# NTSB GAA18CA166: Cessna 140, N2011N, Madison, SD, March 12, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: March 12, 2018, 17:15 local (22:15 UTC) - Place: Madison, SD - Coordinates: 44.012779, -97.086669 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.0128&lon=-97.0867&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report June 14, 2018 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 96890 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA18CA166 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96890/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96890 - Page: https://openairdocs.org/ntsb/GAA18CA166 ## Probable cause The flight instructor’s delayed aborted takeoff on a soft, wet, grass runway, which resulted in a runway overrun. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Cessna 140, 6 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=2071602), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Runway/land/takeoff/taxi surface: soft surface](https://openairdocs.org/ntsb-findings/03023020): Environmental issues › Physical environment · Effect on operation; cases with it: [Cessna 140, 4 cases](https://openairdocs.org/ntsb-findings/03023020/cases.md?model=2071602), [All aircraft, 264 cases](https://openairdocs.org/ntsb-findings/03023020/cases.md) - [Runway/land/takeoff/taxi surface: wet surface](https://openairdocs.org/ntsb-findings/03023010): Environmental issues › Physical environment · Effect on operation; cases with it: [Cessna 140, 5 cases](https://openairdocs.org/ntsb-findings/03023010/cases.md?model=2071602), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/03023010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: 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) - [Takeoff-rejected takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Cessna 140, 18 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=2071602), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Takeoff-rejected takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Cessna 140, 32 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=2071602), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Takeoff-rejected takeoff: Nose over/nose down](https://openairdocs.org/ntsb-events/096); cases with it: [Cessna 140, 49 cases](https://openairdocs.org/ntsb-events/096/sequence.md?model=2071602), [All aircraft, 2,287 cases](https://openairdocs.org/ntsb-events/096/sequence.md) ## Analysis The flight instructor, acting as a safety pilot, in the tailwheel-equipped airplane reported that, to expedite takeoff, he decided to take off from the grass runway instead of the concrete runway. He added that, about midway into the soft-field takeoff roll, he observed that the airplane was "struggling to build airspeed." He added that the runway had previously thawed and was "wet spongy sod." He reduced power and began to apply the brakes to abort the takeoff, but the airplane overran the runway, impacted a snow bank, and nosed over. The airplane sustained substantial damage to the fuselage. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Factual narrative The flight instructor, acting as a safety pilot, in the tailwheel-equipped airplane reported that, to expedite takeoff, he decided to takeoff from the grass runway instead of the concrete runway. He added that, about midway into the soft-field takeoff roll, he observed that the airplane was "struggling to build airspeed". He added that the runway had previously thawed and was "wet spongy sod". He reduced power and began to apply the brakes to abort the takeoff, but the airplane overran the runway, impacted a snow bank, and nosed over. The airplane sustained substantial damage to the fuselage. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N2011N](https://openairdocs.org/aircraft/N2011N), registered now, S/N 12247, built 1947 (OpenAirDocs) - Reported make and model: CESSNA 140 (UNDESIGNAT) - Registry model: [Cessna 140](https://openairdocs.org/model/cessna-140) (registry code 2071602) (OpenAirDocs) - Registry engine: [Continental C85 series](https://openairdocs.org/engine/continental-c85-series) (registry code 17008, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 12247 - Year built: 1947 - Airframe hours: 1324 - Engines: CONT MOTOR C-85-12F 85 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 14, 2017 - Departed: MDS, Madison, SD - Destination: MDS, Madison, SD - Airport: MDS, Madison Muni, runway 03, 2,380 × 200 ft, grass/turf - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 30; injuries: none; flight instructor; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review January 22, 2018; seat: right; restraint: lap only; flight hours: 500 total, 10 in this make and model, 418 as pilot in command - Pilot-rated passenger; injuries: none; private; airplane ratings: single-engine land; medical: unknown; seat: left; restraint: lap only ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 32 °F, dew point 32 °F - Altimeter: 30.36 inHg - Observed at: KMDS ## 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 20180312002339A](https://openairdocs.org/incident/20180312002339A), Mar 12, 2018: Cessna 140, Madison, SD, Substantial damage. Pilot decided to use grass runway (turf). Spring time and the day had warmed up creating wet / soft runway conditions. When pilot realized performance was… ## Docket (1 files) The files NTSB released with the investigation on April 26, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96890. 599 KB in all. - Accident Photo (item 1, .PDF, 1 photo, 599 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40462630&FileExtension=.PDF&FileName=Accident%20Photo-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.