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NTSB investigation record

WPR10FA384

Completed

Cessna 172· N9730H

Date
August 6, 2010
Location
Roche Harbor, WA
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot’s failure to attain an adequate climb airspeed due to his use of flaps for takeoff, and his selection of a runway, which resulted in an uphill, and possibly downwind, takeoff and subsequent collision with a known obstacle. Contributing to the accident was the operator's cockpit checklist that did not accurately reflect the manufacturer's takeoff procedures.

Investigator assessment

Analysis narrative

The pilot departed from an uphill runway, with 10 to 15 degrees of flaps extended for takeoff, which was contrary to the manufacturer's guidance in the Pilot Operating Handbook (POH). The pilot stated that after liftoff, while trying to achieve and maintain an appropriate airspeed, the airplane encountered a downdraft, and he then heard a “pop” that he believed to be an engine problem. The airplane struck trees and terrain about 1,500 feet from the departure end of the runway, and incurred substantial damage to the wings and fuselage. Two separate post accident examinations, including a brief engine run, did not reveal any anomalies that would have precluded normal engine operation, and propeller cuts to tree limbs at the accident site indicated that the engine was developing power. According to the pilot, he selected the departure direction based on his observation of a windsock nearest the runway threshold. He had flown into the airport about 10 times previously, and was aware the runway sloped uphill and that there were trees about 1,000 feet beyond the departure end. The lack of an airport wind information recording system precluded determination of the wind conditions at the time of the accident, but calculations based on wind direction and speed information from the three weather observation stations nearest the accident site yielded values that ranged from a 4-knot headwind to an 8-knot tailwind. The POH stated that normal and obstacle clearance takeoffs were to be performed with wing flaps retracted, and specified the use of takeoff flaps only for soft or rough fields. The operator developed checklist used by the pilot did not include any specific guidance on the use of flaps for takeoff. The performance data in the POH did not enable a takeoff distance calculation that accounted for the runway slope or the use of flaps; calculations that used the available POH data indicated that with a tailwind of 8 knots, about 2,000 feet were required to clear a 50-foot obstacle. The accident site terrain elevation was approximately 100 feet higher than the departure threshold, and the trees at the site were approximately 50 feet tall.

Source record

Factual narrative

HISTORY OF FLIGHT On August 5, 2010, about 1714 Pacific daylight time, a Cessna 172M, N9730H, was substantially damaged when it struck trees shortly after takeoff from Roche Harbor Airport (WA09), Roche Harbor, Washington. The certificated flight instructor and one passenger received minor injuries, and one passenger was uninjured. The flight was operated under the provisions of Title 14 Code of Federal Regulations (CFR) Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the personal flight. According to the pilot, the airplane belonged to the Whidbey Island Navy Flying Club (WINFC) and was based at Whidbey Island Naval Air Station (NUW), Oak Harbor, Washington, located about 27 miles southeast of the accident airport. The accident flight was to be the return leg of a round trip flight from NUW to WA09 and back, with a stop for dining at WA09. The two passengers, who were husband and wife, won the flight in a raffle. Until the day of the flight, the pilot and passengers were unknown to one another. The flight from NUW to WA09 was uneventful, and the preflight and run-up for the return leg were normal. The pilot elected to depart on runway 7, since the windsock indicated approximately 20 degrees crosswind from the right, at about 5 knots. Since a hill topped with trees began about 1,000 feet beyond the east end of the runway, the pilot decided to conduct what he referred to as a short field takeoff, and set the flaps to between 10 and 15 degrees. In his verbal recount to the National Transportation Safety Board (NTSB) investigator, the pilot stated that he planned to lift off at an indicated airspeed of 55, but the airplane became airborne at slightly slower speed. He then leveled the wings to accelerate before beginning the climb, and when he passed the end of the runway he started the climb. At that point, he observed that the airspeed indicator (ASI) registered 60 knots instead of the value of 67 that he expected. The pilot reported that the airplane then, "got a negative gust" and "wobbled a bit," and he adjusted the pitch attitude to continue the climb. The pilot observed that the airspeed had decreased to approximately 60 to 55 knots, and he then heard a "very distinct pop," which he associated with the engine. He told the passengers that there was a problem. The pilot thought that the engine speed was slightly lower than normal, and observed that the tachometer indicated no more than approximately 2,400 rpm. He reported that the airplane was approximately 150 feet above ground level at that time. The pilot realized the airplane was not going to clear the hill and trees just beyond the departure end of the runway, and he started looking for a place to put down. He observed that the airplane was losing airspeed, and that the ASI indicated about 55 to 50 knots. The pilot stated that the stall warning horn sounded momentarily at least one time. Since the pilot did not observe any suitable landing areas, he focused on managing the airspeed. He stated that just before the airplane struck the trees, he extended the flaps further, with the expectation of "ballooning" the airplane over the trees. The airplane struck trees, and came to rest on the ground about 1,500 feet beyond the departure end of the runway. The pilot and both passengers extricated themselves from the airplane. PERSONNEL INFORMATION According to information provided by WINFC, the pilot was the WINFC Chief Pilot. He held multiple Federal Aviation Administration (FAA) certificates and ratings, including flight instructor and airline transport pilot. He had a total flight experience of about 21,600 hours, which included over 500 hours in the accident airplane make and model. The pilot's most recent FAA third-class medical certificate was issued in October 2008, and his most recent flight review was completed in September 2008. He indicated that he had flown into WA09 about 10 times prior to the accident. AIRCRAFT INFORMATION According to FAA records, the airplane was manufactured in 1975, and was first registered to the WINFC in 1993. The airplane was equipped with a Lycoming O-320 series piston engine, and a fixed-pitch propeller. Supplemental type certificates for the use of automotive gasoline in the airplane and engine were issued in 2005. The airspeed indicator registered in knots on the outer scale, and mph on the inner scale. A representative of WINFC estimated the airplane weight at the time of the accident to be about 100 pounds below the maximum certificated gross weight of 2,300 pounds. According to information provided by the operator, the airplane had a total time in service of approximately 12,440 hours. The engine had a total time in service of approximately 2,820 hours, and had accumulated approximately 900 hours since its most recent overhaul. The most recent 100-hour inspection of the airplane was completed on June 24, 2010, and the most recent annual inspection was completed in February 2010. The airplane had accumulated approximately 135 hours in service since the most recent annual inspection, and approximately 35 hours in service since the most recent 100-hour inspection. METEOROLOGICAL INFORMATION No weather broadcast or recording facilities were located at WA09. There were at least two windsocks at WA09; the one closest to airplane during the run-up was located about 410 feet east of the runway 7 threshold, and about 80 feet south of the runway centerline. That windsock was situated about 200 feet northwest of a stand of trees. The next closest windsock was approximately 2,400 feet east of the runway 7 threshold. Commercially available recorded weather information for the town of Roche Harbor included winds of 5 knots from 270 degrees, and a temperature of about 25 degrees C. About the time of the accident, the recorded weather at an airport 5 miles north of WA09 included winds of about 13 knots from 160 degrees. The recorded weather at an airport 7 miles southeast of WA09 included calm winds, and a temperature of about 21 degrees C. The recorded weather at an airport 10 miles northeast of WA09 included winds of about 11 knots from 220 degrees, and a temperature about 20 degrees C. AIRPORT INFORMATION According to commercially available information, WA09 was a private airport with a single runway, and required pilots to have prior permission to land. The runway dimensions were listed as 3,593 feet by 30 feet, and the surface was cited as "asphalt, in fair condition." The published obstacle information for runway 7 was stated as "160 ft. tree, 1136 ft. from runway, 75 ft. left of centerline." Although no FAA data regarding the runway slope was available, commercially available topographic data indicated that the runway 7 threshold elevation was 87 feet above mean sea level (msl), and the runway 25 threshold elevation was 156 feet msl, for an elevation difference of 69 feet. WRECKAGE AND IMPACT INFORMATION According to information provided by law enforcement and FAA personnel, the airplane struck trees, descended to the ground, and came to rest in a steep nose-down attitude. The fuselage was buckled at the tailcone and in the cabin area. The left wing was displaced aft, crumpled, and partially separated from the fuselage. The nose, right wing, and horizontal stabilizer were crumpled in the aft direction. Both wing flaps remained extended equally, and the cockpit flap position indicator reading registered approximately 22 degrees. One blade of the propeller was bent forward, and one was bent aft; both exhibited some chordwise scoring. Recovery personnel reported that tree branch segments with cut ends were found in the immediate vicinity of the wreckage. The terrain elevation at the accident location was approximately 180 feet msl, and the trees were approximately 50 feet tall. TESTS AND RESEARCH Engine Post accident examination of the engine was cond

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