WPR23FA247

NTSB accident investigation · Cessna 172N · Murrieta, CA · July 4, 2023

Accident · FatalClass 3 · FieldFinal report
Date
July 4, 2023, 13:57 local (20:57 UTC)
Place
Murrieta, CA
Injuries
1 fatal, 3 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N5243ECessna 172N
Defining event
Takeoff: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Textron Aviation, Lycoming Engines, Federal Aviation Administration
FAA report
20230704008719A
Case key
192510

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 during takeoff, which resulted in an aerodynamic stall and loss of control. Contributing to the loss of control was the pilot’s sudden retraction of the flaps.

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: pitch controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedCessna 172N: 12 casesAll aircraft: 526 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotCessna 172N: 150 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 was taking his family for scenic flights after receiving his private pilot certificate about 2 weeks earlier. They completed one successful flight and then departed on the second, which was the accident flight. Upon returning to their departure airport, the airplane landed normally, but during the landing roll, the front seat passenger heard a “pop” sound and subsequently felt the airplane shake, at which time the pilot started to panic. The pilot advanced the throttle and the airplane lifted off the runway surface again. Surveillance video captured the airplane as it began to climb in a nose-high attitude, drifted left of the runway, then rolled inverted and rapidly descended. Postaccident examination of the airplane and engine revealed no preimpact mechanical anomalies that would have precluded normal operation. The wing flaps were found in the retracted position. The source of the “pop” sound reported by the passenger could not be determined, nor could it be determined why the pilot chose to take off immediately after having successfully touched down on the runway, as he had planned a full-stop landing. The reported wind at the time of the accident indicated a headwind accompanied by a right crosswind that was within the airplane’s maximum demonstrated crosswind component. The circumstances of the accident are consistent with the pilot’s exceedance of the airplane’s critical angle of attack during takeoff, which resulted in an aerodynamic stall and loss of control. Evidence shows that the pilot retracted the flaps from the fully extended position to the flaps up position while the airplane was in a high angle of attack as it veered left of the runway towards buildings. The sudden retraction of flaps at a low altitude would have resulted in a loss of lift and a descent, which likely contributed to the loss of control.

Factual narrative

Stall Speeds The pilot’s operating handbook (POH) included the airplane’s stall speeds in a power OFF configuration at a weight of 2,220 lbs. According to the POH, the stall speed in a flaps-up configuration at a level attitude with a rearward center of gravity (CG) is 42 knots (kts) and the stall at a 30° bank angle is 45 kts. The stall speed in a flaps-up configuration at a level attitude with a forward center of gravity (CG) is 45 kts and the stall speed at a 30° bank angle is 48 kts. The section also includes a note: “maximum altitude loss during a normal stall recovery is approximately 300 ft.” The normal procedures in the POH state that a balked landing should be conducted at maximum power with flaps at 20° and 55 kts indicated airspeed. These values are based on a maximum weight of 2,220 lbs. Weight and Balance An airplane weight and balance was computed using a basic empty weight of 1,475 lbs, a combined occupant weight of 564 lbs and a fuel weight of 240 lbs (40 gallons). The airplane total weight was approximately 2,279 lbs and the calculated CG was 43.88 inches aft from the datum. According to the pilot’s operating handbook, the airplane’s forward CG limit was 38.5 inches aft from the datum and the aft CG limit was 47.3 inches from the datum. Crosswind Component The reported wind gusts at the time of the accident would have produced a headwind component of about 16 kts and a right crosswind of about 6 kts. The sustained winds at the time would have produced a headwind component of 10 kts and a right crosswind of 3 kts. According to the POH, the maximum demonstrated crosswind velocity in the accident airplane was 15 kts. According to the FAA Airplane Flying Handbook (FAA-8083-H-3C), “After establishing the proper climb attitude and power settings [during a go around maneuver], the pilot's next concern is flap retraction. After the descent has been stopped, the landing flaps are partially retracted or placed in the takeoff position as recommended by the manufacturer. Depending on the airplane’s altitude and airspeed, it is wise to retract the flaps intermittently in small increments to allow time for the airplane to accelerate progressively as they are being raised. A sudden and complete retraction of the flaps could cause a loss of lift resulting in the airplane settling into the ground.” On July 4, 2023, about 1357 Pacific daylight time, a Cessna 172N airplane, N5243E, was substantially damaged when it was involved in an accident near Murrieta, California. The pilot was fatally injured, and the three passengers were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot’s wife reported that they had planned a local scenic flight with their kids. They arrived at the airport about noon and completed one flight with the pilot’s wife and one of their four children. She and her son deplaned, and the other three sons boarded the airplane and subsequently departed on theaccident flight. They flew the same route as the first flight and then returned to the departure airport about 1355 for a full-stop landing. Surveillance video showed the airplane on an approach toward runway 18. The airplane touched down on the runway, rolled for about 1-2 seconds, then departed the runway surface and immediately entered a climb in a nose-high attitude as it drifted left of the runway centerline. After the airplane reached about 60 ft above ground level, it began to settle and subsequently entered a left-wing-low attitude. The airplane rolled inverted and then disappeared from view of the camera behind a building. Approximate flap positions could not be determined due to the resolution of the video. A witness reported that the airplane’s approach to runway 18 was “squirrely” and the flaps appeared to be fully extended. After the airplane made contact with the runway, about 1,000 ft from the approach end of runway 18, the witness heard the engine power advance and observed the airplane take off again. The airplane then veered off the side of the runway about a 35° angle relative to the runway heading. According to the witness, the airplane was still configured with full flaps as it slowly climbed toward a group of buildings at a high angle of attack. As the airplane neared the group of buildings, its wings rocked back and forth, and the flaps started to retract. The airplane rolled to the left and disappeared behind the building, which was immediately followed by a loud sound. He noted that the engine was operating at high power throughout the climb and no interruptions in power were noted. The NTSB investigator-in-charge played an audio clip of the airplane’s stall warning horn for two of the passengers. One of the passengers recalled hearing the stall warning horn during landing and possibly during the takeoff and the other passenger did not recall hearing the stall warning horn. During a subsequent interview, the pilot’s wife reported that her son who was seated in the front right seat on the accident flight told her that the airplane landed normally, but during the landing roll he heard a “pop,” and the airplane began to shake. He then observed his father’s demeanor change as he began to panic and then advanced the throttle again. An autopsy of the pilot was performed by the Riverside County Sheriff – Coroner Division. According to the autopsy report, the cause of death was multiple traumatic injuries. According to records retrieved from the Federal Aviation Administration, the pilot received his private pilot certificate on June 19, 2023. This was the pilot’s first flight following his practical test. The pilot began his flight training with Riverside Flight Academy on July 21, 2020, in the same airplane make and model as the accident airplane. He flew with a total of 7 different flight instructors at the flight academy totaling about 35 hours of instruction. He started training with Executive Flight Institute, LLC (EFI) onSeptember 19, 2020. He accumulated about 7 hours of flight training between November 2020 and July 2021. The pilot did not accrue any flight time with EFI between August 2021 and August 2022. He subsequently flew about 2 to 6 hours per month from September 2022 until the month of his check ride. One of the pilot’s instructors reported that the pilot had trouble advancing the yoke to keep the airplane’s nose down during go-arounds. The instructor reported that the pilot had a habit of configuring the airplane with excessive nose-up trim for landing. According to documents provided by the pilot’s designated pilot examiner (DPE), they performed multiple takeoffs and landings that included a normal takeoff and landing, a full-stop followed by short-field and soft-field takeoffs and landings, a slip, and a go-around at F70. The DPE’s notes showed that the pilot completed each task satisfactory. The airplane came to rest inverted in an industrial complex about 0.3 nm on a heading of about 125° magnetic from the approach end of runway 18. All major structural components of the airplane were accounted for at the accident site. The airplane came to rest adjacent to an approximate 50-ft-tall building, which displayed a diagonal transfer mark that extended nearly the vertical length of the building. A dark black transfer mark was observed on the same wall about 5 ft from the ground and multiple horizontally oriented striations were below the black mark. An additional black transfer mark was located a few inches from the striations. Postaccident examination of the airframe and engine revealed no preimpact mechanical anomalies or malfunctions that would have precluded normal operation. The elevator trim tab exhibited 15° nose-down deflection, consistent with the elevator trim tab indicator. The flap selector was found in the “up” position and the indicator displayed 20°. The flap actuator jackscrew threads were not exposed, consistent with the flaps being fully retracted.

Aircraft

Registration
N5243E
Reported as
Cessna 172N
Category
Airplane
Serial number
17271793
Built
1978
Airframe hours
4,352
Engine
Lycoming O-320 H2AD, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
California Professional Flyers Inc
Registered owner
California Professional Flyers Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 26, 2023 · 44 hours before
Airport
F70 · French Valley Airport, runway 18, 6,000 × 75 ft, asphalt
Equipment
ADS-B

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
39
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
June 19, 2023
Seat
Left
Restraint
3-point
Toxicology
Performed
Flight hours
65.3 total · 64.3 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
200° at 11 knots, gusting 18
Visibility
10 statute miles
Lowest ceiling
None
Temperature
91 °F, dew point 46 °F
Altimeter
29.94 inHg
Observed at
KF70, 1 nm away

Docket · 14

The files NTSB released with the investigation on July 5, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 110 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.