Pilot Debrief

CESSNA 172 near Ramona, CA — 2017-02-12

Final reportWPR17FA063
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Date
2017-02-12
Location
Ramona, CA, USA
Aircraft
CESSNA 172
Registration
N2179L
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Maneuvering

Probable cause

The flight instructor's failure to ensure that adequate clearance from terrain was maintained after performance of a simulated engine failure maneuver, which resulted in controlled flight into terrain.

NTSB narrative

The airplane departed on an instructional flight with a flight instructor in the right front seat, a student pilot in the left front seat, and a passenger in the right rear seat. They completed maneuvers in a practice area, flew to a valley located in mountainous terrain, and performed a simulated engine failure maneuver. The flight instructor and the student pilot provided differing accounts of the events that followed the simulated engine failure maneuver. According to the flight instructor, after performing the simulated engine failure maneuver, the student pilot advanced the throttle to full power and turned east toward rising terrain. The flight instructor reported that the gauges all read normal, but the airplane would not outclimb the approaching terrain. He took over the controls but could not turn left or right due to the rising terrain on both sides of the airplane. According to the instructor, he had no choice but to crash the airplane. According to the student pilot, the flight instructor told him to turn east towards the rising terrain and then took control of the airplane. The student reported that the flight instructor made a comment about demonstrating the airplane's performance, added full power, leaned the mixture, flew straight for 5 seconds, and then said an expletive shortly before the airplane crashed into a mountain. Flight track data recovered from a personal electronic device onboard the airplane showed that, after the simulated engine failure maneuver, the airplane climbed and turned east entering terrain that rose in front and on both sides of the airplane. The track continued to climb for about 1 minute 5 seconds before reaching the accident site. Postaccident examination of the airplane revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. According to the pilot's operating handbook for the airplane, at its maximum gross weight, under standard conditions, with no flaps and full throttle, the airplane was capable of climbing at a maximum rate of 625 ft per minute, at 73 knots indicated airspeed, at 2,000 ft mean sea level (msl). The flight track data for the final 1 minute 5 seconds of the flight indicated that the airplane climbed about 584 ft, corresponding to a rate of climb slightly less than the published maximum rate of climb. During the climb, the left turn towards the east would have decreased the rate-of-climb performance, which likely accounts for the rate of climb being less than the published maximum. During the impact sequence, a tree penetrated up through the center of the cabin floor just behind the front seats and exited through the cabin roof. The airplane came to rest upright. The instructor was able to unbuckle his seatbelt but had to cut the student pilot's seatbelt to free him. After examining the passenger, the instructor realized that her seatbelt was not latched and that her injuries were fatal. The autopsy of the passenger determined her cause of death to be blunt force injuries of the head and neck. These injuries were likely due to impact with the tree that penetrated the cabin area.

Analysis

Primary failure mode
Loss of control
First missed decision gate
Instructor could have avoided the maneuver over rising terrain.

NTSB coding

Evidence available

  • Photos
  • 8 docket documents
View NTSB final reportView NTSB docket

Docket documents8

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