NTSB CAROL · Event
Event ERA15CA152
Aircraft involved
Probable cause & findings
The pilot's failure to use any airport guidance while taxiing, which resulted in geographic disorientation and a takeoff attempt from an inadequate length and unsuitable surface.
Factual narrative
According to the pilot, the runway he intended to depart from was parallel to the taxiway and parking ramp. He assumed that after making two right turns he would be on the runway. He reported that he did not have any airport diagrams to navigate with, while operating on the airport movement area. Following his second right turn he noticed a runway sign, announced his intention to depart over the common traffic advisory frequency, taxied onto what he assumed was the runway, observed "faded yellow chevrons," and added power for takeoff. During the takeoff roll the pilot observed crossing the runway he assumed he was on, and the paved surface he was on was ending. He retarded the throttle and applied brakes. The airplane exited the paved surface and nosed over, coming to rest inverted; which resulted in substantial damage to the fuselage, left wing, and vertical stabilizer. The pilot reported no mechanical abnormalities or malfunctions that would have precluded normal operation. The airport diagram, and the pilot's own drawing of the accident event, revealed the need to make three right turns prior to being on the runway. According to a Federal Aviation Administration inspector, that traveled to the accident location, the runway was "clearly identifiable" and the markings were visible. According to the pilot, the runway he intended to depart from was parallel to the taxiway and parking ramp. He assumed that after making two right turns he would be on the runway. He reported that he did not have any airport diagrams to navigate with, while operating on the airport movement area. Following his second right turn he noticed a runway sign, announced his intention to depart over the common traffic advisory frequency, taxied onto what he assumed was the runway, observed "faded yellow chevrons," and added power for takeoff. During the takeoff roll the pilot observed crossing the runway he assumed he was on, and the paved surface he was on was ending. He retarded the throttle and applied brakes. The airplane exited the paved surface and nosed over, coming to rest inverted; which resulted in substantial damage to the fuselage, left wing, and vertical stabilizer. The pilot reported no mechanical abnormalities or malfunctions that would have precluded normal operation. The airport diagram, and the pilot's own drawing of the accident event, revealed the need to make three right turns prior to being on the runway. According to a Federal Aviation Administration inspector, that traveled to the accident location, the runway was "clearly identifiable" and the markings were visible. 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).
- C Personnel issues-Action/decision-Info processing/decision-Identification/recognition-Pilot - C
- C Personnel issues-Experience/knowledge-Knowledge-Knowledge of geographic area-Pilot - C
- C Personnel issues-Psychological-Perception/orientation/illusion-Situational awareness-Pilot - C
- C Personnel issues-Psychological-Perception/orientation/illusion-Geographic disorient (lost)-Pilot - C
- C Environmental issues-Operating environment-Airport facilities/design-Runway/landing area length-Awareness of condition - C
Verbatim from NTSB's published report. Source file
NTSB_2015_ERA15CA152.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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