO - Coordinates: 38.619724, -91.049255 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.6197&lon=-91.0493&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious - Status: Completed, report April 18, 2003 - Report: Approved by Office Director - Parties: Textron Lycoming, Federal Aviation Adminstration, Cessna Aircraft Company - NTSB case key (mKey): 54610 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI02FA113 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54610/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54610 - Page: https://openairdocs.org/ntsb/CHI02FA113 ## Probable cause The inadequate supervision and the stall encountered by the certified flight instructor. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - airspeed - not attained (cause) - supervision - inadequate, pilot in command(cfi) (cause) - stall - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The instructional flight impacted terrain in a nose down attitude following an initial climb from a touch and go landing. A witness reported seeing the landing gear retract when the airplane was approximately 3-4 feet above the runway. The airplane then descended and the propeller struck the runway. Propeller slash marks were found down the departing runway. Examination of the propeller revealed that the propeller tips were gouged and the landing gear handle was in the gear up position. The landing gear handle and landing gear were in the retracted position. Continuity of the landing gear electrical system was confirmed. Flight control continuity was also confirmed. A pilot who received instruction from the certified flight instructor (CFI) involved in the accident reported that the CFI would have him retract the landing gear prior to reaching a best angle or best rate of climb speed as stipulated in the airplane handbook. ## Factual narrative HISTORY OF FLIGHT On April 23, 2002, at 1510 central daylight time, a Cessna 172RG, N5388R, operated by Thunder Air Charter, Inc., was destroyed during an initial climb from runway 16 at the Washington Memorial Airport (MO6), Marthasville, Missouri. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 instructional flight was not operating on a flight plan. The private pilot was fatally injured, and the certified flight instructor (CFI) received serious injuries. The flight originated from the Spirit of St. Louis Airport, Saint Louis, Missouri, at 1346. The CFI stated, "...[the private pilot] intecepted and tracked the 090 radial to the FTZ VOR. While tracking the radial, she performed slow flight and other manuevers under the hood. She then flew the VOR 16 approach to MO6. After the approach, she perfromed a go-around, and remained in the Runway 16 traffic pattern. She then perfomed 3 short-field takeoffs and landings. She then performed 4 soft-field touch-and-goes. The final soft-field landing was performed well, and she continued with the soft-field takeoff. The landing gear handle was down, and the flaps were 10 degrees. The plane was in ground effect and [the pilot] was waiting for the plane to accelerate through Vy (84 KIAS) to commence climb-out. As the plane was approaching Vy, the nose unexpectedly pitched down, and the prop of the plane hit the runway. [The pilot] reacted to the nose-down pitching movement, and pulled back on the yoke to counteract it; the nose pitched up; and as she said "What do I do?" she relinquished the controls to me. My reaction to the emergency was to immediately pull the power back, select "gear up" (I moved the gear selector switch to the 'up' position), and pitch the nose down from what had become a nose-high attitude. I don't recall retracting flaps to 0 degrees, but may have done so to reduce drag. By the time I had the controls and had initiated the above actions, my judgement was that an off-field landing was imminent, that the plane could not be landed on the remaining runway, and I decided to perform the landing in a field to the left of the runway. There were trees directly off the departure end of Runway 16, so I knew I had to manuever the plane slightly to the left. All of this occured within a matter of seconds, while I was attempting to assume control an aircraft which was vibrating badly and difficult to control under the circumstances. I was unable to control the plane, and it turned over and went nose first into the ground." A witness stated, "I was sitting at the end of the hanger (south side) when I heard and engine cough being an experience pilot I look at the aircraft and saw the aircraft making a sharp turn to the left, at which time the aircraft stalled and nosed straight into the ground." A second witness stated, "Traving south on 47 seen plane going south just off runway flying plane stalled dove left crashing and flipping over [sic]." A third witness stated, "Just left end of runway traveling south on 47 watched plane take off. Stall while turning sharply to the left then nose dived to the ground..." A fourth witness stated, "While cleaning my aircraft in hanger no. 7 I heard an aircraft apply power. (Several aircraft had been practicing landing throughout the day) I noticed the aircraft remained level, about 3-4 feet above the runway for a longer period of time than I thought to be normal. The landing gear started the retraction cycle, the aircraft descended slightly and the landing gear struck the runway. The propeller then struck the runway. The aircraft continued and appeared to climb. I lost sight of the aircraft until I walked out of the hanger. When I regained sight of the aircraft it appeared to be headed east at about 50 feet. Shortly thereafter the aircraft rolled to the left and descended striking the ground in a near vertical attitude about 1,000 ft southeast of the end runway 16." PERSONNEL INFORMATION The pilot, age 22, held a private pilot certificate with a single engine land rating issued on December 21, 2001. According to logbook entries, the pilot accumulated a total flight time of 202.4 hours, all of which was in single engine aircraft. The entries also show that 8.1 hours were accumulated in complex airplanes, and 3.3 hours were in high performance airplanes. The remainder of the total flight time was in Cessna 172 airplanes. The pilot received a checkout in the accident airplane by the CFI on April 10, 2002, after receiving 6.7 hours of dual flight instruction from the CFI. According to the pilot's Aircraft Check Out questionnaire, 6 hours of training relating to the airplane's systems were provided. The pilot was issued a second class medical certificate on October 4, 2001, with "no restrictions" listed in the limitations block of the medical certificate. The CFI, age 28, began employment with Thunder Aviation as an instructor on February 15, 2001. He held a commercial pilot certificate with single engine land, multi engine land, and instrument airplane ratings. His CFI ratings included single engine and instrument airplane ratings. He received a company standardization flight on October 15, 2001, in a Cessna 172M. He received a company checkout in a Cessna 172RG on March 2, 2001, and subsequently received a standardization flight in the accident airplane by the company's chief flight instructor on March 15, 2002. He was given an excellent rating in "takeoff, climb, cruise". The CFI was issued a first class medical certificate on January 28, 2002, with "none" listed in the limitations block of the medical certificate. AIRCRAFT INFORMATION The 1980 Cessna 172RG, serial number 172RG60059, was registered to Thunder Aviation Acquisitions Inc., on April 16, 1998, and was used as a rental and flight instructional aircraft by Thunder Air Charter Inc. The airplane was equipped with a two-bladed constant speed metal propeller and retractable tricycle landing gear. The airplane was last inspected by the operator during a 100-hour inspection on March 15, 2002, at a aircraft total time of 5,506.1 hours. The airplane was powered by a Lycoming O-360-F1A6, serial number L-32214-36A, engine rated at 180 horsepower at 2,700 rpm. The engine accumulated 836.8 hours since a factory overhaul. According to the Cessna 172RG Information Manual, the lower indicated airspeed limit of a Cessna 172RG's normal operating range ("green arc") at a maximum weight and most forward center of gravity with trailing edge flaps retracted is 50 knots. The maximum certificated takeoff weight for the Cessna 172RG is 2,650 lbs. The aircraft empty weight was 1,437.45 pounds. According to the pilots' medical certificates, the pilot's weight was 221 pounds. The CFI's weight was 185 pounds. The Cessna 172RG has a total useable fuel capacity of 62 gallons. The airplane was "topped off" prior to the flight. The Information Manual also describes the landing gear warning system as consisting of a throttle actuated switch which is electrically connected to a dual warning unit. The warning unit is connected to the airplane speaker. When the throttle is retarded below approximately 12 inches of manifold pressure at low altitude (master switch on), the throttle linkage will actuate a switch which is electrically connected to the gear warning portion of the dual warning unit. The Information Manual describes landing gear operation by stating, "To retract or extend the landing gear, pull out on the gear lever and move it to the desired position. After the lever is positioned, the power pack will create pressure in the system and actuate the landing gear to the selected position. During a normal cycle, the gear retracts fully or extends and locks, limit switches close (GEAR DOWN cycle only), and the indicator light comes on (amber for up and green for down) indicating completion ## Aircraft - Registration: [N5388R](https://openairdocs.org/deregistered/N5388R-2002-10-30), registration cancelled 2002-10-30, S/N 172RG0059, built 1979 (OpenAirDocs) - Reported make and model: Cessna 172RG - Registry model: [Cessna 172RG](https://openairdocs.org/model/cessna-172rg) (registry code 2072438) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172RG0059 - Airframe hours: 5506.1 - Engines: Lycoming O-360-F1A6 180 horsepower reciprocating - Damage: Destroyed - Flight: Instructional, Part 91 - Operator: Thunder Aviation, Inc. - Registered owner: Thunder Aviation Acquisitions, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 15, 2002, 61.1 hours before - Departed: MO6, Marthasville, MO - Airport: M06, Washington Memorial, runway 16, 3,281 × 50 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 22; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; last flight review December 21, 2001; seat: left; toxicology performed; flight hours: 202 total, 8 in this make and model, 129 as pilot in command, 17 in the last 90 days, 11 in the last 30 days - Flight instructor; age 23; injuries: serious; commercial, flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review August 28, 2001; seat: right; flight hours: 1,650 total, 27 in this make and model, 1,579 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 160° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 48 °F - Altimeter: 30.00 inHg - Observed at: SUS, 17 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 20020423010109A](https://openairdocs.org/incident/20020423010109A), Apr 23, 2002: Cessna 172RG, Russellvile, AR, No damage, 1 fatal. (-23) Thunder aviation's N5388R had just lifted off on a touch & go from Washington memorial airport, Washington, MO when the landing gear was prematurely… ## Other investigations on N5388R (1) 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. - [NTSB LAX90LA236](https://openairdocs.org/ntsb/LAX90LA236), Jul 6, 1990: Cessna 172RG (N5388R), Concord, CA, substantial damage. Probable cause: THE STUDENT PILOT'S INITIATING AN EXCESSIVE DESCENT AND THE CFI'S INADEQUATE REMEDIAL ACTION. ## Docket (25 files) The files NTSB released with the investigation on February 13, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54610. 5.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 279 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434850&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 & Correspondence (item 2, .PDF, 487 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434851&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20%26%20Correspondence-Redacted.PDF - Witness Statements (item 3, .PDF, 324 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434856&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - C172RG Information Manual (item 4, .PDF, 469 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176270&FileExtension=.PDF&FileName=C172RG%20Information%20Manual-Master.PDF - Flight Instructor Information (item 5, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434852&FileExtension=.PDF&FileName=Flight%20Instructor%20Information-Redacted.PDF - Pilot's Aircraft Checkout (item 6, .PDF, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176273&FileExtension=.PDF&FileName=Pilot%27s%20Aircraft%20Checkout-Master.PDF - Flight Manual (item 7, .PDF, 433 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176275&FileExtension=.PDF&FileName=Flight%20Manual-Master.PDF - Checklists (item 8, .PDF, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176276&FileExtension=.PDF&FileName=Checklists-Master.PDF - Pilot's Paperwork (item 9, .PDF, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176277&FileExtension=.PDF&FileName=Pilot%27s%20Paperwork-Master.PDF - Aircraft Dispatch Sheet (item 10, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176278&FileExtension=.PDF&FileName=Aircraft%20Dispatch%20Sheet-Master.PDF - Toxicological Report (item 11, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434853&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 314 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434854&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434855&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1. Accident Site (item 14, .PDF, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176283&FileExtension=.PDF&FileName=Photo%201.%20%20Accident%20Site-Master.PDF - Photo 2. Accident Site (item 15, .PDF, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176284&FileExtension=.PDF&FileName=Photo%202.%20%20Accident%20Site-Master.PDF - Photo 3. Accident Site (item 16, .PDF, 223 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176285&FileExtension=.PDF&FileName=Photo%203.%20%20Accident%20Site-Master.PDF - Photo 4. Accident Site (item 17, .PDF, 215 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176286&FileExtension=.PDF&FileName=Photo%204.%20%20Accident%20Site-Master.PDF - Photo 5. Accident Site (item 18, .PDF, 221 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176287&FileExtension=.PDF&FileName=Photo%205.%20%20Accident%20Site-Master.PDF - Photo 6. Airplane Nose (item 19, .PDF, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176288&FileExtension=.PDF&FileName=Photo%206.%20%20Airplane%20Nose-Master.PDF - Photo 7. Runway 16 (item 20, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176289&FileExtension=.PDF&FileName=Photo%207.%20%20Runway%2016-Master.PDF - Photo 8. Propeller (item 21, .PDF, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176290&FileExtension=.PDF&FileName=Photo%208.%20%20Propeller-Master.PDF - Photo 9. Propeller (item 22, .PDF, 188 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176291&FileExtension=.PDF&FileName=Photo%209.%20%20Propeller-Master.PDF - Photo 10. Propeller Tip (item 23, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176292&FileExtension=.PDF&FileName=Photo%2010.%20%20Propeller%20Tip-Master.PDF - Photo 11. Propeller Tip (item 24, .PDF, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176293&FileExtension=.PDF&FileName=Photo%2011.%20%20Propeller%20Tip-Master.PDF - Photo 12. Gear Handle (item 25, .PDF, 166 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40176294&FileExtension=.PDF&FileName=Photo%2012.%20%20Gear%20Handle-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.