# NTSB GAA19CA549: Cessna L19, N4584N, Kennett, MO, September 15, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: September 15, 2019, 10:00 local (15:00 UTC) - Place: Kennett, MO - Coordinates: 36.225833, -90.036666 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.2258&lon=-90.0367&mi=10 - Phase of flight: [Prior to flight](https://openairdocs.org/ntsb-phases/100) (OpenAirDocs' grouping) - Defining event: [Prior to flight: Aircraft servicing event](https://openairdocs.org/ntsb-events/020) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report March 17, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 100274 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA549 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100274/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100274 - Page: https://openairdocs.org/ntsb/GAA19CA549 ## Probable cause The pilot's failure to install the engine oil filler cap before the first flight of the day; his subsequent failure to conduct a preflight check before the accident flight, which resulted in his failure to note that the cap was not installed; and his improper landing flare during a precautionary landing, which resulted in a bounced landing and ground loop. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna L-19E, 1 case](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2074016), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna L-19E, 1 case](https://openairdocs.org/ntsb-findings/02041035/cases.md?model=2074016), [All aircraft, 440 cases](https://openairdocs.org/ntsb-findings/02041035/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna L-19E, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2074016), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna L-19E, 6 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2074016), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: landing flare](https://openairdocs.org/ntsb-findings/01062041): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Cessna L-19E, 2 cases](https://openairdocs.org/ntsb-findings/01062041/cases.md?model=2074016), [All aircraft, 1,285 cases](https://openairdocs.org/ntsb-findings/01062041/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: Aircraft servicing event](https://openairdocs.org/ntsb-events/020) (defining event); cases with it: [Cessna L-19E, 1 case](https://openairdocs.org/ntsb-events/020/sequence.md?model=2074016), [All aircraft, 70 cases](https://openairdocs.org/ntsb-events/020/sequence.md) - [Landing: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Cessna L-19E, 8 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=2074016), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis The pilot reported that, during takeoff for the accident flight, which was the second flight of the day, he saw that the oil pressure was falling and realized it was likely due to his failure to install the engine oil filler cap after checking the oil during the first flight of the day. He did not conduct a preflight checklist before the accident flight. He subsequently made a precautionary landing at a nearby airport. During the landing, the airplane bounced, and the landing gear collapsed. The airplane bounced again, skidded off the right side of the runway, and ground looped. The left wing struck the ground before the airplane stopped. The airplane sustained substantial damage to the main rotor blades. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Factual narrative The pilot in the tailwheel-equipped airplane reported that, during post-flight maintenance he left the oil filler cap off. Subsequently, during takeoff, he realized that the oil filler cap was not installed. The pilot noticed a decrease in oil pressure and made a precautionary landing at a nearby airport. During landing, the airplane landed hard, bounced, and the landing gear collapsed. The airplane skidded off the right side of the runway, and ground looped to the right. The left wing struck the ground before the airplane stopped. The airplane sustained substantial damage to the main rotor blades. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N4584N](https://openairdocs.org/aircraft/N4584N), registered now, S/N 24565 (OpenAirDocs) - Reported make and model: Cessna L19 (E) - Registry model: [Cessna L-19E](https://openairdocs.org/model/cessna-l-19e) (registry code 2074016) (OpenAirDocs) - Category: Airplane - Serial number: 24565 - Year built: 1944 - Airframe hours: 6375.2 - Engines: Continental O-470-15 213 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, October 5, 2018 - Departed: M05, CARUTHERSVILLE, MO - Destination: M05, CARUTHERSVILLE, MO - Airport: TKX, Kennett Memorial, runway 20, 5,000 × 75 ft, concrete - Equipment: ADS-B, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 71; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review January 10, 2019; seat: front; restraint: 4-point; flight hours: 1,872.8 total, 46 in this make and model, 14 in the last 90 days, 5 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 6 knots - Visibility: 10 statute miles - Temperature: 88 °F, dew point 72 °F - Altimeter: 30.13 inHg - Observed at: KTKX ## 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 20190915013159A](https://openairdocs.org/incident/20190915013159A), Sep 15, 2019: Cessna L-19E, Kennett, MO, Substantial damage. The pilot lost control (ground loop)while attempting to expedite his landing due to decreasing oil pressure. The aircraft touched down with a high side load on… ## Other investigations on N4584N (1) 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. - [NTSB WPR26LA028](https://openairdocs.org/ntsb/WPR26LA028), Oct 18, 2025: Cessna 305 (N4584N), Phoenix, AZ, substantial damage. Probable cause: A worn tailwheel steering mechanism, which resulted in a locked tailwheel and a ground loop during a landing roll. ## Docket (2 files) The files NTSB released with the investigation on January 3, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100274. 3.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479578&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photos (item 2, .PDF, 181 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40479579&FileExtension=.PDF&FileName=Photos-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.