# NTSB GAA17CA337: Cessna 172, N33FM, Ravenna, OH, June 11, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: June 11, 2017, 11:50 local (15:50 UTC) - Place: Ravenna, OH - Coordinates: 41.210277, -81.251663 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.2103&lon=-81.2517&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report September 7, 2017 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA/FSDO - NTSB case key (mKey): 95363 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA17CA337 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95363/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95363 - Page: https://openairdocs.org/ntsb/GAA17CA337 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [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 172S, 206 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072439), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Cessna 172S, 13 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2072439), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Cessna 172S, 14 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=2072439), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 172S, 16 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=2072439), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Cessna 172S, 4 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=2072439), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Communication (personnel): lack of communication](https://openairdocs.org/ntsb-findings/02063510): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Cessna 172S, 4 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md?model=2072439), [All aircraft, 84 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Cessna 172S, 28 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=2072439), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Approach-VFR pattern final: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Cessna 172S, 21 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=2072439), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Approach-VFR pattern final: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 172S, 49 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072439), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing-flare/touchdown: Hard landing](https://openairdocs.org/ntsb-events/092); cases with it: [Cessna 172S, 102 cases](https://openairdocs.org/ntsb-events/092/sequence.md?model=2072439), [All aircraft, 2,102 cases](https://openairdocs.org/ntsb-events/092/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Cessna 172S, 76 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2072439), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## 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](https://openairdocs.org/aircraft/N33FM), registered now, S/N 172S11196, built 2012 (OpenAirDocs) - Reported make and model: CESSNA 172 (S) - Registry model: [Cessna 172S](https://openairdocs.org/model/cessna-172s) (registry code 2072439) (OpenAirDocs) - Registry engine: [Lycoming IO-360-L2A](https://openairdocs.org/engine/lycoming-io-360-l2a) (registry code 41597, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 172S11196 - Year built: 2012 - Airframe hours: 250.2 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 62; injuries: none; 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 - Student pilot; age 56; injuries: none; 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 ## 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 20170611022389A](https://openairdocs.org/incident/20170611022389A), Jun 11, 2017: Cessna 172S, Ravena, OH, Substantial damage. Student pilot stalled on short final, bounced and hit hard on grass median right of rwy. ## Docket (6 files) The files NTSB released with the investigation on August 17, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95363. 9.6 MB in all. - NTSB 6120.1_Student Pilot Submission (item 1, .PDF, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455362&FileExtension=.PDF&FileName=NTSB%206120.1_Student%20Pilot%20Submission-Master.PDF - NTSB 6120.1_Flight Instructor Submission (item 2, .PDF, 3.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455384&FileExtension=.PDF&FileName=NTSB%206120.1_Flight%20Instructor%20Submission-Master.PDF - Memorandum of Record_Student Pilot Written Statement (item 3, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455383&FileExtension=.PDF&FileName=Memorandum%20of%20Record_Student%20Pilot%20Written%20Statement-Master.PDF - Memorandum of Record_Flight Instructor (item 4, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455385&FileExtension=.PDF&FileName=Memorandum%20of%20Record_Flight%20Instructor-Master.PDF - FAA AC 61_115_Positive Exchange of Flight Controls (item 5, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455386&FileExtension=.PDF&FileName=FAA%20AC%2061_115_Positive%20Exchange%20of%20Flight%20Controls-Master.PDF - Accident Photos (item 6, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40455387&FileExtension=.PDF&FileName=Accident%20Photos-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.