ERA17FA272

NTSB accident investigation · Cessna 172 · New Milford, CT · August 11, 2017

Accident · FatalField investigationFinal report
Date
August 11, 2017, 09:17 local (13:17 UTC)
Place
New Milford, CT
Injuries
1 fatal, 2 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N1727VCessna 172
Defining event
Initial climb: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report August 15, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO, Textron Aviation
FAA report
20170811015789A
Case key
95798

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight instructor's failure to ensure that the wing flaps were properly configured for takeoff, which resulted in an aerodynamic stall and loss of control during the initial climb.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Flight control system: tE flap control systemAircraft › Aircraft systems · Incorrect use/operationCessna 172M: 4 casesAll aircraft: 74 casesProbable cause
Performance/control parameters: configurationAircraft › Aircraft oper/perf/capability · Incorrect use/operationCessna 172M: 2 casesAll aircraft: 80 casesProbable cause
Aircraft capability: climb capabilityAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 172M: 3 casesAll aircraft: 183 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · Instructor/check pilotCessna 172M: 1 caseAll aircraft: 336 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · Instructor/check pilotCessna 172M: 11 casesAll aircraft: 1,391 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The student pilot, who had 15 hours of flight experience, was performing an instructional flight with her flight instructor and a passenger. According to GPS data, the airplane landed on and then took off from a grass airstrip, climbed about 150 ft, then collided with terrain about 1,000 ft past the end of the runway. There were no known eyewitnesses, and the student pilot and passenger did not recall the accident due to their injuries. The flight instructor was fatally injured. An examination of the wreckage did not reveal any evidence of a preaccident mechanical malfunction or anomaly. An examination of the flight controls revealed that the wing flaps were in the fully extended (40º) position at impact. The airplane's operating checklist stated that normal and obstacle clearance takeoffs are performed with wing flaps up, and flap settings greater than 10º are not recommended at any time for takeoff. Upon landing on the grass runway, the flaps should have been retracted as part of the after-landing checklist, then confirmed up as part of the before takeoff and takeoff checklists. It is likely that the flap setting at the time of takeoff resulted in an aerodynamic stall and loss of control during the initial climb. It could not be determined who was at the controls at the time of the takeoff and loss of airplane control; however, the flight instructor, as pilot-in-command, was responsible for the operation and safety of the flight and should have ensured that the flaps were retracted before takeoff. He also should have anticipated and corrected any significant errors made by the student.

Factual narrative

According to the Cessna 172 Owner's Manual pertaining to wing flap settings, "Normal and obstacle clearance takeoffs are performed with wing flaps up." The manual also states, "Flap settings greater than 10º are not recommended at any time for takeoff." The operating checklists for the airplane include the following step in the "Before Takeoff" checklist: "(11) Wing Flaps -- UP." This step is also included as part of the "Normal Takeoff," "Maximum Performance Takeoff," and the "After Landing" checklists. According to 14 CFR Part 1 (Definitions and Abbreviations), a pilot-in-command means the person who: (1) Has final authority and responsibility for the operation and safety of the flight. The single-engine, high-wing, four-seat airplane was manufactured in 1974 and incorporated fixed, tricycle landing gear. It was equipped with a Lycoming O-320-E2D reciprocating engine rated at 160 horsepower. The airplane was equipped with electrically-operated wing flaps and a stall warning system. The cockpit featured dual flight controls. The most recent 100-hour inspections on the airframe and engine were completed on June 28, 2017. The most recent annual inspections on the airframe and engine were completed on February 17, 2017. The Hobbs meter indicated 8,478.5 hours at the time of the accident. On August 11, 2017, about 0917 eastern daylight time, a Cessna 172M, N1727V, collided with terrain at Candlelight Farms Airport (11N), New Milford, Connecticut. The flight instructor was fatally injured, and the student pilot and passenger were seriously injured. The airplane was substantially damaged. The airplane was registered to and operated by Arrow Aviation LLC under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the local instructional flight. The flight originated at Danbury Municipal Airport (DXR), Danbury, Connecticut about 0835. Data from the airplane's Garmin GPSMAP 396 GPS was used to reconstruct the flight on the day of the accident. The GPS was not configured to record time data; therefore, groundspeed and the time of the accident could not be derived. The GPS data revealed that the airplane departed runway 26 at DXR then climbed and turned north. A series of maneuvers were performed about 3,000 ft, then the airplane entered a left downwind for runway 35 at 11N. The airplane landed on runway 35, taxied clear of the runway, and taxied to the south. The airplane took off from runway 35 and continued on runway heading; The final five GPS altitude points indicated 764 ft, 787 ft, 827 ft, 807 ft, and 712 ft. The unit stopped recording data at a point consistent with the accident site. The airport elevation was about 675 ft, and the accident site elevation was about 685 ft. The aft seat passenger, who was the father of the student pilot, walked to a nearby residence after the accident to seek assistance. There were no known eyewitnesses. The passengerrecalled that the airplane landed at Candlelight Farms and then taxied for takeoff. He did not recall the completion of the taxi or the takeoff. The student pilot did not recall any of the events associated with the accident. The State of Connecticut Office of the Chief Medical Examiner, Farmington, Connecticut, performed the autopsy of the flight instructor. The cause of death was blunt trauma of the head, neck, and torso, and the manner of death was accident. The FAA's Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the flight instructor. Losartan was detected in the blood and urine, and ibuprofen was detected in the urine. These medications are not generally considered impairing. DXR was located about 12 miles south of the accident site. The DXR weather at 0953 included wind from 150º at 6 knots, visibility 10 statute miles, sky clear, temperature 24°C, dew point 17°C, and an altimeter setting of 30.17 inches of mercury. The student pilot was enrolled as a student at Arrow Aviation at DXR; she did not possess a Federal Aviation Administration (FAA) student pilot certificate or an FAA medical certificate. According to her pilot logbook, she had logged about 15 total hours of flight experience since July 2015. The instructor held flight instructor and commercial pilot certificates with airplane single-engine land, airplane multi-engine land, and instrument airplane ratings. His most recent FAA second-class medical certificate was issued on May 21, 2016. He did not report his flight experience on his most recent medical certificate application; however, he reported 3,900 total hours of flight experience to the FAA in October 2012. His pilot logbooks were not located. The accident site was located on an open field about 1,000 ft northwest of the airport boundary. The wreckage was found in an upright, nose-low attitude. All components of the airplane were accounted for at the accident site. The nose landing gear separated during the impact sequence. There was no fire. The wreckage path was about 72 ft long and 30 ft wide, oriented on a 300º magnetic heading. The initial ground impact scar contained a broken fragment of the left wingtip navigation light. The airplane came to rest on a heading of 070º. All primary flight control surfaces remained attached. Flight control continuity was established from the ailerons, elevator, and rudder to the cockpit controls. The elevator trim indicator was found in the "takeoff" position. The wing flaps were found in the fully extended position; witness marks and damage on the fuselage adjacent to the inboard end of the flaps were consistent with the fully extended position. The flap switch was found in the full extension, or 40º, position. Impact damage was noted in this area. The flap position indicator on the instrument panel was damaged from impact and the needle was off scale, above the retracted position. The flap indicator potentiometerinside the wing was observed at the full-down position limit. The flap motor was tested after the wreckage was recovered; it operated normally through its full range of travel. The airplane was equipped with a fuel tank in each wing. Both vented fuel caps were in place and secure. The vents were unobstructed. The fuel selector handle was found in the left tank position. About 10 gallons of blue-colored fuel were recovered from the left tank and about 2 gallons were recovered from the right tank. Both tanks were leaking fuel when examined by investigators. The recovered fuel was free of water and debris. The engine was examined at the accident site. It was removed from the airframe to facilitate the examination. The bottom spark plugs were removed; the electrodes displayed normal wear and color when compared to a Champion Check-A-Plug chart. One plug had wet oil on its electrode. The carburetor remained attached to the engine; the intake system remained attached to the carburetor. The foam intake element was covered in organic debris from impact with the ground. The carburetor was partially disassembled, and the bowl contained about 2 ounces of blue-colored fuel, which was free of water and debris. The blue plastic floats were intact and in place. The inlet fuel screen was unobstructed. There was a small amount of lead solder on the screen surface. The cylinder rocker covers were removed for the examination. The engine was rotated by hand at the propeller. Compression and suction were observed on all cylinders and valve action was correct. The propeller remained attached to the engine. The blades displayed chordwise scratching, leading edge gouges, blade twisting, and "s" bending. One blade tip was broken off and found along the wreckage debris field.

Aircraft

Registration
N1727V
Reported as
Cessna 172 (M)
Category
Airplane
Serial number
17263727
Built
1974
Airframe hours
8,478
Engine
Lycoming O-320-E2D, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Arrow Aviation LLC
Registered owner
Arrow Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 28, 2017 · 85 hours before
Departed
DXR · Danbury, CT
Destination
DXR · Danbury, CT
Airport
11N · Candlelight Farms, runway 35, 2,900 × 50 ft, grass/turf
Equipment
Stall warning system, Handheld GPS

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
57
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Last flight review
May 13, 2016
Seat
Right
Restraint
3-point
Toxicology
Performed
Flight hours
3,900 total
Role
Student pilot
Age
16
Injuries
Serious
Seat
Left
Restraint
Lap only
Flight hours
15 total · 15 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 63 °F
Altimeter
30.17 inHg
Observed at
DXR, 12 nm away

Docket · 14

The files NTSB released with the investigation on June 27, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N1727V · 1

Matched to the same aircraft by N-number and date.