# NTSB ERA15CA152: Cessna 182L, N42667, Waycross, GA, March 10, 2015

- Type: NTSB accident investigation
- Classification: Accident · No injuries · Data collection · Final report
- Date: March 10, 2015, 15:00 local (19:00 UTC)
- Place: Waycross, GA
- Coordinates: 31.248332, -82.395278 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=31.2483&lon=-82.3953&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Nose over/nose down](https://openairdocs.org/ntsb-events/096)
- Highest injury: No injuries
- Injuries: 2 uninjured
- Status: Completed, report August 11, 2015
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO
- NTSB case key (mKey): 90853
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15CA152
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90853/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90853
- Page: https://openairdocs.org/ntsb/ERA15CA152

## Probable cause

The pilot's failure to use any airport guidance while taxiing, which resulted in geographic disorientation and a takeoff attempt from an inadequate length and unsuitable surface.

## Findings

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

- [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 182L, 1 case](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=2072726), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md)
- [Knowledge: knowledge of geographic area](https://openairdocs.org/ntsb-findings/02032030): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Cessna 182L, 1 case](https://openairdocs.org/ntsb-findings/02032030/cases.md?model=2072726), [All aircraft, 24 cases](https://openairdocs.org/ntsb-findings/02032030/cases.md)
- [Perception/orientation/illusion: situational awareness](https://openairdocs.org/ntsb-findings/02022035): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 182L, 1 case](https://openairdocs.org/ntsb-findings/02022035/cases.md?model=2072726), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02022035/cases.md)
- [Perception/orientation/illusion: geographic disorient (lost)](https://openairdocs.org/ntsb-findings/02022030): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Cessna 182L, 1 case](https://openairdocs.org/ntsb-findings/02022030/cases.md?model=2072726), [All aircraft, 27 cases](https://openairdocs.org/ntsb-findings/02022030/cases.md)
- [Airport facilities/design: runway/landing area length](https://openairdocs.org/ntsb-findings/03017037): Environmental issues › Operating environment · Awareness of condition (probable cause); cases with it: [Cessna 182L, 1 case](https://openairdocs.org/ntsb-findings/03017037/cases.md?model=2072726), [All aircraft, 34 cases](https://openairdocs.org/ntsb-findings/03017037/cases.md)

## Sequence of events

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

- [Taxi-to runway: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna 182L, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=2072726), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)
- [Takeoff: Nose over/nose down](https://openairdocs.org/ntsb-events/096) (defining event); cases with it: [Cessna 182L, 4 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2072726), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md)

## Analysis

According to the pilot, the runway he intended to depart from was parallel to the taxiway and parking ramp. He assumed that after making two right turns he would be on the runway. He reported that he did not have any airport diagrams to navigate with, while operating on the airport movement area. Following his second right turn he noticed a runway sign, announced his intention to depart over the common traffic advisory frequency, taxied onto what he assumed was the runway, observed "faded yellow chevrons," and added power for takeoff. During the takeoff roll the pilot observed crossing the runway he assumed he was on, and the paved surface he was on was ending. He retarded the throttle and applied brakes. The airplane exited the paved surface and nosed over, coming to rest inverted; which resulted in substantial damage to the fuselage, left wing, and vertical stabilizer. The pilot reported no mechanical abnormalities or malfunctions that would have precluded normal operation. The airport diagram, and the pilot's own drawing of the accident event, revealed the need to make three right turns prior to being on the runway. According to a Federal Aviation Administration inspector, that traveled to the accident location, the runway was "clearly identifiable" and the markings were visible.

## Factual narrative

According to the pilot, the runway he intended to depart from was parallel to the taxiway and parking ramp. He assumed that after making two right turns he would be on the runway. He reported that he did not have any airport diagrams to navigate with, while operating on the airport movement area. Following his second right turn he noticed a runway sign, announced his intention to depart over the common traffic advisory frequency, taxied onto what he assumed was the runway, observed "faded yellow chevrons," and added power for takeoff. During the takeoff roll the pilot observed crossing the runway he assumed he was on, and the paved surface he was on was ending. He retarded the throttle and applied brakes. The airplane exited the paved surface and nosed over, coming to rest inverted; which resulted in substantial damage to the fuselage, left wing, and vertical stabilizer. The pilot reported no mechanical abnormalities or malfunctions that would have precluded normal operation. The airport diagram, and the pilot's own drawing of the accident event, revealed the need to make three right turns prior to being on the runway. According to a Federal Aviation Administration inspector, that traveled to the accident location, the runway was "clearly identifiable" and the markings were visible.

## Aircraft

- Registration: [N42667](https://openairdocs.org/deregistered/N42667-2018-02-01), registration cancelled 2018-02-01, S/N 18259129, built 1968 (OpenAirDocs)
- Reported make and model: CESSNA 182L
- Registry model: [Cessna 182L](https://openairdocs.org/model/cessna-182l) (registry code 2072726) (OpenAirDocs)
- Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 18259129
- Year built: 1968
- Airframe hours: 2702.39
- Engines: CONT MOTOR O-470-R25 230 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, May 21, 2014
- Departed: AYS, WAYCROSS, GA
- Destination: X14, LA BELLE, FL
- Flight plan: IFR
- Airport: AYS, Waycross-Ware County, runway 18, 5,992 × 100 ft, asphalt
- Equipment: Stall warning system, Auto-pilot, Data recorder, Handheld GPS

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 63; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review February 24, 2013; seat: left; restraint: lap only; flight hours: 690 total, 600 in this make and model, 555 as pilot in command, 6 in the last 90 days

## Weather

- Conditions: Visual (VMC), Day
- Wind: 230° at 8 knots, gusting 14
- Visibility: 10 statute miles
- Lowest ceiling: 7,500 ft broken
- Temperature: 88 °F, dew point 64 °F
- Altimeter: 30.12 inHg
- Observed at: AYS

## 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 20150310002829A](https://openairdocs.org/incident/20150310002829A), Mar 10, 2015: Cessna 182L, Waycross, GA, Substantial damage. Pilot was unfamiliar with airport was taxiing out and powered up on the second turn believing he was on runway 18. By the time he realized he was not on runway…

## Docket (7 files)

The files NTSB released with the investigation on July 30, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90853. 4.0 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429921&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF
- Memorandum of Record – Pilot Telephone Interview (item 2, .PDF, 107 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429922&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20%E2%80%93%20Pilot%20Telephone%20Interview-Master.PDF
- Memorandum of Record – Waycross Georgia Weather (item 3, .PDF, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429926&FileExtension=.PDF&FileName=Memorandum%20of%20Record%20%E2%80%93%20Waycross%20Georgia%20Weather-Master.PDF
- Passenger Email Statement (item 4, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429923&FileExtension=.PDF&FileName=Passenger%20Email%20Statement-Redacted.PDF
- Email from FAA On Airport Markings (item 5, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429924&FileExtension=.PDF&FileName=Email%20from%20FAA%20On%20Airport%20Markings-Redacted.PDF
- Photo 1 – Left Side of Airplane at Rest (Courtesy of the Sheriff's Department) (item 6, .PDF, 391 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429927&FileExtension=.PDF&FileName=Photo%201%20%E2%80%93%20Left%20Side%20of%20Airplane%20at%20Rest%20(Courtesy%20of%20the%20Sheriff%27s%20Department)-Master.PDF
- Photo 2 – Right Side of Airplane at Rest (Courtesy of the Sheriff's Department) (item 7, .PDF, 506 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40429928&FileExtension=.PDF&FileName=Photo%202%20%E2%80%93%20Right%20Side%20of%20Airplane%20at%20Rest%20(Courtesy%20of%20the%20Sheriff%27s%20Department)-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.

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