# NTSB FTW95FA147: Cessna R172E, N1438Z, Gladewater, TX, March 27, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 27, 1995, 09:00 local (15:00 UTC) - Place: Gladewater, TX - Coordinates: 32.540008, -94.940917 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.5400&lon=-94.9409&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report September 24, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 19217 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=FTW95FA147 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/19217/pdf - Page: https://openairdocs.org/ntsb/FTW95FA147 ## Probable cause THE PILOT'S FAILURE TO MAINTAIN AN AIRSPEED ABOVE STALL SPEED, RESULTING IN AN INADVERTENT STALL. A FACTOR WAS THE PILOT'S PERFORMANCE OF AN ABRUPT MANEUVER IMMEDIATELY AFTER TAKEOFF. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - maneuver - abrupt, pilot in command (contributing factor) - airspeed(vs) - not maintained, pilot in command (cause) - stall - inadvertent, pilot in command - In flight collision with terrain/water, descent - uncontrolled ## Analysis DURING TAKEOFF INITIAL CLIMB WITNESSES OBSERVED THE AIRPLANE AT 500 FEET ABOVE GROUND LEVEL IN A 90 DEGREE LEFT BANK, 'NOSED OVER TO ALMOST VERTICAL.' PRIOR TO THE AIRPLANE DESCENDING OUT OF VIEW IT 'LOOKED LIKE THE PILOT WAS TRYING TO GET THE NOSE UP AND WINGS LEVEL.' ACCORDING TO A FAA INSPECTOR, SEVERAL SOURCES REPORTED THAT THE PILOT DEMONSTRATED A PAST HISTORY OF ABRUPT MANEUVERS AT LOW ALTITUDE. EXAMINATION OF THE AIRPLANE AND ENGINE DID NOT REVEAL ANY STRUCTURAL OR MECHANICAL ANOMALIES. ## Factual narrative HISTORY OF FLIGHT On March 27, 1995, approximately 0900 central standard time, a Cessna R172E, N1438Z was destroyed during an uncontrolled descent shortly after takeoff at Gladewater Municipal Airport, Gladewater, Texas. The commercial pilot was fatally injured. Visual meteorological conditions prevailed for the pipeline inspection flight. Witnesses reported the following information to the investigator- in-charge. The airplane was preflighted and fueled. The pilot taxied the airplane to runway 31 where a runup was completed. "The takeoff and lift off looked normal," and the "engine sounded normal." The next time the airplane was observed it was at 500 feet and had "nosed over to almost vertical" and was in a 90 degree bank to the left. Prior to the airplane descending out of view it "looked like the pilot was trying to get the nose up and wings level." PERSONNEL INFORMATION According to a Federal Aviation Administration (FAA) inspector, the pilot was observed on previous flights making "abrupt maneuvers on takeoff." The pilot often made "knife edge turns and came back over the hangars at approximately 300 feet." AIRCRAFT INFORMATION The airplane's airframe and engine log books were not located. The operator reported that the log books were normally kept in the airplane, which was destroyed by a post impact fire. The person who performed the annual inspection on November 12, 1994, stated the airplane was in "excellent condition." He also stated he installed outer wing and fuselage fuel tanks on December 15, 1994. WRECKAGE AND IMPACT INFORMATION The wreckage distribution path was on a centerline of 255 degrees magnetic. The aircraft came to rest 63 feet from the initial ground scar on a magnetic heading of 020 degrees. There was a post impact fire. The green wing tip light was found in the initial ground scar. A tree located 53 feet from the wreckage had branches separated 16 feet above the ground. A cut limb with aluminum transfer marks was found on the ground near the tree. Another cut tree limb with aluminum transfer marks was found 55 feet along the energy path, 25 feet to the left. Continuity was established to all flight control surfaces; however, the right aileron control cable was found separated about 13 feet, 8 inches from the outer bell crank attachment. The separated pieces of the cable were shipped to the National Transportation Safety Board, Office of Research and Engineering, Materials Laboratory, Washington, D.C., for further examination and evaluation. The examination and evaluation revealed "most of the wires were elongated near the fracture ends and contained cup-and-cone or slant fracture features, typical of overstress tensile separations." See enclosed report. Examination of the airplane and engine did not disclose any mechanical anomalies. See enclosed wreckage diagram for wreckage distribution details. MEDICAL AND PATHOLOGICAL INFORMATION The autopsy was performed by James R. Bruce, M.D., at the Lufkin Pathology Laboratory, Lufkin, Texas. Toxicology findings were negative. ADDITIONAL DATA The airplane wreckage was released to the owner's representative. ## Aircraft - Registration: [N1438Z](https://openairdocs.org/deregistered/N1438Z-1997-04-07), registration cancelled 1997-04-07, S/N R1720232 (OpenAirDocs) - Reported make and model: CESSNA R172E - Registry model: [Cessna R172E](https://openairdocs.org/model/cessna-r172e) (registry code 2072413) (OpenAirDocs) - Category: Airplane - Serial number: R172-0232 - Airframe hours: 7700 - Engines: LYCOMING O-360-A1A 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Aerial observation, Part 91 - Registered owner: Laurence E. Stratton - Airworthiness certificate: Standard, Normal - Departed: 07F - Destination: CRP, CORPUS CHRISTI, TX ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 6,000 total, 5,000 in this make and model, 200 in the last 90 days, 70 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 315° at 10 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 61 °F ## 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 19950327005729A](https://openairdocs.org/incident/19950327005729A), Mar 27, 1995: Cessna R172E, Gladewater, TX, Destroyed, 1 fatal. On climbout performed a wing over. Stalled and dived in. Had history of prior showoff low altitude maneuvers. 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.