NTSB CAROL · Event
Event ERA18LA191
Aircraft involved
Probable cause & findings
The pilot's failure to properly set the elevator trim before takeoff, which resulted in an exceedance of the airplane's critical angle of attack during takeoff and a subsequent aerodynamic stall. Contributing to the accident was the pilot’s failure to follow the Before Takeoff—Run Up checklist.
Factual narrative
On July 13, 2018, about 1800 eastern daylight time, a Cessna 182T, N291CP, was substantially damaged during takeoff from Geneseo Airport (D52), Geneseo, New York. The commercial pilot sustained serious injuries and the two passengers sustained minor injuries. The airplane was operated by the Civil Air Patrol (CAP) as a familiarization flight conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight.The pilot reported that earlier during the day of the accident, he completed a flight from Greater Rochester International Airport (ROC), Rochester, New York, to D52 uneventfully and did not use the autopilot during that flight or the accident flight. The purpose of the accident flight was to provide a familiarization flight to two CAP cadets. The pilot showed the cadets a thorough preflight inspection and then started the engine and taxied to runway 23. Prior to takeoff, the pilot performed an engine run-up and verified that all flight controls were free and correct. The pilot then initiated a soft-field takeoff procedure on the bumpy grass runway. The airplane became airborne in ground effect about 45 knots and everything seemed normal as it began to climb out of ground effect at 60 knots. At that time, the nose pitched up abruptly and the pilot pushed the yoke forward as hard as he could while engaging nose-down electric elevator trim; however, the airplane continued to climb at an excessive angle-of-attack and stalled. It subsequently rolled left, descended to the ground and came to rest inverted. Both passengers were minors and interviewed separately by a Federal Aviation Administration (FAA) inspector in the presence of a parent. One passenger did not recall the pilot doing a preflight inspection, use a checklist, or perform any type of check and engine run-up prior to takeoff. The other passenger recalled an abbreviated preflight inspection and use of a checklist before and after engine start; however, he did not recall any stopping prior to entering the runway, engine run-up, or control check except for flaps moving. Both passengers sustained concussions in the accident. Initial examination of the wreckage by an FAA inspector revealed damage to both wings and the fuselage. The inspector measured the elevator trim actuator arm, which corresponded to a 10° tab-up (nose-down) trim position. The maximum tab-up position was 24°, plus or minus 2°. The inspector also recovered a memory card from the airplane's multifunction display; however, download and review of the data revealed that the last recorded flight was in 2016. The wreckage was subsequently up-righted and recovered by the operator. The FAA inspector examined the wreckage again with a representative from the airframe manufacturer. All control surfaces were moveable by hand. All flight control cables were intact and attached to their respective flight and cockpit controls except left aileron cable, which had separated between the front door post and instrument panel, in the area of the fuselage separation. The separated ends of the left aileron cable exhibited a broom-straw appearance. The rudder and elevator cables and their routing area were visually examined throughout the length of the airplane. The elevator and elevator trim autopilot servos could be moved by hand. No preimpact impediments to the movement of the control yokes were observed between the firewall and instrument panel and no preimpact abnormalities were observed during the examination. Review of the operator's "Before Takeoff – Run-Up" checklist revealed, "…20. Elevator & Rudder Trim…Take Off…" The recorded weather at ROC, at 1754, included wind from 220° at 7 knots, visibility 10 miles and scattered clouds at 14,000 feet. The commercial pilot reported that, before the accident flight, he repositioned the airplane uneventfully from an airport about 20 miles away. Before takeoff on the accident flight, the pilot performed an engine run-up and verified that all flight controls were free and correct. The pilot then initiated a soft-field takeoff procedure on a bumpy, grass runway. The airplane became airborne in ground effect about 45 knots, and it then began to climb out of ground effect at 60 knots. At that time, the airplane’s nose pitched up abruptly, and the pilot pushed the yoke forward as hard as he could while engaging nose-down electric elevator trim; however, the airplane continued to climb at an excessive angle of attack and subsequently stalled. The airplane then rolled left, descended to the ground, and came to rest inverted. Neither passenger could recall whether the pilot conducted any type of control check or engine run-up before takeoff. Examination of the wreckage did not reveal evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The elevator trim tab was found in a midrange, nose-down position, consistent with the pilot’s statement that he was trimming nose down in an attempt to recover from the loss of control on takeoff. The Before Takeoff – Run-Up checklist stated that the elevator should be trimmed to 20° nose down for takeoff. Given the airplane pitched up abruptly as it began to climb out of ground effect, it is likely that the pilot landed after the previous flight with a nose-up elevator trim setting and that he did not properly reset the elevator trim before takeoff for the accident flight in accordance with the Before Takeoff—Run-Up checklist, which resulted in an exceedance of the airplane’s critical angle of attack during takeoff and the subsequent aerodynamic stall. 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-Task performance-Use of equip/info-Aircraft control-Pilot - C
- C Personnel issues-Task performance-Use of equip/info-Use of checklist-Pilot - C
- C Aircraft-Aircraft systems-Flight control system-Elevator tab control system-Incorrect use/operation - C
Verbatim from NTSB's published report. Source file
NTSB_2018_ERA18LA191.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, loss of control, autopilot). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Semantic Scholar 2016 · Article (Interacción)
Trajectory Recovery System: Angle of Attack Guidance for Inflight Loss of Control
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- NTSB Aircraft Accident Reports 2010 · Accident report
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Colgan Air 3407 / Continental Connection (Q400) Buffalo NY, February 12, 2009 — 50 fatalities. Definitive investigation of the Colgan 3407 stall-stick-pusher crash on approach to Buffalo.
- arXiv 2026 · arXiv preprint
Robust Adaptive Sliding-Mode Control for Damaged Fixed-Wing UAVs
Many unmanned aerial vehicles (UAVs) can remain aerodynamically flyable after sustaining structural or control surface damage, yet insufficient robustness in conventional autopilots often leads to mis…
- NASA NTRS 2026 · Conference Paper
Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
This study presents a computational investigation of steady state aerodynamics of the Subsonic Ultra-Green Aircraft Research (SUGAR) Transonic Truss-Braced Wing (TTBW) configuration over a wide range …
- Embry-Riddle Scholarly Commons 2025 · Journal article (JAAER)
A Scoping Review of Aviation Loss of Control Inflight Research
Loss of control – inflight (LOC-I) contributes to aircraft accidents at unacceptably high rates. Significant industry efforts and research have aimed to improve LOC-I prevention, detection, and recove…
- arXiv 2025 · arXiv preprint
ROSflight 2.0: Lean ROS 2-Based Autopilot for Unmanned Aerial Vehicles
ROSflight is a lean, open-source autopilot ecosystem for unmanned aerial vehicles (UAVs). Designed by researchers for researchers, it is built to lower the barrier to entry to UAV research and acceler…
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