# NTSB ERA21FA258: Cessna 150, N1300Q, Yulee, FL, June 18, 2021

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Field · Final report
- Date: June 18, 2021, 11:06 local (15:06 UTC)
- Place: Yulee, FL · In St. Mary's River, approx. 17 feet of water.
- Coordinates: 30.7097, -81.5436 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=30.7097&lon=-81.5436&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Eastern Region Aviation
- Parties: Textron, FAA-FSDO
- ADs cited in the narratives: [AD 2009-10-09](https://openairdocs.org/ad/2009-10-09) (OpenAirDocs)
- NTSB case key (mKey): 103288
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA21FA258
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103288/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103288
- Page: https://openairdocs.org/ntsb/ERA21FA258

## Probable cause

The flight instructor’s decision to conduct slow flight training at an altitude below the flight school’s minimum recovery altitude and his delayed remedial action when an aerodynamic stall occurred.

## Findings

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

- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Cessna 150L, 15 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2071826), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [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 150L, 26 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2071826), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Cessna 150L, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=2071826), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/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 150L, 4 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2071826), [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.

- [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 150L, 15 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2071826), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Maneuvering: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cessna 150L, 10 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2071826), [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 150L, 37 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2071826), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The flight instructor and the student pilot proceeded to the usual training area over a river for an instructional flight. Radar data indicated that the airplane completed several 360° turns, at slow speed, about 800 to 1,000 ft above ground level (agl); the observed maneuvering was consistent with the performance of slow flight. The last radar return was about 300 ft south of the accident site, at 800 ft agl. Several witnesses at a nearby boat dock reported that the airplane descended into the river in a near-vertical, nose-down attitude. One witness stated that the airplane was circling and turning while descending; another reported that the airplane descended nose down in a “corkscrew” path. The witness observations were consistent with the airplane having entered an aerodynamic stall and subsequent spin. Two of the witnesses recalled that the engine was running until impact with the water. The airplane sank in about 17 ft of water. An examination of the wreckage after recovery from the river did not reveal evidence of a preexisting mechanical malfunction or failure that would have precluded normal operation. The flight school that operated the airplane reported that the minimum altitude for recovery during air work, including stalls and slow flight, was 1,500 ft agl. Another student, who flew with the same flight instructor earlier that day, reported that the flight instructor routinely conducted air work below the 1,500 ft minimum. It is likely that the flight instructor allowed the student to stall the airplane at low altitude and delayed remedial action; the airplane subsequently entered a spin from which the instructor was unable to recover before impact.

## Factual narrative

The FAA Airplane Flying Handbook (FAA-H-8083-3C) addresses upset prevention and recovery training, including slow flight and stalls. It states, in part: As in all maneuvers that involve significant changes in altitude or direction, the pilot should ensure that the area is clear of other air traffic at and below their altitude and that sufficient altitude is available for a recovery before executing the maneuver. It is recommended that stalls be practiced at an altitude that allows recovery no lower than 1,500 feet AGL for single-engine airplanes… The FAA Private Pilot – Airplane Airman Certification Standards (FAA-S-ACS-6B) addresses power-on stalls, power-off stalls, and slow flight. It requires that all tasks be completed no lower than 1,500 ft agl for single-engine aircraft. According to the operator, the airplane was purchased in December 2020 and was used for flight instruction since its purchase. On June 18, 2021, about 1106 eastern daylight time, a Cessna 150L, N1300Q, was destroyed when it was involved in an accident near Yulee, Florida. The flight instructor and the student pilot were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to air traffic control (ATC) radar data obtained from the Federal Aviation Administration (FAA), the flight departed Fernandina Beach Municipal Airport (FHB), Fernandina Beach, Florida, about 1056 and proceeded on a northwesterly heading for about 7 miles until over the St. Mary’s River. No ATC services were provided. The airplane performed several 360° turns, at slow speed, about 800 to 1,000 ft above ground level (agl). The last radar return was about 300 ft south of the accident site, at 800 ft agl. Several witnesses at a nearby boat dock reported that the airplane descended into the St. Mary’s River in a near-vertical, nose-down attitude. One witness stated that the airplane was circling and turning while descending; another reported that the airplane descended nose down in a “corkscrew” path. Two of the witnesses recalled that the engine was running until impact with the water. Toxicology testing performed by the FAA Forensic Sciences Laboratory detected acetaminophen (Tylenol) in the flight instructor’s cavity blood and in his urine. No ethanol was detected. Toxicology testing on the student pilot was performed by the FAA Forensic Sciences Laboratory. No evidence of drugs or ethanol were found. According to the student pilot’s logbook, the accident flight was her fifth flight at the flight school that operated the airplane. All flights were with the accident flight instructor. She had also logged flight instruction at a different flight school in a Diamond DA-20 airplane and had soloed in the DA-20. The operator’s ground operations director reported that she was a “sharp” student. She took her lessons seriously and was always prepared. The ground operations director reported that he met the flight instructor in May 2021, whenthe flight instructor was hired. He held the flight instructor in “high regard.” The flight instructor did not exhibit any unusual personality traits or poor flying habits. He was very cautious and was not one to take any risks while flying. The chief flight instructor where the flight instructor was previously employed reported that the flight instructor was an experienced pilot in both single- and multiengine airplanes and was an excellent pilot and instructor. He also stated that he was very professional and would never perform any risky maneuvers. The flight instructor flew a instructional flight with another student in the airplane during the morning before the accident. The student reported that they took off about 0800 and proceeded up the St. Mary’s River at an altitude of about 1,000 ft agl. He then performed clean stalls, stalls with flaps extended, and a power-off glide at altitudes between 1,000 and 1,200 ft agl. He stated that there were no issues with the airplane mechanically, and there was no unusual looseness or binding in the flight controls. When asked about previous flights with the flight instructor, he reported that they always performed air work, including stalls, at 1,000 to 1,200 ft agl, and never above 1,800 ft agl. A-Cent Aviation’s policy regarding minimum altitude for recovery from stalls and other air work was 1,500 ft agl; however, most instructors at the school performed stalls at a much higher altitude than the minimum recovery altitude of 1,500 ft agl. The airplane impacted the St. Mary’s River and sank in about 17 ft of water. There was no fire. The accident site was about 7 nautical miles northwest of FHB. After recovery from the river, the wreckage was transported to an aircraft salvage facility for examination. Initial examination of the wreckage revealed that all major structural components of the airplane were present. The fixed, tricycle landing gear remained attached to the airframe. The engine was broken from the engine mounts; however, it was held in position by control cables and wires. The fixed-pitch propeller remained attached to the engine. The leading edges of the wings were compressed aft, equally, to about two-thirds of their original chord width. The right wing separated from the forward mount but remained attached at the aft mount. The left wing remained attached at both mounts. The wing flaps remained attached to the wings and were found in the retracted positions. The right aileron was complete and remained attached to the inboard hinge and the push/pull rod. The left aileron was intact and remained attached to the inner and center hinges and the push/pull rod. Aileron cable continuity was confirmed from the control surfaces to the cockpit controls. The rudder remained attached to the vertical stabilizer. The elevators remained attached at the outboard hinge locations and to the elevator control bellcrank and did not exhibit impact damage. The elevator bellcrank was fractured at thebulkhead attach point. The attach bolt and bushing remained attached to the bulkhead. Neither the vertical stabilizer nor the horizontal stabilizer exhibited signs of impact damage. The elevator push/pull rod was intact from the control column to the elevator sector beneath the seats. Rudder cable continuity was confirmed from the rudder horn to the cockpit controls. The elevator bellcrank, rudder, and a portion of tail cone were submitted to the National Transportation Safety Board Materials Laboratory for further examination. The elevator bellcrank had been assembled to the tail cone via a bolted joint; however, a portion of the connection through-hole in the bellcrank had separated. The separated portion consisted of roughly one-half of the through-hole circumference, which allowed the bellcrank to separate from the mating bolt. Both fracture surfaces had rub damage that obscured large areas. The undamaged areas on the fracture surfaces had features consistent with overstress. According to FAA Airworthiness Directive (AD) 2009-10-09, all Cessna 150 model aircraft should have either a placard prohibiting spins and other aerobatic maneuvers or service kit part number SK152-25 installed. SK152-25 replaces the rudder stop, rudder stop bumpers, and the attachment hardware with new duplicate parts and includes the addition of a doubler. Neither stop bolt on the accident aircraft had a doubler nor a nut and washer assembled on the inside surface of the tail cone skin, which indicated that SK152-25 was not installed. A damaged placard was found on the instrument panel that appeared to comply with the AD. The engine exhibited damage from impact and from exposure to salt water and sand. The examination of the engine did not reveal evidence of a preexisting malfunction or anomaly that would have precluded normal operation. One propeller blade was bent aft about 90° and exhibited “s” bending signatures. The other blade was bent slightly aft and exhibited slight “s” bending signatures.

## Aircraft

- Registration: [N1300Q](https://openairdocs.org/aircraft/N1300Q), registered now, S/N 15072600, built 1971 (OpenAirDocs)
- Reported make and model: CESSNA 150 (L)
- Registry model: [Cessna 150L](https://openairdocs.org/model/cessna-150l) (registry code 2071826) (OpenAirDocs)
- Registry engine: [Continental 0-200 series](https://openairdocs.org/engine/continental-0-200-series) (registry code 17020, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 15072600
- Year built: 1971
- Airframe hours: 5422.18
- Engines: Continental O-200-A 100 horsepower reciprocating
- Damage: Destroyed
- Flight: Instructional, Part 91
- Operator: A-Cent Aviation Inc.
- Registered owner: A-Cent Aviation Inc.
- Airworthiness certificate: Standard, Normal
- Last inspection: 100 hour, April 27, 2021, 67 hours before
- Departed: FHB, Fernandina Beach, FL
- Equipment: Unknown

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Flight instructor; age 66; injuries: fatal; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: right; toxicology performed; flight hours: 4,003 total
- Student pilot; age 18; injuries: fatal; student; medical: class 1, without waivers/limitations; seat: left; toxicology performed; flight hours: 21 total, 4 in this make and model

## Weather

- Conditions: Visual (VMC), Day
- Wind: 80° at 7 knots
- Visibility: 10 statute miles
- Lowest ceiling: 9,000 ft overcast
- Temperature: 84 °F, dew point 81 °F
- Altimeter: 30.10 inHg
- Observed at: FHB, 7 nm away
- METAR: KFHB 181535Z AUTO 08007KT 10SM OVC090 29/27 A3010 RMK AO2 T02930265

## 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 20210618007869A](https://openairdocs.org/incident/20210618007869A), Jun 18, 2021: Cessna 150L, Yulee, FL, Destroyed, 2 fatal. Aircraft [privacy data omitted] departed fernandina beach airport at approximately 11 am eastern time on June 18th 2021. The purpose of the flight was flight…

## Docket (29 files)

The files NTSB released with the investigation on April 19, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103288. 71.3 MB in all.

- Witnesses diagram (item 1, PDF, 1 page, 8.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13688472&FileExtension=pdf&FileName=10%20Witnesses%20Diagram-Rel.pdf
- NTSB memorandum for record - f campbell interview (item 2, PDF, 1 page, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13699024&FileExtension=pdf&FileName=1%20Memorandum%20for%20Record%20508%20F%20Campbell_Redacted-Rel.pdf
- NTSB memorandum for record - j campbell interview (item 3, PDF, 2 pages, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13699210&FileExtension=pdf&FileName=2%20Memorandum%20for%20Record%20508%20J%20Campbell_Redacted-Rel.pdf
- NTSB memorandum for record - m lankford interview (item 4, PDF, 2 pages, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13698880&FileExtension=pdf&FileName=3%20Memorandum%20for%20Record%20508%20M%20Lankford_Redacted-Rel.pdf
- NTSB memorandum for record - c scheupbach interview (item 5, PDF, 1 page, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13699034&FileExtension=pdf&FileName=4%20Memorandum%20for%20Record%20508%20C%20Scheupbach_Redacted-Rel.pdf
- FAA record of interview - j bishop (item 6, PDF, 2 pages, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13699521&FileExtension=pdf&FileName=5%20J%20Bishop%20Interview_Redacted-Rel.pdf
- FAA record of interview - t little (item 7, PDF, 2 pages, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13699531&FileExtension=pdf&FileName=6%20T%20Little%20Interview_Redacted-Rel.pdf
- FAA record of interview - r simpkins (item 8, PDF, 2 pages, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13698128&FileExtension=pdf&FileName=7%20R%20Simpkins%20Interview-Rel.pdf
- FAA record of interview - d vigil (item 9, PDF, 1 page, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13699541&FileExtension=pdf&FileName=8%20D%20Vigil%20Interview-Rel.pdf
- FAA record of interview - w walker (item 10, PDF, 1 page, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13699587&FileExtension=pdf&FileName=9%20W%20Walker%20Interview-Rel.pdf
- NTSB memorandum for record - FAA correspondence (item 11, PDF, 1 page, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15276953&FileExtension=pdf&FileName=NTSB%20Memo%20for%20Record%20-%20Correspondence%20with%20FAA-Rel.pdf
- Pilot records - cuttino (item 12, PDF, 5 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13700211&FileExtension=pdf&FileName=12%20Photo%20Array%20-%20Cuttino%20Pilot%20Records_Redacted-Rel.pdf
- Pilot log excerpts - george (item 13, PDF, 6 pages, 14.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13700221&FileExtension=pdf&FileName=13%20Photo%20Array%20-%20George%20Pilot%20Records_Redacted-Rel.pdf
- Excerpts - aircraft logbook (item 14, PDF, 6 pages, 6.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13699661&FileExtension=pdf&FileName=14%20Photo%20Array%20-%20Aircraft%20Logbook%20Excerpts_Redacted-Rel.pdf
- Excerpts - engine logbook (item 15, PDF, 4 pages, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13699671&FileExtension=pdf&FileName=15%20Photo%20Array%20-%20Engine%20Logbook%20Entries_Redacted-Rel.pdf
- Photo array (item 16, PDF, 10 pages, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13982572&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf
- Radar track - entire flight (item 17, PDF, 1 page, 8.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13982461&FileExtension=pdf&FileName=Entire%20Flight-Rel.pdf
- Radar track - flight over st. mary's river (item 18, PDF, 1 page, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13982245&FileExtension=pdf&FileName=Flight%20Path%20Over%20St%20Marys%20River-Rel.pdf
- Radar track - final flight segment (item 19, PDF, 1 page, 5.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13982346&FileExtension=pdf&FileName=Flight%20Track%20Final%20Segment-Rel.pdf
- Radar data (item 20, CSV, 9 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13982701&FileExtension=csv&FileName=N1300Q-Rel.csv
- Wreckage diagram (item 21, PDF, 1 page, 7.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13700249&FileExtension=pdf&FileName=11%20Wreckage%20Diagram-Rel.pdf
- NTSB examination summary (item 22, PDF, 4 pages, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13700289&FileExtension=pdf&FileName=Examination%20Summary-Rel.pdf
- Materials laboratory factual report (item 23, PDF, 13 pages, 11 photos, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13715546&FileExtension=pdf&FileName=22-027%20Materials%20Lab%20Factual%20Report%20(ERA21FA258)-Rel.pdf
- Toxicological report - flight instructor (item 24, PDF, 1 page, 168 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13720366&FileExtension=pdf&FileName=Tox%20-%20Flight%20Instructor_Redacted-Rel.pdf
- Toxicological report - student pilot (item 25, PDF, 1 page, 173 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13720498&FileExtension=pdf&FileName=Tox%20-%20Student_Redacted-Rel.pdf
- NTSB memorandum for record - autopsy findings (item 26, PDF, 1 page, 119 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13719552&FileExtension=pdf&FileName=Memorandum%20for%20Record%20508%20Autopsy%20Findings-Rel.pdf
- Statement of party representatives to NTSB investigation (item 27, PDF, 14 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13792384&FileExtension=pdf&FileName=Party%20Form%20Textron%20Aviation_Redacted-Rel.pdf
- Release of aircraft wreckage, NTSB form 6120.15 (item 28, PDF, 1 page, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13792247&FileExtension=pdf&FileName=N1300Q%20Release_Redacted-Rel.pdf
- Evidence control form (item 29, PDF, 1 page, 896 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13792394&FileExtension=pdf&FileName=Evidence%20Control%20Form%20N1300Q_Redacted-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.

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