# NTSB NYC07FA193: Cessna 172N, N738JE, Rochester, NY, August 16, 2007 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 16, 2007, 11:24 local (15:24 UTC) - Place: Rochester, NY - Coordinates: 43.175889, -77.532138 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=43.1759&lon=-77.5321&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report September 26, 2008 - Report: Approved by Office Director - Parties: Lycoming Engines, FAA/FSDO, Cessna Aircraft Company - NTSB case key (mKey): 66451 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC07FA193 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/66451/pdf - Page: https://openairdocs.org/ntsb/NYC07FA193 ## Probable cause The pilot's failuire to maitain adequate airspeed during a turning maneuver which resulted in an inadvertent stall. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - stall - inadvertent, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - ground ## Analysis The pilot/owner and pilot-rated passenger/owner took off to the south from the bay in the float-equipped Cessna 172N. The airplane climbed to a point just north of the south end of the bay, where it made a left turn to the east. As the airplane continued the turn to gain its on-course heading and to avoid rising terrain, it stalled and descended steeply to the ground. The airplane impacted in a field approximately 1/2 mile east of the takeoff path, and both occupants were killed. The payload consisted of the two occupants, approximately 100 pounds of luggage and supplies, and an undetermined quantity of fuel. Based on the passenger's medical history and autopsy results, the possibility of a distraction due to his impairment or incapacitation shortly after takeoff could not be ruled out. Approximately 33 months and 175 flight hours prior to the accident, the airplane's airspeed indicator was determined to read 20 knots high at all speeds. A dedicated search of maintenance records did not reveal any evidence that this airspeed indicator discrepancy was corrected. The recorded winds at an airport 7 miles southwest of the accident site were from 240 degrees at 9 knots, and the ambient conditions resulted in a density altitude of approximately 2,100 feet. ## Factual narrative HISTORY OF FLIGHT On August 16, 2007, about 1124 eastern daylight time, a Cessna 172N floatplane, N738JE, was substantially damaged when it impacted terrain shortly after takeoff from Irondequoit Bay near Rochester, New York. The certificated pilot/owner and a pilot-rated passenger/owner were fatally injured. The personal flight was operated under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident. A visual flight rules (VFR) flight plan to Arnprior, Ontario, Canada was filed, but not activated by the pilot. The accident airplane was part of a two-airplane, six-person, weekend fishing trip destined for Quebec Province, Canada, with a return planned for 3 days later. The other four persons on this trip departed a few hours earlier in a Grumman Widgeon. The pilot of the Widgeon reported that his airplane took "all the gear and provisions," for the six persons, and stated that the accident airplane only had to transport the other two persons, and "clothes, sleeping bags and fishing gear." The pilots planned to clear customs at Arnprior, located 160 miles northeast of Rochester, and then continue north to Clova, Quebec, located 190 miles north of Arnprior. Eyewitnesses reported that the airplane left its ramp at a marina on the south end of the bay, taxied north for a while, turned around, and began its takeoff run to the south. Acquaintances of the pilot said that the usual starting point for a takeoff run to the south was opposite Snider Island, located approximately 4,500 feet north of the marina. After what witnesses considered a "normal takeoff," the airplane climbed to a point just north of the south end of the bay, where it made a left turn to the east. Several witnesses described the airplane's speed as "slow" or "too slow." Shortly thereafter, the airplane banked to the left, descended steeply, and impacted terrain. Multiple witnesses described the descent as "nose first." One witness stated that "the plane started to roll like a corkscrew," and that when he last saw it airborne, it was "upside down." Most witness estimates of the airplane's altitude at the start of the descent were between 150 and 500 feet above ground level. The airplane impacted in a field approximately 1,500 feet east-northeast of its ramp, and approximately 1/2 mile east of its takeoff path. According to witnesses, a fire broke out immediately, and the airplane continued to burn. No witnesses reported observing smoke or fire prior to impact. PERSONNEL INFORMATION The pilot, seated in the left seat, held a private pilot certificate with airplane single engine land (ASEL), airplane single engine sea (ASES), and instrument ratings. He began his flight training in July 1997, and began his SES training in April 2004. According to his logbook, the pilot had approximately 1,140 total hours of flight experience, 250 hours ASES, and 125 hours of actual instrument time. The pilot had approximately 230 hours of flight time in the accident airplane, and 24 of these were within the 30 days prior to the accident. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on August 18, 2005 The passenger, seated in the right seat, held a private pilot certificate with airplane multiengine land (AMEL), ASEL, and ASES ratings. He reported 972 total hours of flight experience on his most recent application for an FAA third-class medical certificate, dated June 2003. Acquaintances indicated that the passenger continued to fly, but only under the provisions of a sport pilot certificate. AIRCRAFT INFORMATION The accident airplane was a 1978 Cessna 172N. At the time of the accident, the airplane was equipped with a Lycoming O-360-A1D engine, a McCauley Kliptip propeller, model DFA8242, and EDO model 689-2130 floats. Records indicate that the airplane was delivered from Cessna with 'landplane' landing gear, and that in April 1978, the airplane was converted to a floatplane. This was documented on a Federal Aviation Administration (FAA) Form 337, "Major Repair and Alteration," which indicated that EDO model 689-2130 floats were installed in accordance with Kenmore Air Harbor Inc. supplemental type certificate (STC) SA584NW. Another Form 337 documented the March 1981 removal of the O-320-H2AD engine, and installation of an O-320-E2D engine, in accordance with Kenmore STC SA1191NW. In April 1986, another Form 337 documented the removal of the O-320-E2D engine, and the installation of an O-360-A3A engine, in accordance with Penn Yan Aero STC SA332GL. The serial number listed on the Form 337 matched that on the data plate of the accident engine, but the engine model designators on the Form 337 and engine data plate ("A3A" and "A1A," respectively) did not match. The same Form 337 documented the installation of a McCauley model 1A200/DFA propeller, while other maintenance records referred to the propeller as a McCauley Kliptip model DFA8242. In September 1993, two 337 forms were filed that documented the incorporation of STC numbers SA2600CE and SE2563CE. These two STCs permitted the use of "autogas," and the intermix of autogas and aviation gasoline, on the airframe and in the engine. The accident airplane was registered to a corporation. At the time of the accident, the two persons on board, along with a third individual, were the owners of the corporation. The corporation acquired the airplane in May 2002. At the last annual inspection in May 2007, the airframe total time (TT) in service was approximately 4,957 hours. The pilot's logbook indicated that he logged approximately 13 hours in the airplane since the annual inspection. No records substantiating the engine time were located. Each float was constructed with eight separate internal compartments. Preflight inspection procedures required that each of these compartments was to be visually checked for water, and that any water was to be removed prior to flight. Access to each compartment was by means of a removable cover. One partner of the airplane stated that "this plane didn't leak." Cessna records indicated that the airplane was equipped with a pneumatic-type stall warning system that consisted of an inlet on the leading edge of the left wing, plumbed with plastic tubing to an air-operated horn located near the upper left corner of the windshield. As the airplane approached a stall, the negative pressure at the leading edge inlet would draw air through the horn assembly, and sound an audible warning. This resulted in a warning at 5 to 10 knots above stall in all flight conditions. The inlet was located approximately 5 feet above, and 5 feet outboard of, the float. The Cessna Pilot Operating Handbook (POH) stated that the system functionality could be tested during preflight inspection by the application of suction to the leading edge inlet. National Transportation Safety Board investigators acquired copies of the maintenance provider's service orders for the airplane. One service order, dated October 8, 2004, contained the entry "NOTE: Airspeed reads 40 knots on ground, and it reads 20 knots high at all speeds." These values are not in compliance with the accuracy requirements for airspeed indicating systems set forth in Paragraph 23.1323 of 14 CFR 23. The service order listed the airplane TT as 4825.9 hours. A dedicated search of all available maintenance records did not reveal any evidence that this airspeed indication system discrepancy was corrected prior to the accident. Subsequent to the airspeed indicator write-up, the airplane successfully underwent three additional annual inspections. The first was in October 2004, and the second was in April 2006. The airplane's most recent annual inspection was accomplished in May 2007. The records indicate that at that time, the airplane had accumulated a total time in service of 4956.6 hours. All three annual inspections were con ## Aircraft - Registration: [N738JE](https://openairdocs.org/deregistered/N738JE-2013-07-23), registration cancelled 2013-07-23, S/N 17270007, built 1978 (OpenAirDocs) - Reported make and model: Cessna 172N - Registry model: [Cessna 172N](https://openairdocs.org/model/cessna-172n) (registry code 2072434) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 17270007 - Airframe hours: 4956.6 - Engines: Lycoming O-360-A1D 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Rochester Waterwings - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 1, 2007, 5,012 hours before - Departed: Rochester, NY - Destination: Arnprior - Flight plan: VFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; private; airplane ratings: single-engine sea, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 1,140 total, 230 in this make and model, 24 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 64 °F - Altimeter: 29.84 inHg - Observed at: ROC, 7 nm away ## 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 20070816018139A](https://openairdocs.org/incident/20070816018139A), Aug 16, 2007: Cessna 172N, Webster, NY, Destroyed, 2 fatal. (-23) On Thursday, August 16, 2007, at approximately 1124 EDT, a Cessna 172 float plane, N738JE, occupied by [privacy data omitted] and the pilot [privacy data… ## Other investigations on N738JE (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 LAX86LA210](https://openairdocs.org/ntsb/LAX86LA210), Apr 30, 1986: Cessna 172N (N738JE), Clearlake, CA, substantial damage 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.