GAA17CA337

NTSB accident investigation · Cessna 172 · Ravenna, OH · June 11, 2017

Accident · No injuriesData collectionFinal report
Date
June 11, 2017, 11:50 local (15:50 UTC)
Place
Ravenna, OH
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N33FMCessna 172
Defining event
Approach-VFR pattern final: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report September 7, 2017
Report
Approved by Office Director
NTSB office
General Aviation Accidents
Parties
FAA/FSDO
FAA report
20170611022389A
Case key
95363

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight instructor's failure to perform a go-around during final approach, which resulted in an aerodynamic stall and a hard landing. Contributing to the accident was the flight instructor's failure to brief the student pilot on the positive transfer of aircraft control during preflight.

Findings · 6

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotCessna 172S: 206 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededCessna 172S: 13 casesAll aircraft: 990 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Instructor/check pilotCessna 172S: 14 casesAll aircraft: 792 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 172S: 16 casesAll aircraft: 1,681 casesProbable cause
Action: forgotten action/omissionPersonnel issues › Action/decision · Instructor/check pilotCessna 172S: 4 casesAll aircraft: 440 casesProbable cause
Communication (personnel): lack of communicationPersonnel issues › Task performance · Instructor/check pilotCessna 172S: 4 casesAll aircraft: 84 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The flight instructor reported that, during an instructional flight, while on short final, he told the student pilot to "pitch down" to maintain airspeed. He added that the student did not respond and that he again instructed the student to "pitch down now" while simultaneously pressing forward on the yoke. He further added that, as he pushed forward on the yoke, the student "pulled [back] with equal force on the yoke." Subsequently, the flight instructor pushed forward on the yoke "with greater force" than the previous attempt and stated, "my plane," to the student, but "continued to wrestle the controls with the student" as the airplane entered an aerodynamic stall. The airplane then impacted the runway threshold hard, the nose landing gear collapsed, and the airplane veered off the runway to the right. The student pilot reported that this was his first flight with this flight instructor but that he had accumulated about 82 hours of dual instruction previously. He added that, during the second landing of the day, while on final approach, "the instructor had me pull the power and told me nose down." He further added that he "felt we were getting low and I told the instructor I wanted to increase power but the instructor told me to 'nose down.'" The student pilot reported that the instructor again stated multiple times to "nose down," but he "did not believe there was enough room to continue nose down." The student pilot reported that the flight instructor subsequently took the flight controls and nosed the airplane down and that the airplane impacted the runway threshold hard and veered off the runway. The fuselage and firewall sustained substantial damage. The flight instructor and student pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. During postaccident correspondence with the National Transportation Safety Board investigator-in-charge, the flight instructor reported that he could not recall if, during preflight, he and the student pilot discussed the positive transfer of the flight controls. Federal Aviation Administration Advisory Circular 61-115, "Positive Exchange of Flight Controls Program," dated March 10, 1995, stated, in part: During flight training, there must always be a clear understanding between students and flight instructors of who has control of the aircraft. Prior to flight, a briefing should be conducted that includes the procedure for the exchange of flight controls. A positive three-step process in the exchange of flight controls between pilots is a proven procedure and one that is strongly recommended. When an instructor is teaching a maneuver to a student, the instructor will normally demonstrate the maneuver first, then have the student follow along on the controls during a demonstration and, finally, the student will perform the maneuver with the instructor following along on the controls. When the flight instructor wishesthe student to take control of the aircraft, he/she says to the student, "You have the flight controls." The student acknowledges immediately by saying, "I have the flight controls." The flight instructor again says, "You have the flight controls." During this procedure, a visual check is recommended to see that the other person actually has the flight controls. When returning the controls to the instructor, the student should follow the same procedure the instructor used when giving control to the student. The student should stay on the controls and keep flying the aircraft until the instructor says, "I have the flight controls." There should never be any doubt as to who is flying the aircraft.

Factual narrative

The flight instructor reported that, during an instructional flight, while on short final, he told the student pilot to "pitch down" to maintain airspeed. He added that the student did not respond and he again instructed the student to "pitch down now" while simultaneously pressing forward on the yoke. He further added that as he pushed forward on the yoke, the student "pulled [back] with equal force on the yoke." Subsequently, the flight instructor pushed forward on the yoke "with greater force" than the previous attempt and stated, "my plane" to the student, but "continued to wrestle the controls with the student" as the airplane entered an aerodynamic stall and impacted the runway threshold hard. After the airplane impacted the runway threshold, the nose gear collapsed and the airplane veered off the runway to the right. The student pilot reported that this was his first flight ever with this flight instructor, but he had accumulated about 82 hours of dual instruction previously. He added that, during the second landing of the day, while on final approach "the instructor had me pull the power and told me nose down." He further added that he "felt we were getting low and I told the instructor I wanted to increase power but the instructor told me to "nose down." The student pilot reported that the instructor again stated multiple times to "nose down," but he "did not believe there was enough room to continue nose down." Subsequently, the student pilot reported that the flight instructor took the flight controls and nosed the airplane down, but the airplane impacted the runway threshold hard and veered off the runway. The fuselage and firewall sustained substantial damage. The flight instructor and student pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. During postaccident correspondence with the National Transportation Safety Board investigator-in-charge, the flight instructor reported that he could not recall during preflight that he and the student pilot discussed the positive transfer of the flight controls. The Federal Aviation Administration Advisory Circular 61-115, Positive Exchange of Flight Controls Program, dated March 10th, 1995, stated in part: During flight training, there must always be a clear understanding between students and flight instructors of who has control of the aircraft. Prior to flight, a briefing should be conducted that includes the procedure for the exchange of flight controls. A positive three-step process in the exchange of flight controls between pilots is a proven procedure and one that is strongly recommended. When an instructor is teaching a maneuver to a student, the instructor will normally demonstrate the maneuver first, then have the student follow along on the controls during a demonstration and, finally, the student will perform the maneuver with the instructor following along on the controls. When the flightinstructor wishes the student to take control of the aircraft, he/she says to the student, "You have the flight controls." The student acknowledges immediately by saying, "I have the flight controls." The flight instructor again says, "You have the flight controls." During this procedure, a visual check is recommended to see that the other person actually has the flight controls. When returning the controls to the instructor, the student should follow the same procedure the instructor used when giving control to the student. The student should stay on the controls and keep flying the aircraft until the instructor says, "I have the flight controls." There should never be any doubt as to who is flying the aircraft.

Aircraft

Registration
N33FM
Reported as
Cessna 172 (S)
Category
Airplane
Serial number
172S11196
Built
2012
Airframe hours
250.2
Engine
Lycoming IO-360-L2A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 17, 2016
Departed
POV · Ravenna, OH
Destination
POV · Ravenna, OH
Airport
POV · Portage County, runway 27, 3,499 × 75 ft, asphalt
Equipment
Auto-pilot

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
62
Injuries
None
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
April 27, 2016
Seat
Right
Restraint
3-point
Flight hours
2,037 total · 326 in this make and model · 2,001 as pilot in command · 68 in the last 90 days · 32 in the last 30 days
Role
Student pilot
Age
56
Injuries
None
Certificate
Student
Medical
Class 3, With waivers/limitations
Seat
Left
Restraint
3-point
Flight hours
93.5 total · 22.6 in this make and model · 26.8 in the last 90 days · 15.1 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 10 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
79 °F, dew point 59 °F
Altimeter
30.11 inHg
Observed at
KPOV

Docket · 6

The files NTSB released with the investigation on August 17, 2017, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.6 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.