CEN14LA476

NTSB accident investigation · Piper PA-46-350P · Cortez, CO · September 3, 2014

Accident · Minor injuriesLimited investigationFinal report
Date
September 3, 2014, 12:38 local (18:38 UTC)
Place
Cortez, CO
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N747THPiper PA-46-350P
Defining event
Landing: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report January 18, 2017
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration - Salt Lake City
FAA report
20140903020729A
Case key
90011

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight instructor’s delayed decision to abort the simulated engine out maneuver, his failure to unfeather the propeller before restoring engine power, and his inadequate airspeed management, which led to an aerodynamic stall at low altitude.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: delayed actionPersonnel issues › Action/decision · Instructor/check pilotPiper PA 46-350P: 4 casesAll aircraft: 894 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · Instructor/check pilotPiper PA 46-350P: 40 casesAll aircraft: 9,295 casesProbable cause
Propeller system: propeller feather/reversingAircraft › Aircraft propeller/rotor · Incorrect use/operationPiper PA 46-350P: 1 caseAll aircraft: 26 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA 46-350P: 15 casesAll aircraft: 1,681 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA 46-350P: 4 casesAll aircraft: 1,391 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The accident occurred during a local instructional flight to satisfy the commercial pilot's annual insurance currency requirements in the accident airplane. The flight instructor reported that the pilot was demonstrating a simulated loss of engine power during initial climb and return for a downwind landing. During initial climb, upon reaching 1,200 ft above ground level (agl), the flight instructor reduced engine power to flight idle and feathered the propeller. In response, the pilot reduced airplane pitch and entered a left, 45-degree-bank turn back toward the airport. The flight instructor stated that, upon rolling wings level, the airplane appeared to be lower than he had expected as it glided toward the runway; however, he believed there was sufficient altitude remaining to safely land on the runway and told the pilot to continue without increasing the engine power. The flight instructor ultimately decided to abort the maneuver as the airplane crossed over the runway threshold at 40 ft agl. The flight instructor advanced the engine power lever to the full-forward position and increased airplane pitch to arrest the descent; however, he did not perceive an increase in engine thrust. Without an increase in engine thrust and with the increased pitch, the airplane's airspeed decreased rapidly, and the airplane entered an aerodynamic stall about 30 ft above the runway. The airplane impacted the runway before sliding into a grassy area. The flight instructor reported that he did not recall advancing the propeller control when he decided to abort the maneuver, and, as such, the perceived lack of engine thrust was likely because the propeller remained feathered after he increased engine power. Additionally, the flight instructor postulated that the airplane's landing gear had not been retracted after takeoff, which resulted in a reduced climb gradient, and, as such, the airplane entered the maneuver farther away from the airport than anticipated. Further, with the landing gear extended, the airplane experienced a reduction in glide performance during the simulated forced landing. The flight instructor reported that the accident could have been prevented if he had maintained a safe flying airspeed after he took control of the airplane. Additionally, he believed that his delayed decision to abort the maneuver resulted in an insufficient margin of safety.

Factual narrative

On September 3, 2014, about 1238 mountain daylight time, a Piper model PA-46-350P airplane, N747TH, was substantially damaged while landing at the Cortez Municipal Airport (CEZ), Cortez, Colorado. The commercial pilot and his flight instructor sustained minor injuries. The airplane was registered to and operated by Philburto Aviation, LTD, under the provisions of 14 Code of Federal Regulations Part 91 without a flight plan. Day visual meteorological conditions prevailed for the local instructional flight, which had departed shortly before the accident.The flight instructor reported that the purpose of the flight was to satisfy the pilot's annual insurance currency requirements in the accident airplane. The flight instructor stated that earlier in the morning they had completed several visual flight rules (VFR) flight maneuvers before deciding to conduct takeoff-and-landings at CEZ. The flight instructor reported that following several uneventful landings, they decided to perform a simulated loss of engine power following a takeoff from runway 21 (7,205 feet by 100 feet, asphalt) and return for a downwind landing on runway 3. During initial climb from runway 21, upon reaching 1,200 feet above ground level (agl), the flight instructor reduced engine power to flight idle and feathered the propeller. In response, the pilot reduced airplane pitch and entered a 45-degree bank left turn back toward the airport. The pilot maintained best-glide airspeed (90 knots) throughout the left turn and rolled wings-level when the airplane was aligned with runway 3. The flight instructor stated that, upon rolling wings level, the airplane appeared to be lower than he had expected as it glided toward the runway; however, he believed there was sufficient altitude remaining to safely land on the runway and told the pilot to continue without an increase in engine power. The flight instructor ultimately decided to abort the maneuver as the airplane crossed over the runway 3 threshold at 40 feet agl. He reported that despite the airplane having sufficient altitude remaining to land on the remaining runway, he thought it would be safer to abort the simulated engine failure and recover under powered-flight. He took control of the airplane, advanced the engine power lever to the full forward position, and increased airplane pitch to arrest the descent; however, he did not perceive an increase in thrust from the engine. Without an increase in engine thrust, the airplane's airspeed decreased rapidly and the airplane entered an aerodynamic stall about 30 feet above the runway. The airplane impacted the runway, about 500 feet from the approach threshold, before it slid off the runway into a grassy area. The flight instructor reported that the engine continued to operate after the accident, and that he secured it by pulling the condition lever to the full aft position. The main wing spar and fuselage were substantially damaged during the impact sequence. The flight instructorreported that he did not recall advancing the propeller control when he decided to abort the maneuver, and as such, the perceived lack of engine thrust was likely because the propeller remained feathered as he increased engine power. Additionally, the flight instructor reported that neither he or the pilot remember extending the landing gear following the simulated engine failure; however, both pilots recalled seeing the landing gear position lights illuminated during the maneuver. The flight instructor postulated that the airplane's landing gear had not been retracted after takeoff, which resulted in a reduced climb gradient due to the additional aerodynamic drag of the extended landing gear, and as such, the airplane entered the maneuver farther away from the airport than anticipated. Furthermore, with the landing gear extended, the airplane experienced a reduction in glide performance during the simulated forced landing. The flight instructor reported that the accident could have been prevented had he maintained a safe flying airspeed after he took control of the airplane. Additionally, the flight instructor believed that his delayed decision to abort the maneuver had resulted in an insufficient margin of safety. At 1253, the CEZ automated surface observing system (ASOS) reported: wind 220 degrees at 12 knots, visibility 10 miles, clear sky, temperature 29 degrees Celsius; dew point 1 degrees Celsius; and an altimeter setting of 30.07 inches of mercury.

Aircraft

Registration
N747TH
Reported as
Piper PA-46-350P
Category
Airplane
Serial number
4636200
Built
1999
Airframe hours
2,900
Engine
Pratt & Whitney PT6A-35, 560 horsepower, turbo prop
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Philburto Aviation, LTD
Registered owner
Philburto Aviation, LTD
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 2, 2013
Departed
CEZ · Cortez, CO
Destination
CEZ · Cortez, CO
Airport
CEZ · Cortez Municipal Airport, runway 03, 7,205 × 100 ft, asphalt
Equipment
Stall warning system, Onboard weather, Electronic primary flight display, Auto-pilot, Electronic multifunction display

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
54
Injuries
Minor
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
July 18, 2014
Seat
Right
Restraint
3-point
Flight hours
4,184 total · 1,648 in this make and model · 3,979 as pilot in command · 63 in the last 90 days · 21 in the last 30 days · 2 in the last 24 hours
Role
Pilot
Age
60
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
August 31, 2013
Seat
Left
Restraint
3-point
Flight hours
4,000 total · 2,050 in this make and model · 3,917 as pilot in command · 50 in the last 90 days · 29 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 12 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 34 °F
Altimeter
30.06 inHg
Observed at
CEZ

Docket · 2

The files NTSB released with the investigation on November 7, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 997 KB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.