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Atlas / NTSB / GAA19CA549

NTSB CAROL · Event

Event GAA19CA549

2019-09-15 Kennett, Missouri, United States Airport · TKX None 1 aircraft Status: Completed

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 ↗.

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.

Browse the full corpus — academia portal ↗