ERA19FA107

NTSB accident investigation · Cessna 172 · Mansfield, MA · February 23, 2019

Accident · FatalField investigationFinal report
Date
February 23, 2019, 12:25 local (17:25 UTC)
Place
Mansfield, MA
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N224TACessna 172
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report November 6, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Lycoming Engines, FAA/FSDO, Textron Aviation
FAA report
20190223016349A
Case key
99012

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 maintain airplane control during initial climb after a touch-and-go landing, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall.

Findings · 2

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotCessna 172S: 206 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 172S: 13 casesAll aircraft: 990 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

After practicing maneuvers during the instructional flight, the flight instructor and student pilot approached the airport for landing. Witnesses and airport surveillance video indicated that the airplane entered the landing flare, but continued to float down the runway a significant distance, touching down about 2,800 ft down the 3,503-ft-long runway. The pilots then initiated a takeoff (touch-and-go). Although the published airport traffic pattern for the runway indicated left turns, the airplane performed a climb in a steep right bank before slowing and entering a spiraling decent toward a grass area near the airport terminal building. Examination of the wreckage did not reveal any preimpact mechanical malfunctions that would have precluded normal operation of the airplane. It is likely that the flight instructor allowed the airplane to exceed its critical angle of attack during a turning initial climb after a touch-and-go landing, which resulted in an aerodynamic stall and impact with terrain. Although it could not be determined who was flying the airplane at the time of the accident, the flight instructor is ultimately responsible for the safety of the flight.

Factual narrative

The four-seat, high-wing, fixed tricycle landing gear airplane was manufactured in 2002. It was powered by a Lycoming IO-360, 180-horsepower engine equipped with a two-blade, fixed-pitch McCauley propeller. Review of the maintenance records revealed that the airplane's most recent annual inspection was completed on January 29, 2019. At that time, the airframe had accrued 5,660 total hours since new and the engine had accrued 3,358 hours since new. On February 23, 2019, about 1225 eastern standard time, a Cessna 172S, N224TA, was substantially damaged when it impacted terrain during the initial climb after takeoff from Mansfield Municipal Airport (1B9), Mansfield, Massachusetts. The flight instructor and student pilot were fatally injured. The airplane was owned and operated by New Horizon Aviation Inc. as a Title 14 Code of Federal Regulations Part 91 instructional flight. Visual meteorological conditions prevailed and no flight plan was filed for the flight, which originated from Norwood Memorial Airport (OWD), Norwood, Massachusetts, about 1125. After performing maneuvers over the local area, the airplane approached 1B9 for landing. Witnesses and review of airport surveillance video revealed that the airplane was on approach to runway 32, a 3,503-ft-long, 75-ft-wide asphalt runway. The airplane flared over the runway and floated a significant distance before touching down about 2,800 ft down the runway. The pilots then initiated a takeoff (touch-and-go). Although the published traffic pattern for runway 32 indicated left turns, the airplane performed a climb in a steep right bank before slowing and entering a spiraling descent toward a grass area near the airport terminal building. The Massachusetts Office of the Chief Medical Examiner, Boston, Massachusetts, performed autopsies on both pilots. The cause of death for both pilots was blunt force injuries. Toxicology testing performed on both pilots by the FAA Forensic Sciences Laboratory was negative for drugs and alcohol. The accident site was located about 11 miles south of OWD. The 1253 recorded weather at OWD included wind variable at 3 knots, 10 miles visibility, clear sky, temperature 4°C, dew point -7°C, and an altimeter setting of 30.41 inches of mercury. The flight instructor held a commercial pilot certificate with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He also held a flight instructor certificate with a rating for airplane single-engine, issued on November 1, 2018. His most recent Federal Aviation Administration (FAA) first-class medical certificate was issued on January 11, 2019. Review of the flight instructor's logbook revealed that he had accumulated a total flight experience of about 386 hours; of which, 66 and 33 hours were flown during the 90- and 30-day periods preceding the accident, respectively. The student pilot did not possess a student pilot certificate nor was he required to. Review of the student pilot's logbookrevealed that, at that time of the accident, he had completed six lessons with the operator and had accrued a total flight experience of 7.6 hours. The wreckage came to rest nose down in grass oriented on a magnetic heading about 270°; no debris path was observed. Fuel had leaked out of both wings and into the grass. Both wings exhibited leading edge impact damage. The cockpit was crushed, but both front seatbelts remained intact and were unlatched by rescue personnel. The flaps and ailerons remained attached to their respective wings and measurement of the flap actuator corresponded to a flaps-retracted position. The rudder and elevator remained attached to the empennage and measurement of the elevator trim actuator corresponded to a 5° tab-up (nose-down) trim position. Control continuity was confirmed from all flight control surfaces to the cockpit controls. The right aileron cable had separated and both cable ends exhibited broomstraw separation consistent with overstress. The engine had separated from the airframe. The propeller remained attached to the engine; one blade remained undamaged and was bent slightly forward. The other blade was bent aft and exhibited chordwise scratches. The propeller and rear accessories were removed from the engine. The top spark plugs were removed and their electrodes were intact and light gray in color. The crankshaft was rotated via an accessory drive gear. Crankshaft, camshaft, and valve train continuity were confirmed and thumb compression was obtained on all cylinders. Fuel was found in the engine-driven fuel pump, fuel servo, flow divider, and in the fuel lines. The fuel inlet screen of the fuel servo and oil suction screen were absent of debris. Both magnetos produced spark at all leads when rotated by hand.

Aircraft

Registration
N224TA
Reported as
Cessna 172 (S)
Category
Airplane
Serial number
172S9224
Built
2002
Airframe hours
5,660
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
New Horizon Aviation Inc
Registered owner
New Horizon Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 29, 2019
Departed
OWD · Norwood, MA
Destination
1B9 · Mansfield, MA
Airport
1B9 · Mansfield Municipal Airport, runway 32, 3,503 × 75 ft, asphalt
Equipment
Stall warning system, Electronic multifunction display, Electronic primary flight display

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
32
Injuries
Fatal
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
November 1, 2018
Seat
Right
Restraint
3-point
Toxicology
Performed
Flight hours
386 total · 150 in this make and model · 66 in the last 90 days · 33 in the last 30 days · 0 in the last 24 hours
Role
Student pilot
Age
18
Injuries
Fatal
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
7 total · 7 in this make and model · 7 in the last 90 days · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
39 °F, dew point 19 °F
Altimeter
30.40 inHg
Observed at
OWD, 11 nm away

Docket · 13

The files NTSB released with the investigation on September 11, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 13.8 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.