# NTSB ERA18LA191: Cessna 182, N291CP, Geneseo, NY, July 13, 2018

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: July 13, 2018, 18:00 local (22:00 UTC)
- Place: Geneseo, NY
- Coordinates: 42.79861, -77.842498 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=42.7986&lon=-77.8425&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241)
- Highest injury: Serious injuries
- Injuries: 1 serious, 2 minor
- Status: Completed, report April 30, 2019
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO, Textron, Civil Air Patrol
- NTSB case key (mKey): 97768
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18LA191
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97768/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97768
- Page: https://openairdocs.org/ntsb/ERA18LA191

## Probable cause

The pilot's failure to properly set the elevator trim before takeoff, which resulted in an exceedance of the airplane's critical angle of attack during takeoff and a subsequent aerodynamic stall. Contributing to the accident was the pilot’s failure to follow the Before Takeoff—Run Up checklist.

## Findings

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

- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 182T, 26 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072703), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 182T, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2072703), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md)
- [Flight control system: elevator tab control system](https://openairdocs.org/ntsb-findings/01022731): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Cessna 182T, 1 case](https://openairdocs.org/ntsb-findings/01022731/cases.md?model=2072703), [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022731/cases.md)

## Sequence of events

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

- [Takeoff: Abrupt maneuver](https://openairdocs.org/ntsb-events/270); cases with it: [Cessna 182T, 3 cases](https://openairdocs.org/ntsb-events/270/sequence.md?model=2072703), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md)
- [Takeoff: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Cessna 182T, 6 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=2072703), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md)
- [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Cessna 182T, 3 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2072703), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 182T, 17 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072703), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)
- [After landing: Roll over](https://openairdocs.org/ntsb-events/097); cases with it: [Cessna 182T, 1 case](https://openairdocs.org/ntsb-events/097/sequence.md?model=2072703), [All aircraft, 261 cases](https://openairdocs.org/ntsb-events/097/sequence.md)

## Analysis

The commercial pilot reported that, before the accident flight, he repositioned the airplane uneventfully from an airport about 20 miles away. Before takeoff on the accident flight, the pilot performed an engine run-up and verified that all flight controls were free and correct. The pilot then initiated a soft-field takeoff procedure on a bumpy, grass runway. The airplane became airborne in ground effect about 45 knots, and it then began to climb out of ground effect at 60 knots. At that time, the airplane’s nose pitched up abruptly, and the pilot pushed the yoke forward as hard as he could while engaging nose-down electric elevator trim; however, the airplane continued to climb at an excessive angle of attack and subsequently stalled. The airplane then rolled left, descended to the ground, and came to rest inverted. Neither passenger could recall whether the pilot conducted any type of control check or engine run-up before takeoff. Examination of the wreckage did not reveal evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The elevator trim tab was found in a midrange, nose-down position, consistent with the pilot’s statement that he was trimming nose down in an attempt to recover from the loss of control on takeoff. The Before Takeoff – Run-Up checklist stated that the elevator should be trimmed to 20° nose down for takeoff. Given the airplane pitched up abruptly as it began to climb out of ground effect, it is likely that the pilot landed after the previous flight with a nose-up elevator trim setting and that he did not properly reset the elevator trim before takeoff for the accident flight in accordance with the Before Takeoff—Run-Up checklist, which resulted in an exceedance of the airplane’s critical angle of attack during takeoff and the subsequent aerodynamic stall.

## Factual narrative

On July 13, 2018, about 1800 eastern daylight time, a Cessna 182T, N291CP, was substantially damaged during takeoff from Geneseo Airport (D52), Geneseo, New York. The commercial pilot sustained serious injuries and the two passengers sustained minor injuries. The airplane was operated by the Civil Air Patrol (CAP) as a familiarization flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight.The pilot reported that earlier during the day of the accident, he completed a flight from Greater Rochester International Airport (ROC), Rochester, New York, to D52 uneventfully and did not use the autopilot during that flight or the accident flight. The purpose of the accident flight was to provide a familiarization flight to two CAP cadets. The pilot showed the cadets a thorough preflight inspection and then started the engine and taxied to runway 23. Prior to takeoff, the pilot performed an engine run-up and verified that all flight controls were free and correct. The pilot then initiated a soft-field takeoff procedure on the bumpy grass runway. The airplane became airborne in ground effect about 45 knots and everything seemed normal as it began to climb out of ground effect at 60 knots. At that time, the nose pitched up abruptly and the pilot pushed the yoke forward as hard as he could while engaging nose-down electric elevator trim; however, the airplane continued to climb at an excessive angle-of-attack and stalled. It subsequently rolled left, descended to the ground and came to rest inverted. Both passengers were minors and interviewed separately by a Federal Aviation Administration (FAA) inspector in the presence of a parent. One passenger did not recall the pilot doing a preflight inspection, use a checklist, or perform any type of check and engine run-up prior to takeoff. The other passenger recalled an abbreviated preflight inspection and use of a checklist before and after engine start; however, he did not recall any stopping prior to entering the runway, engine run-up, or control check except for flaps moving. Both passengers sustained concussions in the accident. Initial examination of the wreckage by an FAA inspector revealed damage to both wings and the fuselage. The inspector measured the elevator trim actuator arm, which corresponded to a 10° tab-up (nose-down) trim position. The maximum tab-up position was 24°, plus or minus 2°. The inspector also recovered a memory card from the airplane's multifunction display; however, download and review of the data revealed that the last recorded flight was in 2016. The wreckage was subsequently up-righted and recovered by the operator. The FAA inspector examined the wreckage again with a representative from the airframe manufacturer. All control surfaces were moveable by hand. All flight control cables were intact and attached to their respective flight and cockpit controlsexcept left aileron cable, which had separated between the front door post and instrument panel, in the area of the fuselage separation. The separated ends of the left aileron cable exhibited a broom-straw appearance. The rudder and elevator cables and their routing area were visually examined throughout the length of the airplane. The elevator and elevator trim autopilot servos could be moved by hand. No preimpact impediments to the movement of the control yokes were observed between the firewall and instrument panel and no preimpact abnormalities were observed during the examination. Review of the operator's "Before Takeoff – Run-Up" checklist revealed, "…20. Elevator & Rudder Trim…Take Off…" The recorded weather at ROC, at 1754, included wind from 220° at 7 knots, visibility 10 miles and scattered clouds at 14,000 feet.

## Aircraft

- Registration: [N291CP](https://openairdocs.org/deregistered/N291CP-2022-07-30), registration cancelled 2022-07-30, S/N 18281991, built 2007 (OpenAirDocs)
- Reported make and model: Cessna 182 (T)
- Registry model: [Cessna 182T](https://openairdocs.org/model/cessna-182t) (registry code 2072703) (OpenAirDocs)
- Registry engine: [Lycoming IO-540-AB1A5](https://openairdocs.org/engine/lycoming-io-540-ab1a5) (registry code 41808, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 18281991
- Year built: 2007
- Airframe hours: 2057
- Engines: Lycoming IO-540-AB1A5 230 horsepower reciprocating
- Damage: Substantial damage
- Flight: Other work use, Part 91
- Operator: Civil Air Patrol
- Registered owner: Civil Air Patrol
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, July 17, 2017, 83 hours before
- Departed: D52, Geneseo, NY
- Destination: D52, Geneseo, NY
- Airport: D52, Geneseo Airport, runway 23, 4,695 × 90 ft, grass/turf
- Equipment: Onboard weather, Stall warning system, ADS-B, Auto-pilot, Data recorder

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 65; injuries: serious; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review August 6, 2017; seat: left; restraint: 3-point; flight hours: 991 total, 112 in this make and model, 960 as pilot in command, 24 in the last 90 days, 5 in the last 30 days, 1 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 220° at 7 knots
- Visibility: 10 statute miles
- Lowest ceiling: 18,000 ft broken
- Temperature: 88 °F, dew point 55 °F
- Altimeter: 30.10 inHg
- Observed at: ROC, 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 20180713011089A](https://openairdocs.org/incident/20180713011089A), Jul 13, 2018: Cessna 182T, Geneseo, NY, Substantial damage. On Friday, July 13, 2018 at approximately 1800 EDT, a CE-182T, N291CP, departed runway 23 at the Geneseo Airport (D52). Shortly after takeoff, it was reported…

## Docket (6 files)

The files NTSB released with the investigation on December 4, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97768. 3.3 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468853&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- FAA Inspector Statement (item 2, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468854&FileExtension=.PDF&FileName=FAA%20Inspector%20Statement-Master.PDF
- Excerpt from Operator's Airplane Checklist (item 3, .PDF, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468855&FileExtension=.PDF&FileName=Excerpt%20from%20Operator%27s%20Airplane%20Checklist-Master.PDF
- Weather Report (item 4, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468856&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF
- Photo Array (item 5, .PDF, 2 photos, 484 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468857&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF
- Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 407 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468858&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-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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