Fullerton, CA, USA
N2190W
CESSNA 172S
The student pilot completed a preflight inspection and taxied to the runway for a planned solo flight to practice takeoffs and landings. Witness observations and wreckage distribution indicate that about 513 feet into the takeoff roll, the airplane's tail skid struck the runway. About the 750-foot point, the airplane departed the left side of the runway and struck two runway/taxiway signs before becoming airborne around the 937-foot point. Impact with the signs resulted in severe damage to the left horizontal stabilizer. Shortly after becoming airborne, the airplane rolled into a steep right bank, nosed down, and impacted the runway. No preimpact anomalies were noted during examination of the airframe and engine. Measurement of the flap actuator indicated the flaps were in the full down position. The flap selector lever was found in the full up position; however, the lever was bent over to the right, indicating that it was damaged and likely moved during the impact sequence or when the pilot exited the airplane. According to the pilot's operating handbook (POH) for the airplane, flap deflections greater than 10 degrees are not approved for takeoff. Verifying the flap setting is an item included in the Before Takeoff, Normal Takeoff, and Short Field Takeoff checklists in the POH. The evidence indicates that the pilot omitted the checklist item to verify the flap setting and inadvertently initiated a takeoff with the wing flaps in the 30-degree (full down) position. Early in the takeoff roll, the airplane's nose pitched up, the tail skid struck the ground, and the pilot lost directional control. Instead of aborting, the pilot continued the takeoff, and the airplane exited the runway and hit two runway/taxiway signs, which severely damaged the left horizontal stabilizer. Once airborne, the pilot was unable to maintain control of the airplane, possibly due to the damaged stabilizer, and it entered an uncontrolled descent and struck the ground.
HISTORY OF FLIGHT On September 30, 2008, about 1835 Pacific daylight time, a Cessna 172S, N2190W, impacted terrain following a loss of control on takeoff from runway 24 at Fullerton Municipal Airport, Fullerton, California. The student pilot, the sole occupant, sustained serious injuries. The airplane sustained substantial damage. Visual meteorological conditions prevailed for the local solo instructional flight, and no flight plan was filed. The pilot was operating the airplane under 14 Code of Federal Regulations Part 91. The flight was originating when the accident occurred. In a telephone interview conducted by NTSB investigators, the pilot reported that the airplane was based at Fullerton. On the day of the accident, he was planning to fly for about 30 minutes and practice takeoffs and landings at either Fullerton or Long Beach. He pulled the airplane out of its hangar and performed a pre-flight inspection. The pilot commented that he used a detailed checklist to conduct the pre-flight inspection that was "more extensive" than the checklist provided by the airplane's manufacturer. He further commented that he had intended to perform a short field takeoff, but changed his mind before taxiing to the runway. In response to a question concerning his flap setting, the pilot said that he thought it was "just below bottom of center" and that he "does it out of the book." After receiving taxi clearance from the control tower, the pilot taxied to runway 24 and performed an engine run-up. The pilot said that he received clearance for a straight out departure, taxied onto the runway, and applied power. The airspeed reached 65 knots and the airplane became airborne. As soon as it became airborne, it went to the left. The pilot added right rudder, but the airplane did not respond and would not go back to the right. He reduced power and put the airplane back on the ground. It was still going to the left, and he could see that he was going off the left side of the runway into the dirt. He "put full power in again to try to get it back in the air, pulled back on the yoke and turned." The airplane responded, but not "the way it should." The airplane "finally did go to the right and then nosed over and went right back down." The pilot explained that he "never pulled the power out because his intent was to get [the airplane] airborne again and not hit other objects." A witness, a pilot who was flying an airplane on final approach to land on runway 24, reported that he observed the accident airplane roll onto runway 24 and then a few seconds later he started to see dirt trailing from the airplane's main landing gear as it departed the south (left) side of the runway. The airplane then appeared to be airborne between the runway and taxiway A (parallel taxiway on runway's south side) pointed toward the control tower. Shortly after the airplane became airborne, the witness observed the airplane's "left wing rise up and [its] right wing dip very suddenly." The right wing tip struck the runway with the nose of the airplane perpendicular to the runway. Then the nose struck the runway "in a cartwheel motion as [the airplane] flipped over," the tail hit the ground and the airplane came to rest upside down. PERSONNEL INFORMATION The pilot, age 60, held a third-class medical certificate and student pilot certificate that was issued on October 17, 2006. The certificate was issued with the limitation: holder shall possess glasses that correct for near vision. On the back of the certificate, there were endorsements for solo flight in Cessna 172 airplanes, and for solo cross-country flight in airplanes dated December 13, 2006, and September 21, 2008, respectively. Review of the pilot's logbook revealed that he had accumulated 146.5 hours of total flight time since he started flying on July 23, 2006. His logbook indicated his first solo flight occurred on December 13, 2006, and that he had accumulated 40.1 hours of solo flight time at the time of the accident. Starting on June 17, 2007, he flew the accident aircraft exclusively, accumulating 100.2 hours of flight time in it. He had flown 31.5 hours in the 30 days preceding the accident. His most recent flight before the accident occurred on September 27, 2008; the flight was a solo flight that lasted 2.2 hours. AIRCRAFT INFORMATION Examination of the airplane's maintenance records indicated that the 2007 model Cessna Skyhawk SP received its most recent annual inspection on July 11, 2008, at a total time of 116.0 hours. As of that date, the engine, a Lycoming IO-360-L2A, had also accumulated 116.0 hours. The most recent maintenance before the accident occurred on September 24, 2008, at an airframe and engine total time of 153.6 hours. This maintenance consisted of replacement of the transponder antenna and an engine oil and filter change. Review of the maintenance records revealed no evidence of any uncorrected maintenance discrepancies. The Pilot's Operating Handbook (POH) for the airplane contains a section on the wing flap system. This section explains that the wing flaps are extended and retracted by positioning the wing flap switch lever on the instrument panel to the desired flap deflection position from 0 to 30 degrees. The switch lever is moved up or down in a slotted panel that provides mechanical stops at the 10, 20, and 30-degree positions. To move the flaps down, the flap lever is moved to the right to clear the mechanical stops at the 10- and 20-degree positions. The POH also contains a section on takeoff wing flap settings. This section indicates that flap settings of 0 to 10 degrees are used for normal takeoffs, and soft or rough field takeoffs are performed with 10 degrees of flaps. The section states, in part: Flap deflections greater than 10 degrees are not approved for takeoff. Step number 28 of the 31 steps in the Before Takeoff checklist in the POH is "Wing Flaps - UP to 10 degrees (10 degrees preferred). The first step in the Normal Takeoff checklist in the POH is "Wing Flaps - UP to 10 degrees (10 degrees preferred). The first step in the Short Field Takeoff checklist in the POH is "Wing Flaps - 10 degrees." The airplane's four seats were equipped with lap/shoulder (3-point) belts. The two front seats were also equipped with an inflatable restraint (airbag) in the lap portion of the buckle. METEOROLOGICAL INFORMATION At 1840, the reported weather conditions at Fullerton Municipal Airport were wind calm; visibility 10 miles; clear skies; temperature 32 degrees Celsius (C); dew point 8 degrees C; and altimeter setting 29.86 inches of mercury. WRECKAGE AND IMPACT INFORMATION Federal Aviation Administration (FAA) inspectors examined the accident site and reported that the wreckage path began about 513 feet from the point of initiation of the takeoff roll where a plastic fragment from the cap on the bottom of the rudder was found. Additionally, a scrape mark was noted at this location consistent with the airplane's tail tie down ring/skid contacting the runway. About the 750-foot point, a tire track in the dirt and a broken runway light marked the location where the airplane departed the left side of the runway. The airplane impacted a runway/taxiway sign at the 784-foot point, crossed taxiway C leaving tire skid marks on the asphalt, and impacted another runway/taxiway sign at the 937-foot point. Tire marks were noted on the second runway/taxiway sign, and a fragment of skin from the bottom of the left horizontal stabilizer was found nearby. The second runway/taxiway sign was located about 125 feet left (south) of the centerline of runway 24. No further evidence of ground contact was found until the 1,819-foot point. Here, fragments of the right wing tip were located on the south edge of the runway; slash marks and gouges consistent with the airplane's nose impacting the runway were found near the runway centerline; and the airplane was lying inverted on the north (right) side of the runway with its nose pointing north. The wings, empennage, and all three landing gear remained attached to the fuselage. The engine, firewall, and forward fuselage structure were displaced upward, left, and aft into the cabin. The propeller separated from the engine. Both propeller blades displayed leading edge gouging, chordwise scratches, twisting, and bending. A 2-foot section of the outboard right wing was crushed aft and inboard. The left wing sustained minimal damage. The right horizontal stabilizer's leading edge was torn open and crushed aft to the right elevator; black paint transfer consistent with the paint on the runway/taxiway signs was present on the stabilizer's skin. The left horizontal stabilizer had a hole torn in its bottom skin. The wreckage was examined after it was recovered under the supervision of an NTSB investigator by representatives of the FAA, Cessna, and AmSafe. All flight controls remained attached to their respective airframe components. Flight control continuity was established throughout the airplane through cable separations created by recovery personnel. The flap actuator was measured at 5 inches corresponding to 30 degrees (full flaps). The flap selector lever and indicator were at 0 degrees. The lever was bent over to the right, indicating it was damaged and likely moved during the impact sequence or when the pilot exited the airplane. No pre-impact anomalies were noted with the airframe or engine. SURVIVAL FACTORS The pilot's airbag deployed during the impact sequence. The pilot reported that following the impact, he was hanging upside down inside the airplane. He released his seatbelt, fell to the ceiling of the airplane, opened the left door, and crawled out onto the left wing. He could hear the fuel pump running and was concerned about fire; he asked the first people who arrived at the accident site to "shut off the airplane," which they did. The pilot suffered serious bilateral lower extremity injuries, a right upper extremity fracture, a possible rib fracture, facial lacerations, and chest abrasions and contusions. For further details, see the Survival Factors and Biomechanics Factual Report in the public docket for this accident. ADDITIONAL INFORMATION Three video cameras mounted on the roof of the second floor of the control tower captured images of the airplane. The frame rate of the cameras was one frame per second. Only one camera was pointed in a direction to see the airplane's point of impact. This camera recorded two images of the airplane just before the crash, at camera times 18:37:41 and 18:37:42. The image at time 18:37:43 and later images show the crash site after the airplane impacted the ground. At time 18:37:41, the airplane has a near level pitch attitude and a right roll angle of about 45 degrees. At time 18:37:42, the pitch attitude is nose down and the roll angle has increased to about 75 degrees. The images acquired by the cameras do not have sufficient resolution for determining the airplane's flap setting.
The pilot's failure to follow the takeoff checklist and verify the proper flap setting before takeoff.
Source: NTSB Aviation Accident Database
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