WPR19FA209

NTSB accident investigation · Cessna 182 · Wolf Point, MT · August 5, 2019

Accident · FatalClass 3 · FieldFinal report
Date
August 5, 2019, 14:45 local (20:45 UTC)
Place
Wolf Point, MT
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N3469RCessna 182
Defining event
Approach-VFR pattern base: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Textron Aviation (Cessna), Federal Aviation Administration
FAA report
20190805015499A
Case key
99999

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The pilot's exceedance of the airplane's critical angle of attack while maneuvering to land, which resulted in an accelerated aerodynamic stall and subsequent loss of control.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 182L: 1 caseAll aircraft: 990 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 182L: 12 casesAll aircraft: 9,295 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot and passenger planned to visit a farm by landing on an adjacent dirt road. The pilot had previously been to the farm but had never flown there. The owner of the farm watched as the pilot crossed over the road and made a left turn to parallel the road. The airplane then began another left turn, consistent with a left base-to-final turn, during which the airplane continued past the road before it entered a sharp turn and descended into terrain. Upon impact, the airplane burst into flames. A postaccident examination revealed no anomalies that that would have precluded normal operation of the airplane. The circumstances of the accident are consistent with the pilot exceeding the airplane’s critical angle of attack while maneuvering for landing on the road, resulting in an accelerated stall, loss of control, and impact with terrain.

Factual narrative

The pilot purchased the airplane in October 2017. On May 30, 2018, at an airframe total time of 3,191.41 hours, the airplane underwent major repairs to the wings after the pilot collided with a barn. Additionally, the left elevator was replaced, along with the aft bulkhead. The records indicated that the elevator and rudder control cables were adjusted to 30 lbs +/- 10 lbs. According to the logbooks, the only maintenance that occurred thereafter was an annual inspection in June 2019; about 100 flight hours after the repairs. There was no mention of the elevator or rudder in the entry for the June 2019 annual inspection. The tachometer at the accident site was destroyed and the airplane’s total time at the time of the accident could not be determined. The Cessna Owner’s Manual stated that the stall characteristics were conventional, and an aural warning was provided by a stall warning horn, which sounded between 5 and 10 mph above the stall in all configurations. The Owner’s Manual indicated a stall speed of 64 mph at a gross weight of 2,800 lbs with flaps retracted. At bank angles of 30° and 60°, the stall speed increased to 69 and 91 mph, respectively. The maximum flap extension speed was 110 mph, and the recommended final approach speed was 75 knots. On August 05, 2019, about 1445 mountain daylight time, a Cessna 182L, N3469R, was substantially damaged when it was involved in an accident near Wolf Point, Montana. The private pilot and passenger sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. A witness stated that he owned the farm adjacent to the accident site. The pilot had built grain bins for him in the past and he had contracted him to build more. The pilot and passenger, an employee at the pilot’s company, planned to visit the farm that day. The pilot had discussed with the witness landing his airplane at the farm, and had been to the farm on previous occasions, but had never flown there. The witness stated that the pilot called him at 1423 saying that he was flying over the town of Wolf Point and would be landing at the farm shortly. The witness, positioned near his grain bins, watched the airplane fly over his location and make a left turn to the west, paralleling the dirt road upon which he intended to land. The airplane then began a left turn to the east to come back and land. He observed the airplane make a sharp turn and descend into terrain. (refer to figure 1.) Upon impact, the airplane burst into flames and the witness drove his water truck to put out the fire. Figure 1: Presumed Accident Flight Path (According to Witness) A reconstruction of the pilot’s logbooks revealed that he had accrued about 16 hours of flight experience in the previous 3 months. The accident site was located on a flat field composed of hard, dry dirt and short vegetation, about 21 nautical miles north of Wolf Point, Montana. The wreckage was found distributed over an approximate40-foot distance with the nose pointed on a magnetic heading of about 340°. The main wreckage, consisting of all of the major control surfaces, was about 60 ft south of the road. The fuselage and inboard sections of the wings had been consumed by fire. The first identified piece of debris was fragments of red lens, consistent with the tip of the left wing contacting the ground at the beginning of the accident sequence. Farther along the debris path, a disruption in the vegetation, similar in shape and size to that of a wing’s leading edge, contained pieces of lens consistent with the landing light. A crater in the dirt contained the two propeller blades. During the postaccident examination, the engine was rotated via the vacuum pump drive. The engine’s internal mechanical continuity was established during rotation of the crankshaft and thumb compression was obtained on each cylinder. A borescope examination of all cylinders found no foreign object damage, no evidence of detonation, and no indication of excessive oil consumption. The top spark plugs were removed, and the electrodes were gray in color, which corresponded to normal operation according to the Champion Aviation Check-A-Plug AV-27 Chart.

Aircraft

Registration
N3469R
Reported as
Cessna 182 (L)
Category
Airplane
Serial number
18258769
Built
1967
Airframe hours
3,290
Engine
Continental Motors O-470-R, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Business · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 7, 2019
Departed
MLS · Miles City, MT
Destination
Wolf Point, MT
Flight plan
VFR
Equipment
ADS-B, Stall warning system

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
50
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
270 total

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 9 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
88 °F, dew point 117 °F
Altimeter
27.88 inHg
Observed at
KOLF, 22 nm away

Docket · 5

The files NTSB released with the investigation on April 20, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.0 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.