# NTSB CEN11CA526: Piper PA-36-375, N3963E, Cambridge, NE, July 23, 2011 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: July 23, 2011, 06:38 local (11:38 UTC) - Place: Cambridge, NE - Coordinates: 40.308055, -100.166664 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.3081&lon=-100.1667&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report October 20, 2011 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA Lincoln FSDO - NTSB case key (mKey): 81280 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11CA526 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/81280/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=81280 - Page: https://openairdocs.org/ntsb/CEN11CA526 ## Probable cause The pilot's failure to reset the engine's mixture control lever to the full rich position prior to takeoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-36-375, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7103620), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Engine controls: mixture control](https://openairdocs.org/ntsb-findings/01057602): Aircraft › Aircraft power plant · Not used/operated (probable cause); cases with it: [Piper PA-36-375, 1 case](https://openairdocs.org/ntsb-findings/01057602/cases.md?model=7103620), [All aircraft, 41 cases](https://openairdocs.org/ntsb-findings/01057602/cases.md) - [Use of equip/info: use of checklist](https://openairdocs.org/ntsb-findings/02063030): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-36-375, 1 case](https://openairdocs.org/ntsb-findings/02063030/cases.md?model=7103620), [All aircraft, 336 cases](https://openairdocs.org/ntsb-findings/02063030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-36-375, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=7103620), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-36-375, 2 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7103620), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Initial climb: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-36-375, 1 case](https://openairdocs.org/ntsb-events/440/sequence.md?model=7103620), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-36-375, 3 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103620), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Post-impact: Landing gear collapse](https://openairdocs.org/ntsb-events/094); cases with it: [Piper PA-36-375, 1 case](https://openairdocs.org/ntsb-events/094/sequence.md?model=7103620), [All aircraft, 1,787 cases](https://openairdocs.org/ntsb-events/094/sequence.md) ## Analysis The pilot was departing on the first agricultural application flight of the day. He said that as he taxiing, he noticed the engine temperature rising, so he leaned the mixture. He completed his engine run-up and departed. He said that as the airplane was accelerating down the runway, he noticed the airplane was not developing enough power, but he had used up most of the runway and could not abort the takeoff. During climb, the airplane experienced a degrade in performance and struck terrain about 600 feet from the airport. The impact collapsed the landing gear and caused substantial damage to the airframe and elevator. The pilot reported that he inadvertently departed with the engine's mixture control lever at the halfway leaned setting. The pilot reported that there were no mechanical anomalies with the airplane, and the accident could have been prevented if he had used a checklist. ## Factual narrative The airplane departed from a runway with a slight uphill grade, for the first agricultural application flight of the day. The pilot reported that his acceleration was less than expected, and he lifted off near the departure end of the runway with minimum airspeed. The airplane failed to accelerate or climb, and struck terrain about 600 feet from the airport. The impact collapsed the landing gear and caused substantial damage to the airframe and elevator. The pilot reported that he inadvertently departed with the engine mixture control leaned at approximately the halfway setting. The pilot added there was no preimpact mechanical malfunction or failure with the airplane. He also reported that the accident could have been prevented if he had used the checklist. ## Aircraft - Registration: [N3963E](https://openairdocs.org/deregistered/N3963E-2021-05-08), registration cancelled 2021-05-08, S/N 36-7902029, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA-36-375 - Registry model: [Piper PA-36-375](https://openairdocs.org/model/piper-pa-36-375) (registry code 7103620) (OpenAirDocs) - Registry engine: [Lycoming IO-720 series](https://openairdocs.org/engine/lycoming-io-720-series) (registry code 41546, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 36-7902029 - Airframe hours: 5670 - Engines: LYCOMING IO-720 400 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial application, Part 137 - Operator: Joseph M Sides, doing business as Behnke Aviation - Registered owner: Mike E Sides - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, December 15, 2010 - Departed: CSB, Cambridge, NE - Destination: CSB, Cambridge, NE - Airport: CSB, Cambridge Municipal Airport, runway 32, 4,098 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 40; injuries: none; commercial; airplane ratings: single-engine land; medical: class 2, without waivers/limitations; last flight review October 19, 2010; seat: single; flight hours: 480 total, 198 in this make and model, 438 as pilot in command, 99 in the last 90 days, 63 in the last 30 days, 3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 63 °F - Altimeter: 29.85 inHg - Observed at: KMCK, 21 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20110723015989A](https://openairdocs.org/incident/20110723015989A), Jul 23, 2011: Piper PA-36-375, Cambridge, NE, Substantial damage. At 0638 CDT on July 23, 2011, N3963E, Piper PA-36-375, s/n 36-7902029, taxied into position and took off on runway 32 at the Cambridge, NE airport (csb). The… ## Docket (3 files) The files NTSB released with the investigation on September 15, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=81280. 2.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40351840&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot's Operating Handbook, Page 4-5 - Normal Checklist (item 2, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352876&FileExtension=.PDF&FileName=Pilot%27s%20Operating%20Handbook,%20Page%204-5%20-%20Normal%20Checklist-Master.PDF - Map - Showing Airport and Impact Location (item 3, .PDF, 73 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40351839&FileExtension=.PDF&FileName=Map%20-%20Showing%20Airport%20and%20Impact%20Location-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.