Pilot Debrief

CESSNA 172S near Fullerton, CA — 2008-10-01

Final reportLAX08FA301
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Date
2008-10-01
Location
Fullerton, CA, USA
Airport
FUL
Aircraft
CESSNA 172S
Registration
N2190W
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

The pilot's failure to follow the takeoff checklist and verify the proper flap setting before takeoff.

NTSB narrative

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.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Pilot should have ensured proper flap setting before takeoff.

NTSB coding

Evidence available

  • ATC audio
  • Video
  • Photos
  • 24 docket documents
View NTSB final reportView NTSB docket

Docket documents24

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