National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

Fountain, FL

Accident Number:

ERA14FA255

Date & Time:

05/25/2014, 0923 CDT

Registration:

N43113

Aircraft:

PIPER PA-28-140

Aircraft Damage:

Substantial

Defining Event:

Aerodynamic stall/spin

Injuries:

3 Fatal, 1 Serious

Flight Conducted Under:

Part 91: General Aviation - Personal

Analysis

The pilot was conducting a local personal flight in the airplane with three passengers onboard. He was departing from a turf and sand-covered runway that had a usable length of 2,600 ft. Although a relatively clear area was located beyond one end of the runway, the pilot elected to depart in the opposite direction toward a heavily forested area with trees that were about 70 ft tall. After a takeoff run requiring about half of the runway's available length, the airplane began climbing at an abnormally steep angle. The airplane climbed above the trees at the departure end of the runway, stopped climbing, rolled to the right, descended into the trees, and impacted the ground. A post-impact fire consumed the majority of the airplane. Examination of the wreckage at the accident site revealed no evidence of any preimpact mechanical failures or malfunctions of the airframe or engine that would have precluded normal operation.

Review of video recorded both onboard and from outside the airplane showed that the pilot did not use the manufacturer's recommended procedure for a takeoff from a turf (soft) runway with obstacles ahead.  The procedure called for 25 degrees of flaps, and the pilot used no flaps. Further, the procedure called for the pilot to raise the nose wheel off the ground as soon as possible, take off at the lowest possible airspeed, and accelerate to 78 mph before climbing; the pilot did none of these steps. The video also showed that the pilot elected to depart with a slight prevailing tailwind. While the estimated velocity of the tailwind was only 3 knots, this tailwind may have increased the airplane's takeoff distance by as much as 15 percent. Additionally, the calculated density altitude of 1,900 ft resulted in an estimated additional 20 percent increase in the takeoff distance and an estimated 10 percent reduction in rate of climb once the airplane was airborne.

The video showed that, during the takeoff, the engine tachometer indicated an rpm of about 2,000, which was less than the published minimum static rpm of 2,325 for the engine at its maximum throttle setting. While the accuracy of the tachometer's calibration could not be verified due to damage sustained during the accident, one potential cause for this discrepancy was the position of the carburetor heat selector handle. Video and statements from the airplane's owner suggest that the pilot had left the selector in an intermediate position, although the appropriate position for the takeoff phase of flight was the off position. Taking off with the selector in an intermediate position would potentially result in a loss of engine performance consistent with that observed on the tachometer.

 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's decision to depart from a soft runway with a tailwind and toward obstructions, and his failure to follow the manufacturer's recommended procedures for the takeoff. Contributing to the accident were the degradation of airplane and engine performance due to the high density altitude and the pilot's failure to properly configure the airplane's carburetor heat.

Findings

Personnel issues

Decision making/judgment - Pilot (Cause)

Use of policy/procedure - Pilot (Cause)

Use of equip/system - Pilot (Factor)

Environmental issues

High density altitude - Effect on operation (Factor)

Tailwind - Effect on operation

Factual Information

HISTORY OF FLIGHT

On May 25, 2014, about 0923 central daylight time, a Piper PA-28-140, N43113, was substantially damaged when it impacted trees and terrain after a loss of control during initial climb at Maran Airport (68FD), Fountain, Florida. The pilot was seriously injured and his three passengers were fatally injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight conducted under Title 14 Code of Federal Regulations (CFR) Part 91.

On the day of the accident, the pilot conducted two flights with passengers at 68FD. On the first flight, he had one adult male and two small children on board. On the second flight the pilot also had three passengers on board but, this time the passengers were a young male, and two adult females.

The takeoffs at 68FD were performed by the pilot on runway 27, which was a turf-covered runway. Trees existed at the departure end of the runway that were part of a heavily forested area, which extended to the west of the airport.

According to witnesses, during the second flight's takeoff, after a ground roll of approximately 1,200 feet, the airplane rotated and the pilot had the "nose up pretty much." One of the witnesses who observed this began to verbalize that the pilot should "get the nose down." When the airplane reached the trees at the end of the runway, it cleared them. Moments later the witnesses observed that the airplane had begun to sink into the tops of the trees and then roll to the right. It then disappeared from sight, and the sound of impact was heard. Black smoke then rose up from behind the trees.

PERSONNEL INFORMATION

The pilot held a Federal Aviation Administration (FAA) private pilot certificate with a rating for airplane single-engine land. His most recent FAA third-class medical certificate was issued on May 5, 2014. He reported on that date that he had accrued approximately 148 total flight hours, 70 of which were as pilot-in-command.

AIRCRAFT INFORMATION

The accident aircraft was 4-seat, single engine, low wing, fixed gear, monoplane of conventional metal construction

According to FAA records, the airplane was manufactured in 1974, and at the time of manufacturer was equipped with a 4-cylinder, air-cooled, horizontally opposed, normally aspirated, 150 horsepower Lycoming O-320-E3D engine.

The airplane was involved in a previous accident on December 4, 1993 (NTSB Case No. MIA94LA035) when during landing, the airplane struck a canal bank just short of a runway and was substantially damaged. According to maintenance records, approximately 19 years later, on April 29, 2012, the repairs for the structural damage to the wings, fuselage, and landing gear, from the accident were completed.

On July 20, 2012, in accordance with an Avcon Conversions supplemental type certificate (STC), A Lycoming O-360-C4E engine that had been modified into an O-360-A4M engine configuration producing 180 horsepower, was installed.

The airplane's most recent annual inspection was completed on October 1, 2013. At the time of accident, the airplane had accrued approximately 2,906 total hours of operation, and the engine had accrued 6 hours of operation since overhaul. The airplane's most current weight & balance was calculated in 1992.

Computations using the data supplied with the engine modification STC, the propeller, estimated weights of the occupants, 40 gallons of fuel, and data from the last known weight and balance check in 1992 indicated that, the airplane weighed approximately 2,242 pounds at takeoff, which was approximately 158 pounds below the maximum gross weight of 2,400 pounds listed in the STC.

METEOROLOGICAL INFORMATION

The recorded weather at Marianna Municipal Airport (MAI), Marianna, Florida, located 21 nautical miles northeast of the accident site, at 1453, included: winds 100 at 7 knots, 10 miles visibility, skies clear, temperature 32 degrees C, dew point 18 degrees C, and an altimeter setting of 30.10 inches of mercury.

The recorded weather at Northwest Florida Beaches International Airport (ECP), Panama City, Florida, located 24 nautical miles southwest of the accident site, at 1453, included: winds 030 at 3 knots, 10 miles visibility, skies clear, temperature 32 degrees C, dew point missing, and an altimeter setting of 30.09 inches of mercury.

The calculated density altitude at 68FD was approximately 1,900 feet. Review of an FAA Koch chart indicated that due to the density altitude the airplane would have incurred a 20-percent increase in normal takeoff distance, and a 10 percent decrease in rate of climb.

AIRPORT INFORMATION

Maran Airport was a privately-owned, uncontrolled airport, located four miles northeast of Fountain, Florida. The airport elevation was 225 feet above mean sea level and there was one runway oriented in a 09/27 configuration.

Runway 27 was turf, and was in fair condition with areas that were sandy and devoid of turf. The total length was 5,280 feet long and 50 feet wide. At the time of the accident only 2,600 feet of its 5,280 foot runway was available for use due to flooding. Obstacles in the form of 70-foot-tall trees, and electric power transmission lines existed on the departure end of the runway. Examination of runway 09 revealed that a clearway devoid of obstructions existed beyond the departure end.

FLIGHT RECORDERS

The airplane was not equipped with either a cockpit voice recorder or flight data recorder, nor was it required to be., Video footage of the accident flight was captured by a witness on the ground,  and by passengers onboard the airplane during the accident flight.

Ground Witness Video Recording

The video began with the ground based observer standing behind and to the right of the aircraft as it idled in the parking area. The right flap was in the retracted/up position. Engine noise increased and the aircraft began to taxi. The aircraft briefly stopped after it began rolling without a reduction in engine noise. It then quickly began rolling again as it turned left to back taxi down the unpaved landing strip. At this time, the left flap came into view and appeared to be in the retracted/up position. The movement of the rudder during this turn was to the left and was consistent with the pilot inputting left rudder pedal to a ground steering turn. The airplane taxied normally as a white cloud of fine dust formed behind the airplane. There were no visible preaccident mechanical anomalies that would have precluded normal operation.

The video next cut to a view airplane at the far end of the runway. The airplane's engine could be heard at a high idle power setting. At approximately 02:06, an increase in engine noise was heard immediately followed by a slight decrease in engine noise followed by the sound quickly returning to roughly the original level. A second slight decrease in engine noise was heard with a quick recovery to the original noise level. The aircraft was then heard at an increased power level until approximately 02:30 when the engine noise could be heard reducing to a volume level consistent with a high idle power setting.

From 02:52 to 04:08; the video showed the airplane at the far end of the runway. Engine noise at this time was consistent with the airplane at a high power setting. A trail of fine white dust appeared behind the airplane as it began its takeoff roll and started moving toward the camera location at an increasing rate with the nose wheel on the ground. At 03:13.29 the airplane rotated and left the ground. The airplane then entered a steep positive pitch attitude as it continued to travel toward the departure end of the runway. At 03:18.28, the airplane was perpendicular to the ground camera observer in a steep positive pitch attitude. The airplane continued to travel toward the departure end of the runway in a steep pitch attitude slowly gaining altitude. By 03:29.22 the airplane's shadow crossed a stand of trees at the departure end of the runway. At this time, the shadow was consistent with the airplane being in the immediate region of the tree line at the departure end of the runway. Shortly after, at 03:33.20 the airplane was shown behind the first stand of trees as it moved further away from the camera. By 03:35.00 the airplane began rolling right from a previously slightly left wing high bank attitude. Around 03:37.01 the airplane again rolled slightly right. At 03:40.12 the camera operator accident captured a clear view of the windsock. Around the same group of frames multiple thuds are heard, followed by the sound of trees and or tree limbs cracking. The camera operator and bystanders react to what they have observed and no other useable information was captured. The recording ended at 04:08.21.

The airplane's pitch angle during the takeoff portion of flight was able to be estimated using still images from the witness's video recording. At 03:18.28, the accident airplane had become visually aligned with the ground camera operator. An electronic software method was used to replace measuring with a protractor. A still frame at 03:18.28 was chosen for this estimation when, the airplane was aligned normal to the camera's field of view. The video from this portion of the recording was cropped to a horizontal 16:9 format and rescaled to a larger size. This resulted in the image being magnified without distortion. A crop size and scale factor was chosen that would fill a 16:9 aspect ratio frame that included both the airplane and the ground in the same image. The orientation of the ground to the camera was modeled in the image measurement software using a singular line. Two points were chosen on either side of the image to account for the camera's rotation at the moment of image capture. Two points were also selected on a paint line along the fuselage that represented roughly a zero pitch angle when the aircraft was in level flight. Comparison of these lines indicated that the airplane was at an approximate 18 degree, nose up pitch angle when it passed by the camera.

Onboard Video Recordings

Video recordings were able to be recovered from a camcorder that was on the airplane during the accident flight. Review of the video recording showed that the position of the airplane's occupants were as follows:

- Male adult pilot: Left front seat

- Young male passenger: Front right seat

- Adult female passenger No.1: Rear left seat

- Adult female passenger No.2: Rear right seat

The videos were determined to be captured by both rear seat adult female passengers.

The first onboard video recording began with the airplane rolling out from the parking area near a parked low wing airplane, and a housing structure. The runway makeup was mostly turf with patches of sand scattered throughout. The airplane lined up on the runway to back taxi and came to a stop.

At the start of the second onboard video recording, the airplane was aligned with the runway and the pilot appeared to be engaged in an engine run-up procedure. Throughout the run-up portion of the video, different portions of the instrument panel were captured. Among numerous instrument indications, the following pertinent indications and settings were observed during this segment of the video:

- The master switch was in the "ON" position.

- The electric fuel pump switch was in the "ON" position.

- The fuel quantity indicators for both the left and right fuel tanks were reading near the top demarcation of both associated gauges.

- Oil pressure reading was approximately mid-range.

- Fuel pressure was approximately mid-range.

- Oil temperature was approximately mid-range.

- The mixture control was in the full rich position.

- Green colored painter's style tape was visible over the carburetor heat control lever. The lever appeared to be secured by the tape in a position somewhere between mid-range and the lever's travel towards the off position.

- The handle for the wing flaps was in the down position (flaps up position).

The next video began with the airplane at an unknown throttle setting and engine noise could be heard at a level consistent with a run-up check. The front passenger door appeared to be closed and secured. The pilot's right hand was on the throttle and he was looking down towards the tachometer which was indicating approximately 1,800 rpm.

The next video captured the following pertinent occurrences:

- At 00:03, a slight change in engine noise was detected and then quickly returned to a normal level by 00:06.

- At 00:07, a second engine noise level drop was heard and engine noise recovery was obtained around 00:10. During this time the frame rate of the camcorder detected recorded propeller motion consistent with the change in engine rpm.

- At 00:13, the pilot adjusted the attitude indicator.

- At 00:16, the pilot was holding and looking toward a white laminated checklist.

- At 00:17, the pilot reached toward the throttle quadrant with his right arm.

- At 00:21, the engine noise came down to a lower rpm setting, close to idle.

- At 00:30, the pilot stated, "controls free, watch yourself."

- At 00:32, the right control wheel was observed to turn to the right, then move aft, and then turn to the left, and then move forward in a wings level position.

- At 00:37, the camera panned to the right wing. The right wing flap was observed to be in the flaps up position.

- At 00:44, the carburetor heat control lever was observed to still be obscured by green colored painter's style tape in a position between mid-range and "OFF."

- At 00:46, the pilot looked at the checklist again.

- At 00:50, a clear shot of the carburetor heat control lever was visible again, and it was still in the same position.

- At 00:56, the pilot looked back at the laminated checklist.

- At 00:58, the pilot turned his head to the right and asked "…ready to go?" An unidentified rear seat female passenger then responded "we are" as the pilot placed the checklist between the left hand portion of the glareshield and the left windshield.

- At 01:01, the pilot turned toward the front of the airplane. His left hand was visible on the control wheel, and his right hand was briefly visible on the throttle, when an increase in engine noise consistent with the application of takeoff power began. The control wheel was in a neutral position as the takeoff roll began.

- At 01:03, the camera was pointing toward the young male passenger, and movement of the airplane along the grass runway was visible outside of the airplane's windows.

- At 01:08, the young male passenger's shoulder harness can be seen, and appeared unbuckled and hanging from the area of the right rear headliner.

- At 01:20, the pilot's right hand was on the throttle quadrant and the control wheel which was in an approximately neutral position.

- At 01:23, the airplane appeared to be rolling over a sandy portion of the mostly grass runway.

- At 01:24, the airplane began to rotate; a few thuds and camera motion consistent with the airplane in a light bounce were observed, and the manifold gauge was in the 12 o'clock position. The needle of the tachometer was shown in a position reading about a single needle width above 2,000 rpm and appeared steady.

- At 01:27, the camera pans right and the airplane appears to become completely airborne.

- At 01:32, the camera pans to the rear of the right wing and the wing flaps were observed to be in the retracted or "up" position.

- At 01:33 the windsock is captured for a few frames. The windsock was pointed in the direction of a tailwind relative to the takeoff runway and the tail of the windsock was slightly off the at rest position.

- At 01:37, the pilot had his right hand on the throttle, the attitude indicator displayed a nose up attitude, the altimeter indicated approximately 280 feet above mean sea level (msl), the airspeed indicator was in the 2 o'clock position, and the vertical speed indicator displayed a climb of slightly less than 400 feet per minute. At this time, the pilot's shoulder harness was observed secured around his left shoulder.

- At 01:41, the ignition key was observed in an orientation consistent with the magneto switch being in the "BOTH" position. The tachometer was still indicating approximately 2,000 rpm. The camera was panning back toward the right, looking out of the right front passenger window in front of the right wing. Tree tops were visible outside the airplane and the airplane appeared to be in a nose high attitude.

- At 01:45, the airplane appeared to be at the same altitude of the highest tree tops that were along the airplane's flight path. The airplane was traveling forward, and trees were seen passing outside the window swiftly as the airplane lost altitude in a nose high attitude. Power lines were visible out of the front right passenger's window, forward of the airplane.

- At 01:47, the airplane's pitch angle appears to increase, and the airplane settled lower toward the tree tops.

- At 01:49, the airplane's right wing brushed past a tree.

- At 01:50, the airplane's right wing brushed a second tree. The airplane was still pitched nose high and was now in a slight right wing down attitude. The airplane continued to brush tall trees as the altitude decreased and the right wing down attitude increased. A power line support tower became visible through the right front windscreen, just above the glare shield.

- At 01:51, the first sound of tree impact was clearly heard and branches were seen on the wing's upper surface. During this time, the airplane continued to roll toward the right. A few frames later, the airplane had rolled beyond 60 degrees right wing down as the airplane continued to be enveloped by trees as it lost altitude.

- At 01:52, the camera abruptly panned inside the cabin during the impact sequence. Adult female passenger No. 2's lap area was briefly shown where a beige stripe consistent with that of a lap belt was observed. In the same group of frames, the camera also captured a brief view toward the front of the cabin. The turn and slip indicator needle was observed to be pointing to the 1 o'clock position with the ball displaced to the far left portion of the race. The attitude indicator displayed a hard roll to the right, the altimeter indicated 320 feet msl, the vertical speed indicator indicated a slight climb, and the airspeed indicator was seen in the 2 o'clock position.

- At 01:54, the camera's exposure flashed to white and noises consistent with the airplane impacting the ground were heard.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site and wreckage revealed that the airplane first made contact with a group of 70-foot-tall trees with the outboard portion of the right wing, then yawed and rolled to the right. It then struck several other trees on a magnetic heading of 305 degrees, separating the left outboard portion of the horizontal stabilator. The airplane then struck terrain 80 feet later in a right wing down, nose low attitude, then rotated to the right around its vertical axis and came to rest on a 119-degree magnetic heading. It was then partially consumed by a postcrash fire. Further examination also revealed the presence of propeller strikes on broken tree branches and tree trunks that littered the ground, along with areas of burned underbrush and fire damaged trees along the flight path. No evidence of any preimpact failures of the airplane structure was discovered and all major portions of the airplane's structure were present at the accident site.

Control continuity was established from the control wheel to the ailerons and stabilator and from the rudder pedals to the rudder. The pitch trim setting was approximately 25 percent nose up trim or approximately 3 degrees of the available 11 degrees of nose up trim. The wing flaps were in the up position.

Examination of the propeller and engine revealed that engine came to rest nose low on its left side. The engine was fire-damaged and remained partially attached to the tubular engine mount. The propeller remained attached to the propeller flange. One propeller blade exhibited twisting, S-bending, and chord wise scratching and the other propeller blade displayed forward bending and chordwise scratching. The carburetor displayed thermal damage. No debris was present in the float bowl or carburetor inlet screen. Oil was present in the rocker boxes and oil sump, and the oil suction and pressure screens were absent of debris. Crankshaft and valve train continuity was confirmed and compression and suction was observed on all four cylinders. Examination of the interior of the cylinders with a lighted borescope did not reveal evidence of any preimpact damage to the piston domes, cylinder walls, or valves. The spark plugs were normal in appearance with the exception of the No. 2 and No. 4 cylinder's spark plugs, which were oil-soaked consistent with the engine's post-impact position. The magnetos were fire damaged and could not be tested.

MEDICAL AND PATHOLOGICAL INFORMATION

The pilot survived the accident with serious injuries. Toxicological testing of specimens obtained from the pilot was conducted by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens from the pilot were negative for basic, acidic, and neutral drugs with the exception of Etomidate, which is a general anesthetic and Midazolam which is a hypnotic benzodiazepine used as a preoperative sedative. Both drugs were administered to the pilot postaccident by medical personnel. The specimens from the pilot were not tested for cyanide, and were insufficient for analysis of Carbon Monoxide.

Autopsies were performed on the three deceased passengers by the State of Florida, Medical Examiner District 14. The listed causes of death were smoke inhalation and thermal injuries.

TESTS AND RESEARCH

Weather Effects

The barometric pressure and winds recorded at MAI and ECP, as well as images of the windsock captured on the onboard video indicated that a tailwind existed during the takeoff from runway 27. Further examination of the images of the windsock indicated that it was aligned with the wind and just off the at rest position. According to FAA Advisory Circular 150/5345-27D this indicated that the tailwind velocity was approximately 3 knots. According to the Pilot's Handbook of Aeronautical Knowledge (FAA-H-8083-25A), a tailwind component has almost five times the performance effect as a comparable headwind component and can increase takeoff distance by 10 percent for every two knots of tailwind component.

Performance Charts

The airplane had been changed from its original configuration by the STC, essentially converting it from a PA-28-140 to a pseudo PA-28-180. Review of the Pilot's Operating Manuals for both the PA-28-140 and PA-28-180 revealed that they both contained performance charts to determine density altitude, and takeoff performance.

The takeoff performance charts for the PA-28-140 were based on a flaps zero degree configuration on a paved, level, dry runway, with full power before brake release, and zero wind. At a weight of 2,150 pounds (92 pounds less than the calculated takeoff weight), approximate ground run on a paved runway would have been 1,063 feet, and approximate distance to clear a 50 foot obstacle would have been 2,188 feet.

The takeoff performance charts for the PA-28-180 was based on a flaps 25 degree configuration on a paved, level, dry runway, with full power before brake release, and zero wind. At a weight of 2,450 pounds (208 pounds more than the calculated takeoff weight), approximate ground run on a paved runway would have been 875 feet, and approximate distance to clear a 50 foot obstacle would have been 1,900 feet.

Carburetor Heat Control and Ground Check

According to the Airplane Flying Handbook (FAA-H-8083-3A), the pilot should ensure that the engine is operating properly, and that all controls, including flaps and trim tabs, are set in accordance with the before takeoff checklist.

The Pilot's Operating Manuals also advised in the "GROUND CHECK" to check the magnetos at 2,000 rpm by switching from 'BOTH" to "RIGHT," then back to "BOTH," before switching to "LEFT." Differential drop should not exceed 50 rpm while the total drop on either magneto should not exceed 175 rpm. Review of the onboard video indicated however, that the "GROUND CHECK" was performed by the pilot at 1,800 rpm instead of the required 2,000 rpm.

According to the engine manufacturer, the engine's rated speed was 2,700 rpm. The PA-28-180 pilot operating manual also indicated that the static rpm at maximum permissible throttle setting should not be less than 2,325 rpm. During the takeoff and climb however, the onboard video indicated that the tachometer was only indicating a little over 2,000 rpm.

The Pilot's Operating Manuals and Lycoming Engines Service Instruction 1148C also advised that the carburetor heat control lever was supposed to be in the "OFF" position for takeoff, to prevent a loss of power, due to variation in mixture, detonation, and preignition, and to keep dirt and foreign substances from being taken into the engine, as application of carburetor heat changed the flow of engine air from the outside air intake to unfiltered hot air from the heater muff. Review of the onboard video footage indicated that the carburetor heat control lever was in a position between mid-range and "OFF," and was taped over with green colored painter's style tape which would have precluded the pilot from checking the carburetor heat for proper operation during the "GROUND CHECK," from clearing any ice which may have formed during taxiing, and from moving the carburetor heat control lever to the "OFF" position during the "BEFORE TAKEOFF" check.

Takeoff and Climb

Review of the Pilot's Operating Manual for the PA-28-140 revealed that the manufacturer had provided procedures for "Soft Field, Obstacle Clearance" takeoff , stating; "Lower the flaps to 25 degrees (second notch), accelerate aircraft, pull nose gear off as soon as possible and lift off at lowest possible airspeed. Accelerate just above the ground to best angle of climb speed, 78 miles per hour to climb past obstacle clearance height; continue climb while accelerating to best rate of climb speed, 89 miles per hour and slowly retract the flaps."

Review of the Pilot's Operating Manual for the PA-28-180 revealed that it also provided guidance stating that "takeoffs are normally made with flaps up. However for short field takeoffs and for takeoffs under difficult conditions such as deep grass or on a soft surface, distances can be reduced appreciably by lowering flaps to 25 degrees." It goes on to say that "the best rate of climb at gross weight will be obtained at 85 mph. The best angle of climb may be obtained at 74 mph.

Pilot Interviews

During interviews conducted with the pilot, he advised that he had flown in to and out of the airport numerous times. Of the 10 takeoffs that he had done in the airplane, the first couple were performed with him and another person on board. He had three or four onboard during the others.

During the takeoff on the accident flight, he taxied all of the way down to the end of the runway, ran the engine up to full power with both feet on the brakes, and then released them. On Takeoff he noticed the windsock "oscillating a little". He rotated at approximately 50 knots (57 mph). He climbed out at 70 knots (80 mph). He did not use any flaps for the takeoff. During the climb, it seemed like someone was "pushing the tail from behind, pushing the airplane down into the trees." The pilot then "pulled back a little" on the control wheel, and the airplane "seemed to stall."

He further advised that he never used flaps during takeoff. The airplane owner had taught him to fly this particular airplane and taught him to do short and soft field takeoffs in it. He originally taught him to do them on a paved runway. The airplane owner also never talked about best angle of climb speed or best rate of climb speed. He would "just use conservative numbers" and would "climb out at 70 knots."

When asked why there was tape covering the carburetor heat control lever, the pilot stated the airplane owner advised that the linkage for the carburetor heat may not have been working, and that a friend told him "don't use it." When asked if he looked at the tachometer when he was taking off, he stated that the only thing he was looking at was the airspeed. When asked why he did not use flaps during the takeoff he stated that he felt more comfortable taking off "clean," and that when he flew with the airplane owner, he took off clean.

Airplane Owner

According to the airplane owner, he was an airframe and powerplant mechanic and he maintained the airplane. He stated that the weight and balance form was not up to date. When he bought the airplane it had a Lycoming O-320 in it, and they just worked off the old weight and balance form. He also stated that there was nothing wrong with the airplane, and that the tape over the carburetor heat control lever was to remind the pilot "not to mess with it" as "it was a little stiff" and that the pilot "did not need it as Lycoming suggests not using it unless you need it," and that "it would travel both ways, it was just a little stiff." He also advised that he did not teach the pilot how to fly the airplane as the pilot had learned in a previous "140" a few years before.

To check the pilot out in the airplane, he flew with him about 45 minutes on the Friday before the accident and also flew with him about an hour the Saturday before the accident. He believed that the pilot was aware of the amount of runway, and the trees at the end. They did not use flaps when they took off. He believed that weight should not have been a problem on the accident flight as he weighed 300 pounds. The airplane owner did note that when the pilot did their first takeoff, that he did get the "nose high," but on the next two takeoffs with him, "he did fine."

ADDITIONAL INFORMATION

Airspeed Indicator Anomaly

On January 28, 2016, on-board photographs from the flight prior to the accident were provided by a relative of the airplane's occupants. Review of these photographs revealed that four of the photographs that were taken in cruise flight, indicated that at the time that the photographs were taken, the airspeed indicator needle appeared to be pointing to approximately the at rest (zero airspeed) position. Review of the video taken during the accident flight showed that the airspeed indicator's needle was within a nominal range consistent with the phase of flight.

 

History of Flight

Takeoff

Miscellaneous/other

Initial climb

Aerodynamic stall/spin (Defining event)

Uncontrolled descent

Collision with terr/obj (non-CFIT)

Post-impact

Fire/smoke (post-impact)

 

 

Pilot Information

Certificate:

Private

Age:

36, Male

Airplane Rating(s):

Single-engine Land

Seat Occupied:

Left

Other Aircraft Rating(s):

None

Restraint Used:

 

Instrument Rating(s):

None

Second Pilot Present:

No

Instructor Rating(s):

None

Toxicology Performed:

Yes

Medical Certification:

Class 3 Without Waivers/Limitations

Last FAA Medical Exam:

05/02/2014

Occupational Pilot:

No

Last Flight Review or Equivalent:

05/02/2014

Flight Time:

148 hours (Total, all aircraft), 70 hours (Pilot In Command, all aircraft), 1 hours (Last 30 days, all aircraft)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

PIPER

Registration:

N43113

Model/Series:

PA-28-140

Aircraft Category:

Airplane

Year of Manufacture:

 

Amateur Built:

No

Airworthiness Certificate:

Normal

Serial Number:

287425334

Landing Gear Type:

Tricycle

Seats:

4

Date/Type of Last Inspection:

10/01/2013, Annual

Certified Max Gross Wt.:

2400 lbs

Time Since Last Inspection:

 

Engines:

1 Reciprocating

Airframe Total Time:

2906 Hours as of last inspection

Engine Manufacturer:

LYCOMING

ELT:

C91 installed, not activated

Engine Model/Series:

O-360-A4M

Registered Owner:

JONES DANIEL S

Rated Power:

180 hp

Operator:

On file

Operating Certificate(s) Held:

None

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Day

Observation Facility, Elevation:

MAI, 110 ft msl

Distance from Accident Site:

21 Nautical Miles

Observation Time:

0953 CDT

Direction from Accident Site:

45°

Lowest Cloud Condition:

Clear

Visibility

10 Miles

Lowest Ceiling:

None

Visibility (RVR):

 

Wind Speed/Gusts:

7 knots /

Turbulence Type Forecast/Actual:

/ None

Wind Direction:

100°

Turbulence Severity Forecast/Actual:

/ N/A

Altimeter Setting:

30.1 inches Hg

Temperature/Dew Point:

32°C / 18°C

Precipitation and Obscuration:

No Obscuration; No Precipitation

Departure Point:

Fountain, FL (68FD)

Type of Flight Plan Filed:

None

Destination:

Fountain, FL (68FD)

Type of Clearance:

None

Departure Time:

0923 CDT

Type of Airspace:

Class G

 

Airport Information

Airport:

Maran Airport (68FD)

Runway Surface Type:

Grass/turf

Airport Elevation:

225 ft

Runway Surface Condition:

Dry; Soft

Runway Used:

27

IFR Approach:

None

Runway Length/Width:

2600 ft / 50 ft

VFR Approach/Landing:

None

 

Wreckage and Impact Information

Crew Injuries:

1 Serious

Aircraft Damage:

Substantial

Passenger Injuries:

3 Fatal

Aircraft Fire:

On-Ground

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

3 Fatal, 1 Serious

Latitude, Longitude:

30.522222, -85.388611

 


 


Administrative Information

Investigator In Charge (IIC):

Todd G Gunther

Report Date:

03/09/2016

Additional Participating Persons:

Charles Carlisle; FAA/FSDO; Birmingham, AL

Mike McClure; Piper Aircraft; Vero Beach, FL

James M  Childers; Lycoming Aircraft Engines; Williamsport, PA

Publish Date:

03/09/2016

Note:

The NTSB traveled to the scene of this accident.

Investigation Docket:

http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=89266