# NTSB GAA16CA403: Cessna 172, N3677S, Rexburg, ID, July 28, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: July 28, 2016, 17:30 local (23:30 UTC) - Place: Rexburg, ID - Coordinates: 43.833889, -111.805 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.8339&lon=-111.8050&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report December 5, 2016 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 93724 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA403 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93724/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93724 - Page: https://openairdocs.org/ntsb/GAA16CA403 ## Probable cause The student pilot's failure to retract the flaps during a go-around in high density altitude conditions, resulting in the airplane's inability to climb and a subsequent collision with terrain and nose over. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent rate](https://openairdocs.org/ntsb-findings/01062037): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 172E, 1 case](https://openairdocs.org/ntsb-findings/01062037/cases.md?model=2072412), [All aircraft, 242 cases](https://openairdocs.org/ntsb-findings/01062037/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Cessna 172E, 8 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072412), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Cessna 172E, 2 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2072412), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Student/instructed pilot (probable cause); cases with it: [Cessna 172E, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=2072412), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Effect on equipment; cases with it: [Cessna 172E, 3 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=2072412), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Landing area overshoot](https://openairdocs.org/ntsb-events/380); cases with it: [Cessna 172E, 2 cases](https://openairdocs.org/ntsb-events/380/sequence.md?model=2072412), [All aircraft, 400 cases](https://openairdocs.org/ntsb-events/380/sequence.md) - [Landing: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Cessna 172E, 2 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=2072412), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Cessna 172E, 2 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=2072412), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 172E, 12 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2072412), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The student pilot reported that while practicing short-field landings on runway 17, a 4,200 foot asphalt runway, he overshot his intended landing area. He reported that about 65 knots indicated air speed and 25 feet above ground level (AGL), he executed a go-around by applying mixture rich, full throttle, carburetor heat cold, but the electric flaps were left fully extended. He reported that he pulled back on the yoke, but he could not get the airplane to climb, and the airplane descended to the right side of the runway, and touched down in the safety area to the right of the runway and nosed over. The airplane sustained substantial damage to both wings, vertical stabilizer and the rudder. The pilot reported that there were no mechanical malfunctions or anomalies with any portion of the airplane during the flight that would have prevented normal flight operations. Photographs of the accident airplane provided by the Federal Aviation Administration (FAA) showed the airplane inverted with the flaps extended. The airplane manufacturer pilot operating handbook prescribed Balked Landing procedure states: 1. Throttle – Full Open 2. Carburetor Heat – Cold 3. Wing Flaps - 20 Degrees (Immediately) 4. Climb Speed – 55 Knots 5. Wing Flaps 10 Degrees (Until obstacles are cleared) Retract (after reaching a safe altitude and 60 KIAS) The meteorological aerodrome report at accident airport about the time of the accident indicated: The temperature was 90 degrees Fahrenheit, dew point was 37 degrees Fahrenheit, the wind was out of 170 degrees true at 7 knots and varying between 140 degrees and 200 degrees true. The altimeter setting was 30.10. The field elevation at the airport was 4,858 feet and the density altitude was 7,850 feet. According to the FAA Pamphlet 8740-2 pertaining to Density Altitude: Whether due to high altitude, high temperature, or both, reduced air density (reported in terms of density altitude) adversely affects aerodynamic performance and decreases the engine's horsepower output. Takeoff distance, power available (in normally aspirated engines), and climb rate are all adversely affected. Landing distance is affected as well; although the indicated airspeed (IAS) remains the same, the true airspeed (TAS) increases. From the pilot's point of view, therefore, an increase in density altitude results in the following: • Increased takeoff distance. • Reduced rate of climb. • Increased TAS (but same IAS) on approach and landing. According to the aforementioned FAA Pamphlet, the Koch Chart (chart in docket) depicting the relationship between airport temperature (90 degrees) and airport pressure altitude (4,693 feet), the climb rate decreases by 64 percent. The pilot initiated the balked landing procedure at 25 feet AGL. ## Factual narrative The student pilot reported that while practicing short-field landings on runway 17, a 4,200 foot asphalt runway, he overshot his intended landing area. He reported that about 65 knots indicated air speed and 25 feet above ground level (AGL), he executed a go-around by applying mixture rich, full throttle, carburetor heat cold, but the electric flaps were left fully extended. He reported that he pulled back on the yoke, but he could not get the airplane to climb, and the airplane descended to the right side of the runway, and touched down in the safety area to the right of the runway and nosed over. The airplane sustained substantial damage to both wings, vertical stabilizer and the rudder. The pilot reported that there were no mechanical malfunctions or anomalies with any portion of the airplane during the flight that would have prevented normal flight operations. Photographs of the accident airplane provided by the Federal Aviation Administration (FAA) showed the airplane inverted with the flaps extended. The airplane manufacturer pilot operating handbook prescribed Balked Landing procedure states: 1. Throttle – Full Open 2. Carburetor Heat – Cold 3. Wing Flaps - 20 Degrees (Immediately) 4. Climb Speed – 55 Knots 5. Wing Flaps 10 Degrees (Until obstacles are cleared) Retract (after reaching a safe altitude and 60 KIAS) The meteorological aerodrome report at accident airport about the time of the accident indicated: The temperature was 90 degrees Fahrenheit, dew point was 37 degrees Fahrenheit, the wind was out of 170 degrees true at 7 knots and varying between 140 degrees and 200 degrees true. The altimeter setting was 30.10. The field elevation at the airport was 4,858 feet and the density altitude was 7,850 feet. According to the FAA Pamphlet 8740-2 pertaining to Density Altitude: Whether due to high altitude, high temperature, or both, reduced air density (reported in terms of density altitude) adversely affects aerodynamic performance and decreases the engine's horsepower output. Takeoff distance, power available (in normally aspirated engines), and climb rate are all adversely affected. Landing distance is affected as well; although the indicated airspeed (IAS) remains the same, the true airspeed (TAS) increases. From the pilot's point of view, therefore, an increase in density altitude results in the following: • Increased takeoff distance. • Reduced rate of climb. • Increased TAS (but same IAS) on approach and landing. According to the aforementioned FAA Pamphlet, the Koch Chart (chart in docket) depicting the relationship between airport temperature (90 degrees) and airport pressure altitude (4,693 feet), the climb rate decreases by 64 percent. The pilot initiated the balked landing procedure at 25 feet AGL. ## Aircraft - Registration: [N3677S](https://openairdocs.org/deregistered/N3677S-2019-10-04), registration cancelled 2019-10-04, S/N 17250877 (OpenAirDocs) - Reported make and model: CESSNA 172 (E) - Registry model: [Cessna 172E](https://openairdocs.org/model/cessna-172e) (registry code 2072412) (OpenAirDocs) - Registry engine: [Continental 0-300 series](https://openairdocs.org/engine/continental-0-300-series) (registry code 17022, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17250877 - Year built: 1964 - Engines: CONT MOTOR 0-300 145 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Departed: RXE, REXBURG, ID - Destination: RXE, REXBURG, ID - Airport: RXE, Rexburg-Madison County, runway 17, 4,204 × 75 ft, asphalt - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 67; injuries: none; student; medical: class 2, without waivers/limitations; seat: left; restraint: lap only; flight hours: 180 total, 70 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 37 °F - Altimeter: 30.10 inHg - Observed at: KRXE ## 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 20160728011709A](https://openairdocs.org/incident/20160728011709A), Jul 28, 2016: Cessna 172E, Rexburg, ID, Substantial damage. On 7/28/16, the pilot, a student pilot, took off out of Rexburg id, on a solo flight to practice maneuvers to prepare for his private pilot practical test. He… ## Docket (5 files) The files NTSB released with the investigation on November 3, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93724. 1.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 835 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446075&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Memorandum for Record - Telephone Interview, Pilot (item 2, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446076&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20-%20Telephone%20Interview,%20Pilot-Master.PDF - Density Altitude (item 3, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446077&FileExtension=.PDF&FileName=Density%20Altitude-Master.PDF - Koch Chart (item 4, .PDF, 94 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446078&FileExtension=.PDF&FileName=Koch%20Chart-Master.PDF - Photos (Courtesy of FAA) (item 5, .PDF, 2 photos, 236 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40446079&FileExtension=.PDF&FileName=Photos%20(Courtesy%20of%20FAA)-Master.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.