# NTSB WPR19FA209: Cessna 182, N3469R, Wolf Point, MT, August 5, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: August 5, 2019, 14:45 local (20:45 UTC) - Place: Wolf Point, MT - Coordinates: 48.435832, -105.760833 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=48.4358&lon=-105.7608&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern base: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Textron Aviation (Cessna), Federal Aviation Administration - NTSB case key (mKey): 99999 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19FA209 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99999/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99999 - Page: https://openairdocs.org/ntsb/WPR19FA209 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Cessna 182L, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=2072726), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/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 182L, 12 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=2072726), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern base: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Cessna 182L, 3 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=2072726), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## 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](https://openairdocs.org/deregistered/N3469R-2021-03-06), registration cancelled 2021-03-06, S/N 18258769, built 1967 (OpenAirDocs) - Reported make and model: Cessna 182 (L) - Registry model: [Cessna 182L](https://openairdocs.org/model/cessna-182l) (registry code 2072726) (OpenAirDocs) - Registry engine: [Continental O-470 series](https://openairdocs.org/engine/continental-o-470-series) (registry code 17026, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 18258769 - Year built: 1967 - Airframe hours: 3290 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 50; injuries: fatal; 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 ## 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 20190805015499A](https://openairdocs.org/incident/20190805015499A), Aug 5, 2019: Cessna 182L, Wolf Point, MT, Destroyed, 2 fatal. Aircraft crashed in a field with two occupants on board. Both occupants were killed upon impact. Post-crash fire was extinguished by local farmer with water… ## Docket (5 files) The files NTSB released with the investigation on April 20, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99999. 6.0 MB in all. - Record of conversation (item 1, PDF, 2 pages, 825 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13178674&FileExtension=pdf&FileName=Z%20-%20Attachment%2002%20-%20ROC-Rel.pdf - Investigation support materials (item 2, PDF, 8 pages, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13178517&FileExtension=pdf&FileName=Z%20-%20Attachment%2001%20-%20Examination%20Notes-Rel.pdf - Statement of party representatives to NTSB investigation (item 3, PDF, 1 page, 250 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13647995&FileExtension=pdf&FileName=Z%20-%20Attachment%2010%20-%20Party%20FOrm_Redacted-Rel.pdf - Toxicological report (item 4, PDF, 1 page, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13648770&FileExtension=pdf&FileName=Toxicology%20Report_Redacted-Rel.pdf - Record of memorandum - autopsy (item 5, PDF, 1 page, 149 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13647965&FileExtension=pdf&FileName=RECORD%20OF%20MEMORANDUM-Rel.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.