# NTSB CEN15CA165: Piper PA 28-181, N3575X, Lee's Summit, MO, March 1, 2015 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: March 1, 2015, 15:30 local (21:30 UTC) - Place: Lee's Summit, MO - Coordinates: 38.95972, -94.371391 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=38.9597&lon=-94.3714&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report December 17, 2015 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, Kansas City FSDO - NTSB case key (mKey): 90833 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN15CA165 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90833/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90833 - Page: https://openairdocs.org/ntsb/CEN15CA165 ## Probable cause The pilot-receiving-instruction's excessive pitch control during takeoff, which resulted in an aerodynamic stall shortly after liftoff and the subsequent loss of control. Contributing to the accident was the flight crew's decision to have the flight instructor separately control the throttle while the pilot-receiving-instruction manipulated the flight controls, which resulted in inadequate coordination between the flight crew during the attempted stall recovery. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-181, 6 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=7102807), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-181, 7 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7102807), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Piper PA-28-181, 53 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102807), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Flight crew (probable cause); cases with it: [Piper PA-28-181, 21 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102807), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Communication (personnel): lack of communication](https://openairdocs.org/ntsb-findings/02063510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/02063510/cases.md?model=7102807), [All aircraft, 84 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md) - [Communication (personnel): lack of communication](https://openairdocs.org/ntsb-findings/02063510): Personnel issues › Task performance · Student/instructed pilot (probable cause); cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/02063510/cases.md?model=7102807), [All aircraft, 84 cases](https://openairdocs.org/ntsb-findings/02063510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Piper PA-28-181, 5 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7102807), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Piper PA-28-181, 18 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102807), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Takeoff: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Piper PA-28-181, 8 cases](https://openairdocs.org/ntsb-events/090/sequence.md?model=7102807), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) ## Analysis The pilot-receiving-instruction reported that the purpose of the flight was to receive a checkout in the flying club airplane. After completing three uneventful takeoffs and landings, the flight instructor asked the pilot-receiving-instruction to perform a simulated soft-field takeoff from a high-altitude airport. The pilot-receiving-instruction had not performed the requested maneuver previously, which was described as a soft-field takeoff at 50-percent engine power to simulate the atmospheric conditions of a high-altitude airport. Before attempting the takeoff, both pilots agreed that the pilot-receiving-instruction would manipulate the flight controls and that the throttle would be separately controlled by the flight instructor. The pilot-receiving-instruction reported that during the takeoff, shortly after becoming airborne, while still in ground-effect, the airplane encountered an aerodynamic stall. The pilot-receiving-instruction briefly reduced airplane pitch to recover from the aerodynamic stall, but as the airplane drifted toward the right side of the runway he subsequently increased yoke backpressure to keep the airplane airborne. The pilot-receiving-instruction reported that the airplane encountered a second aerodynamic stall after he increased airplane pitch. The airplane subsequently drifted left, crossing back over the runway, before the airplane landed along the left side of the runway. The flight was terminated and the aircraft inspected for damage. The airplane exhibited damage to the tail skid, tail tie-down ring, left wingtip, the nose and left main landing gear, and the propeller. An additional examination established that the aft fuselage bulkhead had sustained substantial damage when the tail struck the runway. The pilot-receiving-instruction reported there were no mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. The flight instructor reported that the engine power had been set at 2,100 rpm to simulate the available engine power while operating at a high-altitude airport. He reported that the pilot-receiving-instruction had used excessive pitch control inputs during the initial takeoff roll to keep the nose wheel off the runway, the airplane veered to the right before coming airborne, and that the airplane encountered an aerodynamic stall upon liftoff. The flight instructor reported that the airplane subsequently bounced, drifted to the left, and eventually landed along the left side of the runway. The flight crew's decision to have the flight instructor separately control the throttle during the accident takeoff likely prevented the pilot-receiving-instruction from adequately recovering from the initial aerodynamic stall. Additionally, following the initial aerodynamic stall, there was likely inadequate coordination between the flight crew to reestablish control of the airplane before it impacted the ground. ## Factual narrative The pilot-receiving-instruction reported that the purpose of the flight was to receive a checkout in the flying club airplane. After completing three uneventful takeoffs and landings, the flight instructor asked the pilot-receiving-instruction to perform a simulated soft-field takeoff from a high-altitude airport. The pilot-receiving-instruction had not performed the requested maneuver previously, which was described as a soft-field takeoff at 50-percent engine power to simulate the atmospheric conditions of a high-altitude airport. Before attempting the takeoff, both pilots agreed that the pilot-receiving-instruction would manipulate the flight controls and that the throttle would be separately controlled by the flight instructor. The pilot-receiving-instruction reported that during the takeoff, shortly after becoming airborne, while still in ground-effect, the airplane encountered an aerodynamic stall. The pilot-receiving-instruction briefly reduced airplane pitch to recover from the aerodynamic stall, but as the airplane drifted toward the right side of the runway he subsequently increased yoke backpressure to keep the airplane airborne. The pilot-receiving-instruction reported that the airplane encountered a second aerodynamic stall after he increased airplane pitch. The airplane subsequently drifted left, crossing back over the runway, before the airplane landed along the left side of the runway. The flight was terminated and the aircraft inspected for damage. The airplane exhibited damage to the tail skid, tail tie-down ring, left wingtip, the nose and left main landing gear, and the propeller. An additional examination established that the aft fuselage bulkhead had sustained substantial damage when the tail struck the runway. The pilot-receiving-instruction reported there were no mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation.The flight instructor reported that the engine power had been set at 2,100 rpm to simulate the available engine power while operating at a high-altitude airport. He reported that the pilot-receiving-instruction had used excessive pitch control inputs during the initial takeoff roll to keep the nose wheel off the runway, the airplane veered to the right before coming airborne, and that the airplane encountered an aerodynamic stall upon liftoff. The flight instructor reported that the airplane subsequently bounced, drifted to the left, and eventually landed along the left side of the runway. ## Aircraft - Registration: [N3575X](https://openairdocs.org/aircraft/N3575X), registered now, S/N 28-8090199, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA 28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8090199 - Year built: 1979 - Airframe hours: 8605 - Engines: Lycoming O-360-A4M 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Wing Flying Club, Inc. - Registered owner: Wing Flying Club, Inc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 1, 2015 - Departed: LXT, Lee's Summit, MO - Destination: LXT, Lee's Summit, MO - Airport: LXT, Lee's Summit Municipal Airport, runway 36, 4,016 × 75 ft, concrete - Equipment: Auto-pilot, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review February 16, 2015; seat: left; restraint: 3-point; flight hours: 112 total, 6 in this make and model, 79 as pilot in command, 34 in the last 90 days, 17 in the last 30 days, 0 in the last 24 hours - Flight instructor; age 77; injuries: none; flight instructor, flight engineer, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review April 13, 2013; seat: right; restraint: 3-point; flight hours: 24,945 total, 14,438 as pilot in command, 34 in the last 90 days, 23 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 310° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: 3,000 ft overcast - Temperature: 32 °F, dew point 19 °F - Altimeter: 30.37 inHg - Observed at: LXT ## 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 20150301003179A](https://openairdocs.org/incident/20150301003179A), Mar 1, 2015: Piper PA-28-181, Lee'S Summit, MO, Substantial damage. A private pilot was receiving a check-out in a PA-28-181 from a flying club CFI. After completing three take-offs and landings, the pilot receiving instruction… ## Other investigations on N3575X (1) 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. - [NTSB CHI05CA039](https://openairdocs.org/ntsb/CHI05CA039), Dec 1, 2004: Piper PA-28-181 (N3575X), Lee's Summit, MO, substantial damage. Probable cause: The inadequate in-flight planning/decision which resulted in fuel exhaustion and the loss of engine power. Contributing factors were the muddy terrain and the vegetation. ## Docket (3 files) The files NTSB released with the investigation on December 2, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90833. 1.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 880 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434425&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot Statement (Justin Culpepper) (item 2, .PDF, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434426&FileExtension=.PDF&FileName=Pilot%20Statement%20(Justin%20Culpepper)-Master.PDF - Memorandum of Conversation (James Wornack) (item 3, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40434427&FileExtension=.PDF&FileName=Memorandum%20of%20Conversation%20(James%20Wornack)-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.