# NTSB CEN14CA164: Piper PA 28R-201, N3398M, Ruidoso, NM, March 19, 2014 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: March 19, 2014, 17:32 local (23:32 UTC) - Place: Ruidoso, NM - Coordinates: 33.465557, -105.548614 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.4656&lon=-105.5486&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report April 23, 2014 - Report: Approved by Office Director - NTSB office: Central Region - NTSB case key (mKey): 88938 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14CA164 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88938/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88938 - Page: https://openairdocs.org/ntsb/CEN14CA164 ## Probable cause The pilot's failure to adjust the engine's fuel-air mixture and decision to takeoff in high density attitude conditions which degraded the airplane's performance. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Piper PA-28R-201, 2 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=7102816), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28R-201, 4 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7102816), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28R-201, 2 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=7102816), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md) - [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Pilot; cases with it: [Piper PA-28R-201, 1 case](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=7102816), [All aircraft, 226 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28R-201, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102816), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Landing: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-201, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102816), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) - [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) (defining event); cases with it: [Piper PA-28R-201, 3 cases](https://openairdocs.org/ntsb-events/220/sequence.md?model=7102816), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md) ## Analysis The pilot initiated the takeoff roll from runway 30 with the throttle and mixture control in the full forward position. When the airspeed reached 65 knots, the airplane began to climb and the pilot noticed that the airplane was not accelerating. He flew over the departure end of runway 30 at 100 feet and started a shallow left turn. He noticed that the landing gear indicator lights were illuminated green so he adjusted the landing gear lever down and then up again. The pilot continued to be distracted when the green lights remained illuminated. He then decided to fly to runway 6 and make a forced landing. The airplane was still 100 above the ground and began to lose altitude. The pilot made a forced landing straight ahead into a field and the airplane struck several trees. Prior to departure, the fuel tanks were filled with 40 gallons of fuel and the airplane contained 40 pounds of luggage. The calculated density altitude for the flight was about 7,800 feet. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. Based on the information gathered, it is likely that the airplanes performance was degraded due to a high density altitude and a rich fuel-air mixture. ## Factual narrative The pilot initiated the takeoff roll from runway 30 with the throttle and mixture control in the full forward position. When the airspeed reached 65 knots, the airplane began to climb and the pilot noticed that the airplane was not accelerating. He flew over the departure end of runway 30 at 100 feet and started a shallow left turn. He noticed that the landing gear indicator lights were illuminated green so he adjusted the landing gear lever down and then up again. The green lights remained illuminated. He then decided to fly to runway 6 and make a forced landing. The airplane was still 100 above the ground and began to lose altitude. The pilot made a forced landing straight ahead into a field and the airplane struck several trees. Prior to departure, the fuel tanks were filled with 40 gallons of fuel and the airplane contained 40 pounds of luggage. The calculated density altitude for the flight was about 7,800 feet. The pilot reported that there were no preaccident mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N3398M](https://openairdocs.org/deregistered/N3398M-2018-01-04), registration cancelled 2018-01-04, S/N 28R-7837113, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA 28R-201 (201) - Registry model: [Piper PA-28R-201](https://openairdocs.org/model/piper-pa-28r-201) (registry code 7102816) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7837113 - Year built: 1977 - Airframe hours: 13031 - Engines: LYCOMING IO360 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Harvey and Rihn Aviation, TX - Registered owner: De Aviation Inc - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, July 12, 2013, 94 hours before - Departed: SRR, RUIDOSO, NM - Destination: CNM, CARLSBAD, NM - Airport: SRR, Sierra Blanca Rgnl, runway 06, 8,120 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: none; commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review September 9, 2013; seat: left; restraint: lap only; flight hours: 3,787 total, 137 in this make and model, 3,207 as pilot in command, 64 in the last 90 days, 45 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 11 knots, gusting 15 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 54 °F, dew point 7 °F - Altimeter: 30.19 inHg - Observed at: KSRR, 2 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 20140319002329A](https://openairdocs.org/incident/20140319002329A), Mar 19, 2014: Piper PA-28R-201, Ruidoso, NM, Substantial damage. On March 19, 2014 at approximately 1732 MDT N3398M (PA-28R) departed Sierra Blanca Regional (srr), Ruidoso NM on runway 30. Upon departing the pilot reported… ## Docket (4 files) The files NTSB released with the investigation on April 3, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88938. 3.2 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410955&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation - FAA Inspector (item 2, .PDF, 109 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410956&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20FAA%20Inspector-Master.PDF - DA Calculation (item 3, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410957&FileExtension=.PDF&FileName=DA%20Calculation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 4, .PDF, 209 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40410958&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.