# NTSB ERA19FA107: Cessna 172, N224TA, Mansfield, MA, February 23, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 23, 2019, 12:25 local (17:25 UTC) - Place: Mansfield, MA - Coordinates: 42.004444, -71.199722 - Nearby events: https://openairdocs.org/map.md?lat=42.0044&lon=-71.1997&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report November 6, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, FAA/FSDO, Textron Aviation - NTSB case key (mKey): 99012 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19FA107 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99012/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99012 - Page: https://openairdocs.org/ntsb/ERA19FA107 ## 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 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 · Instructor/check pilot (probable cause); cases with it: [Cessna 172S, 206 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072439), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 172S, 13 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2072439), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 172S, 49 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072439), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cessna 172S, 21 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2072439), [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 172S, 118 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072439), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N224TA-2019-04-22), registration cancelled 2019-04-22, S/N 172S9224, built 2002 (OpenAirDocs) - Reported make and model: Cessna 172 (S) - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming IO-360-L2A](https://openairdocs.org/engine/lycoming-io-360-l2a) (registry code 41597, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S9224 - Year built: 2002 - Airframe hours: 5660 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 32; injuries: fatal; 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 - 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 ## 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 20190223016349A](https://openairdocs.org/incident/20190223016349A), Feb 23, 2019: Cessna 172S, Mansfield, MA, Destroyed, 2 fatal. History of flight On February 23, 2019 about 1230 eastern daylight time, a Cessna 172S single engine airplane, N224TA, owned and operated by new horizon… ## Docket (13 files) The files NTSB released with the investigation on September 11, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99012. 13.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8169470&FileExtension=pdf&FileName=6120_Redacted-Rel.pdf - FAA interview summaries of witnesses (item 2, PDF, 3 pages, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8177262&FileExtension=pdf&FileName=FAA%20Interview%20Summaries_Redacted-Rel.pdf - Excerpts from flight instructor logbook (item 3, PDF, 10 pages, 846 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8180030&FileExtension=pdf&FileName=CFI%20Logbook%20Excerpts_Redacted-Rel.pdf - Excerpt from student pilot logbook (item 4, PDF, 1 page, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8180453&FileExtension=pdf&FileName=Student%20Logbook_Redacted-Rel.pdf - Excerpts from maintenance records (item 5, PDF, 6 pages, 362 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8177452&FileExtension=pdf&FileName=Mx%20Excerpts_Redacted-Rel.pdf - Weather report (item 6, PDF, 1 page, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8177558&FileExtension=pdf&FileName=Metars-Rel.pdf - Excerpt from FAA ATC report (item 7, PDF, 1 page, 232 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8177149&FileExtension=pdf&FileName=ATC%20Excerpt-Rel.pdf - Photo array (item 8, PDF, 5 pages, 929 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8179515&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Toxicological reports (item 9, PDF, 2 pages, 251 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8176965&FileExtension=pdf&FileName=Toxes_Redacted-Rel.pdf - Excerpt from runway 32 video camera recording (6.5MB avi file) (item 10, AVI, 6.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8177158&FileExtension=avi&FileName=Runway%20Excerpt-Rel.avi - Excerpt from taxiway b video camera recording (663K avi file) (item 11, AVI, 680 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8177461&FileExtension=avi&FileName=Taxiway%20B%20Excerpt-Rel.avi - Statement of party representatives to NTSB investigation (item 12, PDF, 10 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8177689&FileExtension=pdf&FileName=Party_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 13, PDF, 1 page, 252 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8177567&FileExtension=pdf&FileName=Wreckage%20Release-Rel.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.