NTSB CEN12LA059 — 2011-11-11 · Sturgis, South Dakota, United States

Aircraft involved

N13584 Cessna 172M Fatal

Probable cause & findings

The student pilot’s failure to maintain control of the airplane during takeoff with extended flaps.

Factual narrative

HISTORY OF FLIGHT

On November 11, 2011, about 0905 mountain standard time, N13584, a Cessna 172M, operated by Bear Butte Flying Club, piloted by a student pilot, sustained substantial damage on impact with terrain following a loss of control during climbout from runway 29 (5,100 feet by 60 feet, dry/concrete) at the Sturgis Municipal Airport (49B), near Sturgis, South Dakota. The instructional flight was operating under 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed at the time of the accident. No flight plan was on file. The pilot sustained fatal injuries. The local flight originated from 49B about 0800 and was taking off at the time of the accident. The student pilot’s certified flight instructor (CFI) stated that during the student pilot’s second solo landing, the airplane was stopped on the runway and the airplane’s flaps were not raised before the next takeoff. The airplane was observed after takeoff to rotate up to 60 degrees pitch up. According to the CFI, the airplane’s engine sounded like it was developing full power. The airplane was observed in a half-turn spin prior to when it impacted terrain vertically.

PERSONNEL INFORMATION

The pilot held a student pilot certificate. He held a Third Class Medical Certificate dated September 29, 2011. A limitation on his medical certificate indicated that he must wear corrective lenses to exercise the rights of his certificate. His logbook endorsements indicated that he had accumulated 9.6 hours of total flight time of which 0.4 hours of flight time was as pilot-in-command.

AIRCRAFT INFORMATION

N13584 was a 1973 Cessna model 172M airplane with serial number 17262858. The airplane was a high wing, all-metal, single-engine, four-place monoplane. It had a fixed tricycle landing gear configuration, and was powered by a naturally aspirated four-cylinder, Lycoming O-320-E2D engine, bearing serial number L-36653-27A, and marked as producing 150-horsepower. A review of Federal Aviation Administration (FAA) airworthiness documents revealed that the engine was converted to 160-horsepower using the SA2375SW and SE3692SW supplemental type certificates. The airplane had its most recent annual inspection performed on July 15, 2011. At the time of that annual inspection, the airplane accumulated 6,546 hours of total time and the airplane’s engine accumulated 1,180 hours of time since a major overhaul.

METEOROLOGICAL INFORMATION

At 0855, the recorded weather at the Ellsworth Air Force Base, near Rapid City, South Dakota, was: Wind 240 degrees at five knots; visibility 10 statute miles; sky condition clear; temperature 11 degrees C; dew point -10 degrees C; altimeter 29.76 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

The airplane came to rest on the grass south of runway 29. FAA inspectors, assisted by safety representatives from the airplane manufacturer and engine manufacturer, conducted an on-scene postaccident examination of the wreckage. Flight control continuity was established except for separations consistent with overload and damage consistent with impact crushing. Control continuity was established to the engine. The engine exhibited a thumb compression at all cylinders when its crankshaft was rotated. The tachometer indicated 6,570.3 hours. The flap jackscrew was observed and its thread extension of 4.6 inches indicated that the flaps were extended about 30 degrees. No airplane or engine preimpact anomalies were detected.

MEDICAL AND PATHOLOGICAL INFORMATION

An autopsy was performed on the pilot at the Clinical Laboratory of the Black Hills. That autopsy indicated the pilot’s cause of death was due to blunt trauma injuries sustained in an airplane crash. The FAA Civil Aerospace Medical Institute prepared a Final Forensic Toxicology Accident Report. That report indicated: 19.72 (ug/ml, ug/g) Acetaminophen detected in Urine Diphenhydramine detected in Urine Diphenhydramine NOT detected in Blood The FAA Forensic Toxicology's WebDrugs website description of Acetaminophen, in part, stated: Acetaminophen is a common over the counter analgesic/antipyretic (Tylenol). It is available in many oral dosage forms and in combination with various decongestants and/or antihistamines. It is also available by prescription in combination with various opiate derivatives. Large doses of acetaminophen can produce hepatotoxicity. People who use moderate amounts of ethanol on a regular basis have a greater risk of acetaminophen-induced hepatotoxicity. The FAA Forensic Toxicology's WebDrugs website description of Diphenhydramine indicated it was a common over the counter antihistamine used in the treatment of the common cold and hay fever.

ADDITIONAL INFORMATION

N13584 was involved in a previous accident listed in the NTSB database as report number CHI01LA051. That report, in part, indicated that the elevator trim tab and the cockpit trim indicator were not consistent with each other. It was reported that when the pilot aligned the indicator for a takeoff setting, the actual trim surface was in a full nose down position. A postaccident review of the maintenance records subsequent to this accident found no history of unresolved airworthiness issues. The flight instructor stated that during the student pilot’s second solo landing, the airplane’s flaps were not retracted before the next takeoff. After takeoff, the airplane pitched up to a 60-degree nose-up attitude. According to the flight instructor, the airplane’s engine sounded like it was developing full power. The airplane entered a half-turn spin and impacted the terrain vertically. Postaccident examination showed that the flaps were extended and revealed no evidence of preimpact mechanical malfunction or anomaly that would have precluded normal operation. Toxicology tests detected acetaminophen and diphenhydramine in the pilot's urine. Although diphenhydramine can cause drowsiness, the investigation could not determine whether it contributed to the accident. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12

NTSB Findings

FAA avdata. C = Cause, F = Factor.

C Aircraft-Aircraft structures-Wing structure-Trailing edge flaps-Incorrect use/operation - C
C Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Pitch control-Not attained/maintained - C
C Personnel issues-Action/decision-Action-Incorrect action performance-Student pilot - C
— Personnel issues-Experience/knowledge-Experience/qualifications-Total experience-Student pilot

Verbatim from NTSB's published report. Source file NTSB_2011_CEN12LA059.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

Search this event elsewhere

External sources are reported, not agency: signal that something happened, not fact about what happened.

Related research

Matched on aircraft type or causal vocabulary (loss of control, maintenance). All research papers