# NTSB NYC95FA210: Cessna 172M, N6564H, Portland, ME, September 1, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 1, 1995, 11:15 local (15:15 UTC) - Place: Portland, ME - Location: 43.6419° N, 70.3279° W: Placed by OpenAirDocs from NTSB’s distance and direction from PORTLAND INTL JETPORT (PWM), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=43.6419&lon=-70.3279&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report June 7, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 38863 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC95FA210 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38863/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=38863 - Page: https://openairdocs.org/ntsb/NYC95FA210 ## Probable cause an engine malfunction for an undetermined reason, and the pilot's failure to maintain airspeed during a forced landing which resulted in an accelerated stall. A factor was the pilot's lack of recent experience. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power, takeoff - initial climb - reason for occurrence undetermined (cause) - Forced landing, emergency landing after takeoff - Loss of control - in flight, emergency landing after takeoff - airspeed - not maintained, pilot in command (cause) - lack of recent experience in type operation, pilot in command (contributing factor) - stall/spin - inadvertent, pilot in command - In flight collision with terrain/water, descent - uncontrolled ## Analysis After takeoff, while climbing through about 400 ft AGL, the pilot transmitted, '...I just lost.' Some witnesses saw smoke trailing from the airplane as it descended to just above the runway. Still in the air, and nearing the departure end of the runway, the airplane then climbed to about 100 ft, and entered a left turn which was described by witnesses as at least 60 degrees of bank. Some witnesses reported the engine was smooth, while others reported the engine was erratic. While in the turn, the airplane descended, struck the ground nose first, came to rest inverted, and burned. In a test run, the engine produced takeoff power. The pilot had flown 6.5 hours in past 12 months. The pilot received a checkout in the airplane in July 1995. According to the instructor who gave the checkout flight, neither accelerated stalls nor simulated forced landings were done during the checkout. ## Factual narrative HISTORY OF FLIGHT On September 1, 1995, at 1115 eastern daylight time, a Cessna 172M, N6564H, struck the ground while maneuvering for a forced landing, after takeoff from the Portland International Jetport, Portland, Maine. The airplane was destroyed, and the private pilot and two passengers were fatally injured. Visual meteorological conditions prevailed and no flight plan had been filed for the flight which was conducted under 14 CFR Part 91. The flight was destined for Chatham, Massachusetts. At 1045, the pilot reported to Portland Clearance Delivery, that she was ready to taxi, and was cleared to taxi to runway 29. At 1048, the pilot requested to return to the ramp due to a red light on the instrument panel. After receiving information about the light, the pilot contacted Portland Clearance Delivery at 1103, and reported that she was ready to taxi to runway 29. She was cleared as requested. At 1112:33, N6564H was instructed to, "...taxi into position and hold", and at 1113:20, N6564H was cleared for takeoff with a left turn on course approved. These were acknowledged by the pilot. At 1114:18, and after becoming airborne, the pilot transmitted, "four hotel i just lost" No further transmissions were received from the airplane. Several witnesses saw the airplane, which they thought was about 400 feet high, begin its descent. One witness reported seeing gray smoke trailing from the airplane, while another witness reported seeing black smoke trailing from the airplane. Witnesses reported that the airplane leveled off about 5 to 10 feet above the runway, and continued toward the departure end. One witness reported that he could see the flaps extended to about 3/4 as the airplane went by. The airplane was then observed to pull up to about 75 to 100 feet, and enter a left turn. Witnesses described the bank angle as 60 degrees or steeper. One witness, at the airport entrance described the engine sound as erratic. Two other witnesses in a parking lot, southwest of the accident site, described the engine sound as steady and at high power, or like other airplanes taking off. Witnesses reported that during the turn, the nose dropped and the airplane contacted the ground. It came to rest on its back, after which a fire developed. The accident occurred during the hours of daylight, at location 43 degrees, 38 minutes North and 70 degrees, 19 minutes West. PERSONNEL INFORMATION The pilot held a Private Pilot Certificate with airplane single engine land, single engine sea, and instrument airplane ratings. She held an FAA 3rd Class Airman Medical certificate issued on November 15, 1993. According to her pilot log book, her last biennial flight review occurred on October 8, 1994, in a Piper PA-28. Her pilot log book revealed the following times: Total Time 992 hours Pilot-In-Command 880 hours Additionally, according to the pilot's log book, she had flown 24.3 hours in the preceding 3 years. In the preceding year, she had flown 6.5 hours which included a 1.5 hour checkout on July 10, 1995. Her last logged flight prior to the accident occurred on July 19, 1995. According to her flight instructor, the checkout did not include forced landings or accelerated stalls. In her application to the flying club, she reported her total time in a Cessna 172 as 800 hours. AIRCRAFT INFORMATION The airplane, a 1975 Cessna 172M, had been modified with the installation of a Lycoming o-360-A4M engine. On August 25, 1995, the airplane was modified with the installation of a standby vacuum pump. This included the installation of a red warning light on the instrument panel to warn of low vacuum, and occurred concurrently with an annual inspection. The airplane was last serviced on August 30, 1995, with 33.1 gallons of 100 low lead aviation grade gasoline. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the Portland International Jetport from September 1, 1995, to September 3, 1995. Initial ground contact occurred 274 feet beyond the 200 foot overrun, on the departure end of runway 29, and 252 feet southwest of the left edge of runway 29. A series of multiple ground scars on a heading of 220 degrees, for 77 feet led to the airplane which was inverted, and heading 360 degrees. The center section, including the cockpit and passenger cabin was destroyed by fire. Cabin seats were laying loose in the burned area, and the seat rails were not identified. The fuel selector was not identified. The primer was found locked, and loose in the burned area with the knob missing. The empennage remained attached by control cables. The elevator trim was found extended .06 inches beyond it maximum limit of 1.88 inches. The wing spar was bent in the center section, with both wings bent forward. The left aileron pushrod was fractured, and the aileron interconnect cable near the flap aileron junction in the left wing had failed with frayed ends, similar to a tension overload. The wing flap jack screw was found in the fully extended position. The left flap was destroyed, and the right flap was partially extended. The firewall was burned, and there were soot accumulations on the engine. The fuel sump drain was crushed. The fuel line leading to the sump drain was fractured. The blades of the propeller were bent rearward. Chord wise scratches were found on the front face of both blades. Valve train continuity was verified, and compression was found in all cylinders. The engine oil filter was clean, and spark was obtained from all leads, of both magnetos. The mount for the carburetor was fractured. The finger screen was clean. The accelerator pump was operative. The bowl was drained of a mixture of water and foam. No fuel was found in the carburetor and there was no smell of fuel. The carburetor was equipped with a single piece venturi which was in place. MEDICAL AND PATHOLOGICAL INFORMATION Autopsies were conducted on the pilot and right front seat passenger on September 3, 1995, by Dr. Henry Ryan, Chief Medical examiner for the State of Maine. An autopsy was conducted on the rear seated passenger on September 2, 1995, by Dr. Antonio Boschetti, Medical Examiner, State of Massachusetts. Toxicological testing on the pilot, which was conducted by the FAA Civil Aeromedical Institute in Oklahoma City, Oklahoma, was negative for drugs and alcohol. TESTS AND RESEARCH The following items were examined in the NTSB Metallurgical Laboratory in Washington, DC: Left Aileron Push Rod Finding: "...bending overstress separation...." Fuel Line to Main Sump Finding: "...typical of an overstress separation with no evidence of a preexisting crack." The engine was placed in a test cell at Textron Lycoming on September 22, 1995, and developed takeoff power. A 1/4 inch hole was then drilled in the number 4 intake tube to simulate a hole found in the original intake tube. Again, the engine developed takeoff power. At the completion of the engine test run, the carburetor was disassembled. No evidence of a sticking float or contamination was found inside. The main jet was clear. ADDITIONAL INFORMATION Emergency Procedures The following is from the Cessna 172M OWNER'S MANUAL, Section III, EMERGENCY PROCEDURES, Engine Failure, Engine Failure After Take-Off, Page 3-1: Prompt lowering of the nose to maintain airspeed and establish a glide attitude is the first response to an engine failure after take-off. In most cases, the ## Aircraft - Registration: [N6564H](https://openairdocs.org/deregistered/N6564H-1996-11-06), registration cancelled 1996-11-06, S/N 17265489 (OpenAirDocs) - Reported make and model: CESSNA 172M - Registry model: [Cessna 172M](https://openairdocs.org/model/cessna-172m) (registry code 2072418) (OpenAirDocs) - Category: Airplane - Serial number: 17265489 - Airframe hours: 4840 - Engines: LYCOMING O-360-A4M 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Registered owner: Bald Eagle Flying Club - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: Annual, August 25, 1995, 9 hours before - Departed: PWM - Destination: CQX, CHATHAM, MA - Airport: PWM, Portland Intl Jetport, runway 29, 8,600 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; private; airplane ratings: single-engine sea, single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 992 total, 800 in this make and model, 880 as pilot in command, 5 in the last 90 days ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 61 °F - Altimeter: 29.00 inHg - Observed at: PWM, 1 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 19950901027439A](https://openairdocs.org/incident/19950901027439A), Sep 1, 1995: Cessna STC172, Portland, ME, Destroyed, 3 fatal. Lost power on takeoff. Stalled on steep turn full flaps trying return. No anomalies. Possible fuel selector in off. ## Docket (9 files) The files NTSB released with the investigation on May 2, 1996, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=38863. 758 KB in all. - Supplement A (item 1, .PDF, 196 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40045989&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 2, .PDF, 278 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40045990&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement S (item 3, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40045991&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Wreckage Diagram (item 4, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40045994&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Photo 1: Arrows point to ground impact scars prior to airplane. (item 5, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40046000&FileExtension=.PDF&FileName=Photo%201%3A%20%20Arrows%20point%20to%20ground%20impact%20scars%20prior%20to%20airplane.-Master.PDF - Photo 2: Side view of airplane. Arrow points to control tower. (item 6, .PDF, 33 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40046001&FileExtension=.PDF&FileName=Photo%202%3A%20%20Side%20view%20of%20airplane.%20%20Arrow%20points%20to%20control%20tower.-Master.PDF - Photo 3: Empennage of airplane, held in place by control cables. (item 7, .PDF, 61 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40046002&FileExtension=.PDF&FileName=Photo%203%3A%20%20Empennage%20of%20airplane,%20held%20in%20place%20by%20control%20cables.-Master.PDF - Photo 4: Fuel filter in carburetor which was clean. (item 8, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40046003&FileExtension=.PDF&FileName=Photo%204%3A%20%20Fuel%20filter%20in%20carburetor%20which%20was%20clean.-Master.PDF - Photo 5: Overall view of the components, as received. Insert photograph is a 2X magnification view of the separated end in the fitting, showing the fracture face by arrow "f". (item 9, .PDF, 28 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40046004&FileExtension=.PDF&FileName=Photo%205%3A%20%20Overall%20view%20of%20the%20components,%20as%20received.%20%20Insert%20photograph%20is%20a%202X%20magnification%20view%20of%20the%20separated%20end%20in%20the%20fitting,%20showing%20the%20fracture%20face%20by%20arrow%20%22f%22.-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.