# NTSB WPR17CA001: Cessna R172K, N736LZ, Rosamond, CA, October 2, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: October 2, 2016, 14:45 local (21:45 UTC) - Place: Rosamond, CA - Coordinates: 34.870555, -118.211944 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.8706&lon=-118.2119&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report December 5, 2016 - Report: Approved by Office Director - NTSB office: Western Pacific Region - NTSB case key (mKey): 94124 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR17CA001 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/94124/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=94124 - Page: https://openairdocs.org/ntsb/WPR17CA001 ## Probable cause The pilot's improper use of the control lock, combined with his incomplete execution of two pre-departure procedures, which resulted in a takeoff with the control lock installed. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Cessna R172K, 2 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=2072431), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) - [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 R172K, 3 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=2072431), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Action: incomplete action](https://openairdocs.org/ntsb-findings/02041040): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Cessna R172K, 1 case](https://openairdocs.org/ntsb-findings/02041040/cases.md?model=2072431), [All aircraft, 105 cases](https://openairdocs.org/ntsb-findings/02041040/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 inspection event](https://openairdocs.org/ntsb-events/050); cases with it: [Cessna R172K, 1 case](https://openairdocs.org/ntsb-events/050/sequence.md?model=2072431), [All aircraft, 229 cases](https://openairdocs.org/ntsb-events/050/sequence.md) - [Prior to flight: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Cessna R172K, 1 case](https://openairdocs.org/ntsb-events/030/sequence.md?model=2072431), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Takeoff: Flight control sys malf/fail](https://openairdocs.org/ntsb-events/333) (defining event); cases with it: [Cessna R172K, 2 cases](https://openairdocs.org/ntsb-events/333/sequence.md?model=2072431), [All aircraft, 410 cases](https://openairdocs.org/ntsb-events/333/sequence.md) - [Takeoff-rejected takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Cessna R172K, 9 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072431), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing-landing roll: Landing area overshoot](https://openairdocs.org/ntsb-events/380); cases with it: [Cessna R172K, 1 case](https://openairdocs.org/ntsb-events/380/sequence.md?model=2072431), [All aircraft, 400 cases](https://openairdocs.org/ntsb-events/380/sequence.md) - [Landing-landing roll: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Cessna R172K, 1 case](https://openairdocs.org/ntsb-events/094/sequence.md?model=2072431), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## Analysis The pilot/owner and three non-pilot acquaintances decided to use the airplane to fly to another airport for lunch. The pilot had owned and operated the airplane about 10 years, and reported a total time of about 550 hours in that make and model. His normal procedures included hangaring the airplane, and using a yoke-mounted iPad "mini" for in-flight information. The outbound flight was uneventful. After landing, the pilot installed the flight control lock in the pilot-side yoke shaft. After lunch, the four persons returned to the airplane for the return trip. The pilot reported that the preflight inspection and taxi out to the run-up area were normal, but during the before-takeoff check process there, he noticed that the two fuel tank gauges indicated different quantities from one another, which was unusual for the high wing airplane. The pilot decided to interrupt the before-takeoff check process, shut down the engine, and physically "stick" the tanks to accurately determine the total fuel quantity. After the pilot measured the fuel quantities, which he determined were satisfactory, he re-boarded the airplane, re-started the engine, and taxied from the run-up area onto the runway for departure. The airplane lifted off about half-way down the 3,600 foot runway, but when it was at an altitude of about 20 feet above the ground, it stopped climbing. The pilot "immediately recognized something was wrong," aborted the departure, and the airplane landed on the remaining runway. The pilot was unable to stop the airplane on the runway, and it sustained substantial damage to the fuselage as a result. None of the occupants were injured. After the accident, the pilot determined that he had left the control lock in for the takeoff. The pilot reported that he normally used the airplane manufacturer's checklists on all his flights, including this one, but the evidence in this event contradicts that account. The manufacturer's checklists explicitly specified that the flight controls be checked for freedom of travel during two separate pre-departure phases; the walk-around preflight inspection, and the before-takeoff operational checks. For undetermined reasons, the pilot omitted those items from both of those phases, and deprived himself of two opportunities to detect the presence of the control lock. Investigation revealed that the manufacturer-issued control lock had been installed backwards by the pilot, which prevented it from accomplishing one of its primary design functions, that of inhibiting pilot access to the ignition switch. Further investigation revealed that the pilot rarely used the control lock due to the fact that he hangared his airplane, and that he was unaware that he had installed it backwards. The yoke-mounted iPad limited the pilot's view of the installed control lock, which reduced the potential for visual detection. The pilot reported that the winds were "light," which reduced the likelihood of the need for flight control inputs on theground during taxi, and thus deprived the pilot of another opportunity for detection of the locked controls. Finally, after his impromptu physical check of the fuel quantity, the pilot did not re-commence the interrupted before-takeoff checklist from the beginning, and thus missed another opportunity to detect the locked flight controls. ## Factual narrative The pilot/owner and three non-pilot acquaintances decided to use the airplane to fly to another airport for lunch. The pilot had owned and operated the airplane about 10 years, and reported a total time of about 550 hours in that make and model. His normal procedures included hangaring the airplane, and using a yoke-mounted iPad "mini" for in-flight information. The outbound flight was uneventful. After landing, the pilot installed the flight control lock in the pilot-side yoke shaft. After lunch, the four persons returned to the airplane for the return trip. The pilot reported that the preflight inspection and taxi out to the run-up area were normal, but during the before-takeoff check process there, he noticed that the two fuel tank gauges indicated different quantities from one another, which was unusual for the high wing airplane. The pilot decided to interrupt the before-takeoff check process, shut down the engine, and physically "stick" the tanks to accurately determine the total fuel quantity. After the pilot measured the fuel quantities, which he determined were satisfactory, he re-boarded the airplane, re-started the engine, and taxied from the run-up area onto the runway for departure. The airplane lifted off about half-way down the 3,600 foot runway, but when it was at an altitude of about 20 feet above the ground, it stopped climbing. The pilot "immediately recognized something was wrong," aborted the departure, and the airplane landed on the remaining runway. The pilot was unable to stop the airplane on the runway, and it sustained substantial damage to the fuselage as a result. None of the occupants were injured. After the accident, the pilot determined that he had left the control lock in for the takeoff. The pilot reported that he normally used the airplane manufacturer's checklists on all his flights, including this one, but the evidence in this event contradicts that account. The manufacturer's checklists explicitly specified that the flight controls be checked for freedom of travel during two separate pre-departure phases; the walk-around preflight inspection, and the before-takeoff operational checks. For undetermined reasons, the pilot omitted those items from both of those phases, and deprived himself of two opportunities to detect the presence of the control lock. Investigation revealed that the manufacturer-issued control lock had been installed backwards by the pilot, which prevented it from accomplishing one of its primary design functions, that of inhibiting pilot access to the ignition switch. Further investigation revealed that the pilot rarely used the control lock due to the fact that he hangared his airplane, and that he was unaware that he had installed it backwards. The yoke-mounted iPad limited the pilot's view of the installed control lock, which reduced the potential for visual detection. The pilot reported that the winds were "light," which reduced the likelihood of the need for flight control inputs on theground during taxi, and thus deprived the pilot of another opportunity for detection of the locked controls. Finally, after his impromptu physical check of the fuel quantity, the pilot did not re-commence the interrupted before-takeoff checklist from the beginning, and thus missed another opportunity to detect the locked flight controls. ## Aircraft - Registration: [N736LZ](https://openairdocs.org/deregistered/N736LZ-2020-02-28), registration cancelled 2020-02-28, S/N R1722624, built 1977 (OpenAirDocs) - Reported make and model: CESSNA R172K (K) - Registry model: [Cessna R172K](https://openairdocs.org/model/cessna-r172k) (registry code 2072431) (OpenAirDocs) - Registry engine: [Continental IO-360 series](https://openairdocs.org/engine/continental-io-360-series) (registry code 17025, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: R1722624 - Year built: 1977 - Airframe hours: 1550 - Engines: Continental IO-360-K 195 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 13, 2016, 17 hours before - Departed: L00, Rosamond, CA - Destination: CMA, Camarillo, CA - Airport: L00, Rosamond Skypark, runway 26, 3,600 × 50 ft, asphalt - Equipment: Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review September 25, 2014; seat: left; restraint: 3-point; flight hours: 591.7 total, 553 in this make and model, 507 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 240° at 20 knots, gusting 26 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 77 °F, dew point 41 °F - Altimeter: 29.92 inHg - Turbulence: Unknown - Observed at: WJF, 10 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 20161002017749A](https://openairdocs.org/incident/20161002017749A), Oct 2, 2016: Cessna R172K, Rosamond, CA, Substantial damage. On 10/02/2016, N736LZ, a Cessna 172, attempted a take-off from Rosamond sky park, Rosamond, CA. As N736LZ accelerated down the runway, the take-off was… ## Docket (4 files) The files NTSB released with the investigation on October 25, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=94124. 3.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40445657&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Responses to NTSB Questions October 7 (item 2, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40445658&FileExtension=.PDF&FileName=Pilot%20Responses%20to%20NTSB%20Questions%20October%207-Master.PDF - Pilot Responses to NTSB Questions October 19 (item 3, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40445659&FileExtension=.PDF&FileName=Pilot%20Responses%20to%20NTSB%20Questions%20October%2019-Master.PDF - Pertinent Images (item 4, .PDF, 3 photos, 644 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40445660&FileExtension=.PDF&FileName=Pertinent%20Images-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.