# NTSB CEN12LA441: Piper PA-32-300, N1127X, Elkader, IA, July 14, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: July 14, 2012, 10:21 local (15:21 UTC) - Place: Elkader, IA - Coordinates: 42.847221, -91.382225 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.8472&lon=-91.3822&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-aborted after touchdown: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report November 26, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration - Des Moines FSDO - NTSB case key (mKey): 84319 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12LA441 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/84319/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=84319 - Page: https://openairdocs.org/ntsb/CEN12LA441 ## Probable cause The pilot's failure to attain the proper touchdown point while landing on the wet grass runway. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Aircraft capability: landing distance](https://openairdocs.org/ntsb-findings/01061030): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-32-300, 4 cases](https://openairdocs.org/ntsb-findings/01061030/cases.md?model=7103212), [All aircraft, 68 cases](https://openairdocs.org/ntsb-findings/01061030/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-32-300, 5 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7103212), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Runway/land/takeoff/taxi surface: wet surface](https://openairdocs.org/ntsb-findings/03023010): Environmental issues › Physical environment · Effect on operation; cases with it: [Piper PA-32-300, 1 case](https://openairdocs.org/ntsb-findings/03023010/cases.md?model=7103212), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/03023010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-flare/touchdown: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Piper PA-32-300, 4 cases](https://openairdocs.org/ntsb-events/090/sequence.md?model=7103212), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Landing-aborted after touchdown: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Piper PA-32-300, 11 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7103212), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis The pilot reported that the airplane touched down on the first third of the wet grass runway, but the braking action was ineffective. He stated that because of the ineffective braking action and the short runway length, he applied full engine power to abort the landing. He reported that although the airplane initially cleared trees located off the departure end of the runway, it was inexplicably pushed down into the tree line. The airplane came to rest in a 100-foot deep wooded ravine located off the departure end of the runway. The pilot noted that there were no preaccident mechanical malfunctions or failures that would have precluded normal operation of the airplane. Based on the available weather radar data and witness observations, localized instrument flight rule conditions likely existed due to thunderstorms and heavy rain in the vicinity of the airport. An on-site investigation found tire marks on the grass runway consistent with the tire width of the accident airplane. The first of these tire marks was more than halfway down the 1,705-foot-long runway, about 741 feet from the departure end. These tire tracks continued past the departure threshold until a point where the terrain sloped away from the runway elevation, indicating that the airplane had not become airborne on the usable runway. The physical evidence was consistent with the airplane running off the end of the runway before descending into treetops that were at or below the runway elevation. Review of available performance data indicated that the expected landing distance for a wet grass runway would be in excess of 748 feet. The landing performance calculations established that there was sufficient runway available for a ground roll if the pilot had touched down within the first half of the runway. ## Factual narrative On July 14, 2012, about 1021 central daylight time, a Piper model PA-32-300 airplane, N1127X, was substantially damaged while landing at the Elkader Airport (I27) near Elkader, Iowa. The private pilot sustained minor injuries. The passenger sustained serious injuries. The airplane was registered to and operated by Wild River Flying Club, LLC, under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. Day instrument meteorological conditions prevailed at the time of the accident. The personal flight originated from L.O. Simenstad Municipal Airport (KOEO), Osceola, Wisconsin, at 0910. The pilot reported that as the flight approached the intended destination he descended from 5,500 feet to 2,000 feet mean sea level in order to remain clear of clouds. The flight subsequently encountered light rain and reduced forward visibilities. The pilot eventually performed a 180-degree turn while he considered diverting to an alternate airport. He stated that during the turn he noticed that the weather had closed-in behind him; however, as he continued the turn he was able to establish visual contact with the intended destination because the clouds had moved past the airport. He overflew the airport before entering a left traffic pattern for runway 17 on the upwind leg. He stated that the airplane touched down within the first third of the runway with the wing flaps fully extended. The pilot reported that braking action was ineffective after touchdown due to the wet grass runway condition. Because of the ineffective braking action and the short runway length (1,705 feet), the pilot applied full engine power to abort the landing. He reported that although the airplane initially cleared trees located off the departure end of the runway, it was inexplicably pushed down into the tree line. (The treetops were at or below the runway elevation, due to sloping terrain located off the end of the runway.) The airplane came to rest in a 100-foot deep wooded ravine. The fuselage and both wings were substantially damaged during the accident. The pilot noted that there were no preimpact mechanical malfunctions or failures that would have precluded normal operation of the airplane. Witnesses located at the destination airport reported that the airplane first overflew the airport at approximately 1020, at which time there was heavy rain and lightning. A few minutes later the witnesses heard the airplane attempting to land on runway 17; however, they were subsequently unable to locate the airplane as they drove the length of the runway. Based on the available weather radar data and the witness observations, localized instrument flight rule (IFR) conditions existed due to the thunderstorms and heavy rain affecting the destination airport. The closest weather observing station was at Prairie du Chien Municipal Airport (KPDC), located about 15 miles northeast of the accident site. At 1035, the KPDC automated surface observing system reported thefollowing weather conditions: wind 130 degrees at 7 knots; visibility 3 miles with light rain; scattered clouds at 1,100 feet above ground level (agl), a broken ceiling at 3,800 feet agl, and a overcast ceiling at 4,900 feet agl; temperature 20 degrees Celsius; dew point 20 degrees Celsius; altimeter setting 30.04 inches of mercury. An on-site investigation was completed by local law enforcement and inspectors with the Federal Aviation Administration. Their investigation revealed that there were visible tracks located on the grass runway that were consistent with the tire width of the accident airplane. According to photographs and direct measurements, the first visible tire marks were located about 741 feet from the departure end of runway 17. These tire tracks continued past the departure threshold until a point where the terrain sloped away from the runway elevation. A global positioning system (GPS) handheld device was found at the accident site. The plotted GPS data suggested that the airplane landed about halfway down the 1,705 foot long runway; however, the exact touchdown point could not be inferred from the track data. The GPS data indicated that the airplane's groundspeed was 46 knots and 45 knots when it was 638 feet and 180 feet from the departure threshold, respectively. These groundspeeds were not consistent with the airplane decelerating during a landing roll. The final GPS data point was located about 195 feet past the departure threshold. The pilot reported that the airplane's weight was 2,858 pounds at time of the accident. According to the Piper PA-32-300 Pilot's Operating Manual (POM), the stall speed is 50 knots with the wing flaps fully extended to 40-degrees. The landing ground roll for a paved, level, and dry surfaced runway with no headwind and using maximum braking is about 575 feet. The POM does not provide landing distances for grass or wet surfaces; however, Civil Aviation Authority research indicates that ground rolls increase 30-percent to 40-percent when landing on wet grass runways. Therefore, the expected landing roll distance on a level, wet grass runway without a headwind and using maximum braking would be between 748 feet and 805 feet. ## Aircraft - Registration: [N1127X](https://openairdocs.org/deregistered/N1127X-2013-08-14), registration cancelled 2013-08-14, S/N 32-7540146, built 1975 (OpenAirDocs) - Reported make and model: PIPER PA-32-300 - Registry model: [Piper PA-32-300](https://openairdocs.org/model/piper-pa-32-300) (registry code 7103212) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32-7540146 - Airframe hours: 8130.95 - Engines: Lycoming IO-540 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Wild River Flying Club, Inc. - Registered owner: Wild River Flying Club, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 9, 2012, 73.85 hours before - Departed: KOEO, Osceola, WI - Destination: I27, Elkader, IA - Airport: I27, Elkader Airport, runway 17, 1,705 × 75 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; injuries: minor; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review May 16, 2012; seat: left; flight hours: 287 total, 80 in this make and model, 221 as pilot in command, 6 in the last 90 days, 1 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: 130° at 7 knots - Visibility: 3 statute miles - Lowest ceiling: 3,800 ft broken - Temperature: 68 °F, dew point 68 °F - Altimeter: 30.04 inHg - Observed at: KPDC, 15 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 20120714016009A](https://openairdocs.org/incident/20120714016009A), Jul 14, 2012: Piper PA-32-300, Elkader, IA, Destroyed. The VFR rated pilot recieved a weather briefing at 1245Z with a planned departure time of 1400Z from osceola WI (oeo) to Elkader IA (I27). The briefer stated,… ## Docket (13 files) The files NTSB released with the investigation on September 14, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=84319. 6.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 627 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376189&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Witness Statements (item 2, .PDF, 242 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376190&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - FAA Inspector Statements (item 3, .PDF, 334 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376206&FileExtension=.PDF&FileName=FAA%20Inspector%20Statements-Redacted.PDF - Email Correspondence With FAA Inspector (item 4, .PDF, 42 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376192&FileExtension=.PDF&FileName=Email%20Correspondence%20With%20FAA%20Inspector-Redacted.PDF - Clayton County Sheriff Investigative Report Summary (item 5, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376193&FileExtension=.PDF&FileName=Clayton%20County%20Sheriff%20Investigative%20Report%20Summary-Redacted.PDF - Global Positioning System Data Plots (item 6, .PDF, 787 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376194&FileExtension=.PDF&FileName=Global%20Positioning%20System%20Data%20Plots-Master.PDF - Postaccident Runway Survey of Tire Track Markings (item 7, .PDF, 824 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376195&FileExtension=.PDF&FileName=Postaccident%20Runway%20Survey%20of%20Tire%20Track%20Markings-Master.PDF - Piper PA-32-300 Pilot's Operating Manual, Excerpts (item 8, .PDF, 554 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376196&FileExtension=.PDF&FileName=Piper%20PA-32-300%20Pilot%27s%20Operating%20Manual,%20Excerpts-Master.PDF - Airfield Performance Considerations, Source: Civil Aviation Authority (CAA) (item 9, .PDF, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376197&FileExtension=.PDF&FileName=Airfield%20Performance%20Considerations,%20Source%3A%20Civil%20Aviation%20Authority%20(CAA)-Master.PDF - Meteorological Data Summary (item 10, .PDF, 710 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376198&FileExtension=.PDF&FileName=Meteorological%20Data%20Summary-Redacted.PDF - Weather Radar Data Plots (item 11, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376199&FileExtension=.PDF&FileName=Weather%20Radar%20Data%20Plots-Master.PDF - Transcript of Pilot's Preflight Weather Briefing (item 12, .PDF, 524 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376200&FileExtension=.PDF&FileName=Transcript%20of%20Pilot%27s%20Preflight%20Weather%20Briefing-Redacted.PDF - Return Confirmation For Pilot's Global Positioning System Receiver (item 13, .PDF, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40376207&FileExtension=.PDF&FileName=Return%20Confirmation%20For%20Pilot%27s%20Global%20Positioning%20System%20Receiver-Redacted.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.