NTSB CAROL · Event
Event CEN21FA364
Aircraft involved
Probable cause & findings
The pilot’s failure to maintain control of the airplane with full flaps during the takeoff.
Factual narrative
HISTORY OF FLIGHTOn August 9, 2021, about 1115 central daylight time, a Cessna 210H airplane, N5940F, was destroyed when it was involved in an accident near Melbourne, Arkansas. The private pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot intended to fly the airplane from Melbourne Municipal Airport (42A), Melbourne, Arkansas, to his home airport 60 miles away in Heber Springs, Arkansas. A witness, who was at the departure airport, reported observing the pilot conduct a preflight of the airplane and taxi to runway 21 for takeoff. The witness stated that the airplane seemed to have an extended takeoff roll, and then he observed the airplane lift off near the departure end of the runway. No radio or distress calls were heard from the pilot. At the time of the accident, the departure airport’s UNICOM radio receiver was not staffed and did not have the capability to record. AIRCRAFT INFORMATIONAccording to the Cessna Turbo-System Centurion Owner’s Manual, at a gross weight of 3,400 pounds (maximum gross weight), the airplane’s stall speed at 0° of bank with the landing gear down and the flaps retracted was 74 mph. With the landing gear down and the flaps fully down (30o), the stall speed was 63 mph. With 30o of bank, the gear down, and the flaps fully down, the stall speed was 68 mph. With 60o of bank, the gear down, and the flaps fully down, the stall speed was 89 mph. The before takeoff checklist stated that flaps should be set between 0 o (flaps up) and 20o (maximum performance takeoff configuration). The takeoff discussion does not reference any flap setting greater than 20o. The owner’s manual stated that, for a balked landing (go-around) climb, the flaps should be reduced to 20o immediately after full power is applied. The manual also stated that, after all obstacles are cleared and a safe altitude and airspeed are obtained, the flaps should be retracted. The owner’s manual only cited two uses for full flaps (30o): shortfield landings and the emergency landing procedure with a defective nose gear. The field elevation at 42A was 734 ft. Runway 21 was 4,003 ft long. The temperature was 89.6oF (32oC), the dew point was 75oF (24oC), and the altimeter was 30.01 inches. On the basis of this information, at 3,400 pounds and with 20o of flaps and no headwind, the airplane would have a takeoff ground run of about 920 ft, and the distance needed to clear a 50ft obstacle would be 1,708 ft. AIRPORT INFORMATIONAccording to the Cessna Turbo-System Centurion Owner’s Manual, at a gross weight of 3,400 pounds (maximum gross weight), the airplane’s stall speed at 0° of bank with the landing gear down and the flaps retracted was 74 mph. With the landing gear down and the flaps fully down (30o), the stall speed was 63 mph. With 30o of bank, the gear down, and the flaps fully down, the stall speed was 68 mph. With 60o of bank, the gear down, and the flaps fully down, the stall speed was 89 mph. The before takeoff checklist stated that flaps should be set between 0 o (flaps up) and 20o (maximum performance takeoff configuration). The takeoff discussion does not reference any flap setting greater than 20o. The owner’s manual stated that, for a balked landing (go-around) climb, the flaps should be reduced to 20o immediately after full power is applied. The manual also stated that, after all obstacles are cleared and a safe altitude and airspeed are obtained, the flaps should be retracted. The owner’s manual only cited two uses for full flaps (30o): shortfield landings and the emergency landing procedure with a defective nose gear. The field elevation at 42A was 734 ft. Runway 21 was 4,003 ft long. The temperature was 89.6oF (32oC), the dew point was 75oF (24oC), and the altimeter was 30.01 inches. On the basis of this information, at 3,400 pounds and with 20o of flaps and no headwind, the airplane would have a takeoff ground run of about 920 ft, and the distance needed to clear a 50ft obstacle would be 1,708 ft. WRECKAGE AND IMPACT INFORMATIONThe accident site was located about 3,500 ft from the departure end of the runway on a magnetic heading of 188°, as shown in the figure below. Figure. Accident site location in relation to 42A. Examination of the wreckage showed that the airplane impacted several large 80-ft-tall trees before it came to rest on the ground. Pieces of the right elevator and right horizontal stabilizer were found embedded in tree branches about 20 ft above the ground. The fuselage, wings, and engine were laying on the ground adjacent to a large tree. Most of the airframe was consumed by the postimpact fire. The engine was found separated from the fuselage about 4 ft from the main wreckage. The engine was mostly intact and had minor fire damage. Several cut branches observed in the trees were consistent with propeller blade strikes. The propeller remained attached to the engine at the flange. All three blades showed S-bending, chordwise rubs and scratches, and leading-edge nicks. Flight control continuity was confirmed from all control surfaces to the cockpit. Further examination of the airframe showed that the flap actuator was in the fully extended position (30°). The elevator trim actuator was measured at a 2inch extension, which was consistent with a 20° nose-down position. The engine was examined, and no pre-impact anomalies were found. ADDITIONAL INFORMATIONAfter the accident, 42A installed radio transmission recording capability on its UNICOM frequency. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy of the pilot was performed by the State Crime Lab, Medical Examiner Division, Little Rock, Arkansas. His cause of death was multiple blunt force injuries. Toxicology testing by the Federal Aviation Administration Forensic Sciences Laboratory identified no tested-for drugs. The pilot’s glucose (sugar) was 144 mg/dL in vitreous specimens and 195 mg/dl in urine specimens. The pilot’s hemoglobin A1C (HbA1c) blood level was 7.2%. The FAA considers glucose levels in vitreous and urine specimens to be abnormal if above 125 and 100 mg/dL, respectively. HbA1c is an indirect measure of a person’s average blood sugar during the preceding 3 months. Generally, an HbA1c of 6.5% or higher indicates diabetes, and an HbA1c of less than 7% indicates control of diabetes. The pilot was conducting a personal flight to his home airport. A witness at the departure airport reported observing the pilot conduct a preflight examination of the airplane and then taxi the airplane to the runway for takeoff. The witness stated that the airplane seemed to have an extended takeoff roll and that the airplane lifted off near the departure end of the runway. Witnesses who were located beyond the departure end of the runway reported that the airplane was flying low and seemed to be turning just before it crashed. The airplane impacted trees and terrain. A postcrash fire ensued and destroyed the airplane. Postaccident examination of the airframe and engine revealed no preimpact anomalies that would have precluded normal operations. The flap actuator was found in the fully extended position (30°). The elevator trim actuator was measured at a 2-inch extension, which was consistent with a 20° nose-down position. With the flaps fully extended, the airplane’s ability to climb and maneuver was significantly degraded. As a result, the pilot was unable to maintain airplane control while making a turn at a low altitude after liftoff. Postmortem toxicology testing showed that the pilot’s hemoglobin A1C level was 7.2%, which indicated the pilot’s diabetes was uncontrolled (but not severely) during the months before the accident. His elevated glucose (sugar) level placed him at risk for fatigue, dehydration, and blurred vision. The investigation could not determine whether the pilot’s uncontrolled diabetes impaired his ability to properly monitor the airplane’s configuration and safely perform the takeoff and climb. Source: NTSB Aviation Accident Database Retrieved: 2026-02-12
NTSB Findings
Hierarchical cause / factor breakdown from the FAA bulk avdata database. Each finding tagged C (Cause) or F (Factor).
- — Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot
- — Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Climb rate-Not attained/maintained
- — Personnel issues-Task performance-Use of equip/info-Use of equip/system-Pilot
- — Aircraft-Aircraft systems-Flight control system-(general)-Incorrect use/operation
Verbatim from NTSB's published report. Source file
NTSB_2021_CEN21FA364.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, go-around). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
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A Training Study to Improve Monitoring During A Go-Around
As part of an FAA program to improve go-around (GA) safety, we were asked to determine if we could improve the performance of the Pilot Monitoring (PM) during a GA maneuver.
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Go-Around Safety Forum Findings
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Two-dimensional square ice in graphene nanocapillaries at room temperature is a fascinating phenomenon and has been confirmed experimentally.
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Polycrystallinity enhances stress build-up around ice
Damage caused by freezing wet, porous materials is a widespread problem, but is hard to predict or control. Here, we show that polycrystallinity makes a great difference to the stress build-up process…
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