ERA15FA203

The student pilot's failure to maintain airplane control during the initial climb. Contributing to the accident was the student's inappropriate configuration of the airplane's wing flaps for the initial climb.

On the morning of the accident, the student pilot departed from his home airport and flew to two other airports before returning to his home airport. None of these cross-country flights were conducted under the supervision of a flight instructor nor was there any documentation available to show that the student was endorsed to conduct these flights. Upon reaching his home airport, the student pilot entered the traffic pattern to land on the 5,500-ft-long runway with a prevailing right quartering tailwind. A pilot-rated witness reported that he saw the airplane approach the runway "high and fast," that it was about 100 to 150 ft above the ground as it crossed over the runway threshold, and that it then appeared to "float" down the runway. He then lost sight of the airplane. Another witness noted that, after touching down near the midpoint of the runway, the airplane lifted off and reached about 50 ft above the ground, at which point, the engine power increased. The airplane then began climbing steeply and then banked left, making an arcing flightpath that continued to ground contact. Based on available evidence, the investigation was unable to determine whether the pilot was attempting to conduct a go-around following the previous landing approach, or was conducting a touch-and-go landing when the accident occurred. Postaccident examination of the airframe and engine revealed no evidence of any mechanical malfunctions or failures that would have precluded normal operation. Although fuel drained from the airplane after the accident contained water, witness statements and wreckage signatures were consistent with the engine operating normally to ground impact. The flaps were found extended 40°; however, airplane manufacturer guidance stated that during a go-around climb, the "flap setting should be reduced to 20° immediately after full power is applied" and that "flap settings of 30° to 40° are not recommended at any time for takeoff." It is likely that the inappropriate flap setting for the initial climb contributed to the student pilot's failure to maintain airplane control. Although the student pilot's autopsy identified the presence of coronary artery disease that could have caused acute symptoms such as chest pain, shortness of breath, palpitations, or fainting, there was no evidence of any such event occurring.

Runway 19 at PEO was 5,499 ft long and 100 ft wide. The approach end of the runway had an elevation of 916 ft, and the departure end of the runway had an elevation of 987 ft, or a 1.4% gradient. A two-light precision approach path indicator was available at both runway ends. According to the 1966 Cessna Model 172 and Skyhawk Owner's Manual, "Slips are prohibited in full flap approaches because of a downward pitch encountered under certain conditions of airspeed and sideslip angle." Additionally, the manual stated that "In a balked landing (go-around) climb, the wing flap setting should be reduced to 20° immediately after full power is applied," and that "Flap settings of 30° to 40° are not recommended at any time for takeoff." The Geneva General Hospital Laboratory, Geneva, New York, performed an autopsy of the pilot. The reported cause of death was "crash related injuries." The autopsy report also identified significant coronary artery disease with a heart weight of 510 grams. The right ventricle was 0.5 centimeter (cm) thick, and the left ventricle was 1.5 cm thick. In addition, all three main coronary arteries were narrowed at least 50% and up to 75% by atherosclerosis, but there were no areas of scarring from previous heart attacks. The liver and stomach were also mildly inflamed. The FAA's Civil Aerospace Medical Institute performed toxicological testing on specimens from the pilot. The results were negative for ethanol, carbon monoxide, and drugs. The airplane came to rest upright with the right wing resting on the airport perimeter fence, about 300 ft left of the runway centerline and about 2,800 ft from the runway 19 approach threshold. All of the major components of the airplane were accounted for at the accident site. Areas of disturbed soil and intermittent ground scars extended from the initial impact point oriented on a magnetic heading of 145°. A piece of left wing navigation light was located in the wreckage path about 20 ft from the initial impact point. About 15 ft further down the path, a ground scar was found oriented 90° to the path, about the length of the propeller diameter and the width of a propeller blade. About 2 ft further down the path was an impact crater that was 3 ft wide and 8 ft long and contained paint chips and windscreen fragments, followed by the main wreckage, which came to rest oriented on a magnetic heading of about 340°. The propeller remained attached to the crankshaft flange, and both blades displayed s-bending, chordwise scratching, and leading-edge gouging. The engine remained partially attached to the firewall by its mounts. The nose landing gear was fractured and separated from the airplane at the firewall attachment point, consistent with impact. The nose section from the firewall forward had separated from the fuselage on both sides, and the windscreen was fractured and separated from the fuselage. The outboard portion of the left wing was deformed upward and displayed aft crush damage, consistent with ground contact. The right wing displayed a concave depression and was deformed aft beginning outboard of the wing strut. First responders reported that, upon their arrival, they observed fuel leaking from the left wing near the vent tube and that they subsequently drained about 7 gallons of fuel from the left wing and about 10 gallons of fuel from the right wing. Fuel samples from both tanks displayed a color and odor consistent with automotive gasoline. A trace amount of water was detected in the sample from the left wing and in fuel recovered from the carburetor float bowl. Flight control continuity was established from each control surface to the cockpit area. The elevator trim tab actuator position was consistent with 5° to 10° of tab deflection in the nose-up direction. The flap actuator extension was measured and found in a position consistent with a 40° flap extension. The front seat tracks and seat roller brackets for both seats were checked for wear and found to be within prescribed limits. The left seat positioning rod was found bent forward about 1 inch from the engagement end. The engine crankshaft was rotated by hand at the propeller flange, and continuity was confirmed from the valve and powertrains to the rear accessory gears. The oil screen and paper oil filter element were unobstructed and free of metallic contamination. The spark plugs were removed, and the No. 6 cylinder plugs displayed black-colored, carbon-type fouling. Thumb compression was confirmed on all cylinders. The fuel strainer screen and carburetor inlet screen were free of debris. The carburetor floats were intact, and both displayed concave, inward, uniform deformation. The magnetos were removed and actuated by hand, and spark was observed at each of their respective terminal leads. The 1135 weather observation at PEO included wind from 310° at 8 knots, 10 statute miles visibility, clear skies, temperature 73° F, dew point 37° F, and an altimeter setting of 30.08 inches of mercury. According to FAA registration records, the pilot purchased the accident airplane in May 2014. A review of maintenance logbooks revealed that new main and nose landing gear tires were installed on May 15, 2014, at an airframe total time of 4,558 flight hours. The airplane's most recent annual inspection was completed on August 17, 2014, at an airframe total time of 4,575 flight hours and 784 hours since the engine's most recent overhaul. An airframe maintenance log entry made the day of the accident noted that the right main landing gear wheel bearing and brake pads were installed, and that the wheel bearing was regreased and then reinstalled. At the time of the accident, the airframe had accumulated 4,625 total flight hours. On May 3, 2015, at 1134 eastern daylight time, a Cessna 172G, N3969L, impacted terrain and an airport perimeter fence during initial climb at Penn Yan Airport (PEO), Penn Yan, New York. The airplane was being operated as a 14 Code of Federal Regulations Part 91 personal flight. The student pilot was fatally injured, and the airplane sustained substantial damage. Visual meteorological conditions prevailed at PEO about the time of the accident, and no flight plan was filed. The flight originated from Finger Lakes Regional Airport (0G7), Seneca Falls, New York, about 1115. On the morning of the accident, the pilot contacted flight service and requested a weather briefing for a flight from PEO to Oswego County Airport (FZY), Fulton, New York, departing about 0730 and returning about 1100. The briefer advised the pilot of the current conditions at PEO and FZY, the forecast sky conditions for the area, and the NOTAMs applicable for the proposed flight. Review of airport security video footage showed that the accident airplane began taxiing at PEO about 0800. Data downloaded from a handheld GPS receiver recovered from the accident site showed that the device began recording on the morning of the accident at 0818. The airplane's first recorded position was about 22 nautical miles (nm) northeast of PEO, roughly along a course line between PEO and FZY. Over the next 17 minutes, three additional positions were recorded, the last of which was at 0835 and showed the airplane about 3 nm south of FZY. The next position was recorded at 0944 and showed the airplane about 2 nm southwest of FZY. Over the next 17 minutes, three additional positions were recorded; the last recorded position showed the airplane about 5 nm northeast of 0G7. The airplane arrived at 0G7 on the morning of the accident, and the student pilot spoke with his mechanic. According to the mechanic, he and the pilot discussed an ongoing issue with the airplane involving water contamination of its fuel. The pilot and mechanic then drained about 1 quart of fuel through the fuel strainer before it was clear of water. At the pilot's request, the mechanic inspected the airplane's right main landing gear, relubricated the wheel bearings, and