# NTSB ERA23LA139: Cessna 140, N2419V, Keystone Heights, FL, February 15, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Limited · Final report - Date: February 15, 2023, 10:00 local (15:00 UTC) - Place: Keystone Heights, FL · In a pasture about 3 miles south of the airfield. - Coordinates: 29.804163, -82.040263 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.8042&lon=-82.0403&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 106824 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA23LA139 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106824/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106824 - Page: https://openairdocs.org/ntsb/ERA23LA139 ## Probable cause The pilot’s improper decision to perform an impromptu off-airport landing and his failure to maintain control of the airplane during the landing, which resulted in a nose-over. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 140, 27 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=2071602), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna 140, 56 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2071602), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna 140, 14 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=2071602), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Cessna 140, 46 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2071602), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis The pilot reported that he was about three miles south of the non-tower-controlled airport, inbound for landing, when he heard another pilot announce they were on the downwind leg of the traffic pattern for the same runway. He elected to perform a 360° right turn to “allow the other aircraft time to clear the pattern.” He further reported that while in the turn, he “noticed acres and acres of pristine/plush land.” The pilot then decided to perform an off-airport landing in a field. During the landing roll, livestock began to walk in front of the airplane and the pilot took action to avoid a collision. This resulted in a nose over and substantial damage to the vertical stabilizer, rudder, wings, and fuselage. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N2419V](https://openairdocs.org/deregistered/N2419V-2023-09-18), registration cancelled 2023-09-18, S/N 14665, built 1948 (OpenAirDocs) - Reported make and model: CESSNA 140 - Registry model: [Cessna 140](https://openairdocs.org/model/cessna-140) (registry code 2071602) (OpenAirDocs) - Registry engine: [Continental C90 series](https://openairdocs.org/engine/continental-c90-series) (registry code 17009, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 14665 - Year built: 1948 - Airframe hours: 2433 - Engines: Continental O-200 100 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 1, 2022 - Departed: X58, Indiantown, FL - Destination: 42J, Keystone Heights, FL - Airport: 42J, Keystone Heights ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 76; injuries: none; private, recreational; airplane ratings: single-engine land; medical: sport pilot, without waivers/limitations; last flight review March 1, 2021; seat: left; restraint: 3-point; flight hours: 2,000 total, 65 in this make and model, 2,000 as pilot in command, 6 in the last 90 days, 2 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 59 °F - Altimeter: 30.21 inHg - Observed at: 42J - METAR: METAR K42J 151535Z AUTO 19011KT 10SM CLR 22/15 A3021 RMK A01 ## 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 20230215001699A](https://openairdocs.org/incident/20230215001699A), Feb 15, 2023: Cessna 140, Key Stone Heigh, FL, Substantial damage. Pilot left port st lucie, Florida and was attempting to stop at keystone heights airport (42J) for fuel before continuing to his final destination of north… ## Other investigations on N2419V (1) 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. - [NTSB MKC78FCD06](https://openairdocs.org/ntsb/MKC78FCD06), Oct 19, 1977: Cessna 140 (N2419V), Ankeny, IA, substantial damage ## Docket (3 files) The files NTSB released with the investigation on June 15, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106824. 7.5 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 6.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15295734&FileExtension=pdf&FileName=6120.1%20Form%20Pilot_Redacted-Rel.pdf - Memorandum for record a�� telephone interview, pilot (item 2, PDF, 1 page, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15295536&FileExtension=pdf&FileName=MOR%20Pilot%20interview%20summary-Rel.pdf - Photographs (item 3, PDF, 5 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15296229&FileExtension=pdf&FileName=Photo%20Array%20ERA23LA139-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.