NTSB CAROL · Event
Event GAA19CA549
Registry · N4584N
FAA Aircraft Registry record.
Make / Model
CESSNA L-19E
Seats / Engines
2 seats · 1 engine
Last airworthiness date
19840201
ADS-B equipped
Yes — Mode-S A592C5
Registrant of record
LEADING EDGE LLC
Source: FAA Aircraft Registry (releasable master file).
Aircraft involved
Probable cause & findings
The pilot's failure to install the engine oil filler cap before the first flight of the day; his subsequent failure to conduct a preflight check before the accident flight, which resulted in his failure to note that the cap was not installed; and his improper landing flare during a precautionary landing, which resulted in a bounced landing and ground loop.
Factual narrative
The pilot in the tailwheel-equipped airplane reported that, during post-flight maintenance he left the oil filler cap off. Subsequently, during takeoff, he realized that the oil filler cap was not installed. The pilot noticed a decrease in oil pressure and made a precautionary landing at a nearby airport. During landing, the airplane landed hard, bounced, and the landing gear collapsed. The airplane skidded off the right side of the runway, and ground looped to the right. The left wing struck the ground before the airplane stopped. The airplane sustained substantial damage to the main rotor blades. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The pilot reported that, during takeoff for the accident flight, which was the second flight of the day, he saw that the oil pressure was falling and realized it was likely due to his failure to install the engine oil filler cap after checking the oil during the first flight of the day. He did not conduct a preflight checklist before the accident flight. He subsequently made a precautionary landing at a nearby airport. During the landing, the airplane bounced, and the landing gear collapsed. The airplane bounced again, skidded off the right side of the runway, and ground looped. The left wing struck the ground before the airplane stopped. The airplane sustained substantial damage to the main rotor blades. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. 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-Use of equip/system-Pilot - C
- C Personnel issues-Action/decision-Action-Forgotten action/omission-Pilot - C
- C Personnel issues-Task performance-Use of equip/info-Use of checklist-Pilot - C
- C Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot - C
- C Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Landing flare-Incorrect use/operation - C
Verbatim from NTSB's published report. Source file
NTSB_2019_GAA19CA549.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, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2023 · Conference paper
The Value of Strong Partnerships to Build a Successful Aviation Maintenance Career Pathway Program for Transitioning Military Service Members
The aerospace industry is competing with other industries for a qualified workforce, and many of those competing industries are investing heavily in creating workforce development pipelines.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- 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 …
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
Browse the full corpus — academia portal ↗