CEN18LA328

NTSB accident investigation · Piper PA32R · South Beloit, IL · August 12, 2018

Accident · Serious injuriesLimited investigationFinal report
Date
August 12, 2018, 08:32 local (13:32 UTC)
Place
South Beloit, IL
Injuries
1 serious, 2 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N9894KPiper PA32R
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report April 13, 2020
Report
Approved by Office Director
NTSB office
Central Region
Parties
Flight Standards District Office
FAA report
20180812011039A
Case key
98060

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 pilot’s failure to maintain airspeed after being startled and distracted when the engine cowling opened during takeoff, which led to a subsequent impact with terrain.

Findings · 2

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-32R-300: 14 casesAll aircraft: 9,295 casesProbable cause
Attention/monitoring: attentionPersonnel issues › Psychological · PilotPiper PA-32R-300: 2 casesAll aircraft: 226 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 private pilot indicated that soon after takeoff for the personal flight, the airplane's engine cowling opened and began to swing back and forth. Concerned the cowling might fracture the windshield, he reduced engine power to land straight ahead, but, after realizing that the runway remaining was insufficient to do so, he attempted to climb and return to the runway. During his attempted go-around, the airplane began to descend and then impacted a cornfield off the end of the runway. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal flight operations. The pilot stated that he was very startled by the opening of the cowling, which distracted him from maintaining airspeed.

Factual narrative

On August 12, 2018, about 0832 central daylight time, a Piper PA32R airplane, N9894K, impacted terrain near South Beloit, Illinois after departing from Beloit Airport (44C), Beloit, Wisconsin. The pilot and one passenger suffered minor injuries, one passenger suffered serious injuries, and the airplane was substantially damaged. The airplane was registered to DBG Aviation Inc. and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions prevailed for the flight, which was destined for Baraboo–Wisconsin Dells Airport (DLL), Baraboo, Wisconsin. After takeoff from runway 25, the pilot stated the engine cowling opened and begin to rapidly swing back and forth. Based on his concern the cowling might fracture the windshield and cause an injury, the pilot reduced power and considered landing straight ahead. Realizing he was too far down the runway to land, the pilot increased power and attempted to climb and return to the runway with a shallow left bank. The airplane developed a sink rate and impacted a cornfield about ½ mile off the end of the runway, damaging the engine mounts and fuselage. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal flight operations. The pilot stated that he was very startled by the sudden and unexpected opening of the cowling, which distracted him from maintaining airspeed control. A Federal Aviation Administration Safety Team (FAAST) safety briefing titled "Startle Response", located in the public docket for this investigation, included the following information: Humans are subject to a "startle response" when they are faced with unexpected emergency situations and may delay action or initiate inappropriate action in response to the emergency. Some examples of unexpected events during flight that could crop up and cause an emergency, or an accident if it is not managed properly, include: • Partial/full loss of power on takeoff • Landing gear extension/retraction failure • Bird strike • Cabin door opening Train and plan for emergencies. In many cases, pilots don't review and practice how they will handle unexpected events and abnormal or emergency situations, except during flight reviews or other recurrent training. "Chair Flying" - Unexpected events, especially those occurring close to the ground, require rapid, appropriate action. Your chances of a safe outcome are greatly improved if your response to an unexpected event is planned out ahead of time. Review "what if" scenarios in your head and practice what you would immediately do should a certain event take you by surprise.

Aircraft

Registration
N9894K
Reported as
Piper PA32R (300)
Category
Airplane
Serial number
32R-7880041
Built
1978
Airframe hours
3,414
Engine
Lycoming IO-540, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Dbg Aviation Inc
Registered owner
Dbg Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 14, 2018
Departed
44C · Beloit, WI
Destination
DLL · Baraboo, WI
Airport
44C · Beloit, runway 25, 3,300 × 50 ft, asphalt
Equipment
Stall warning system, Auto-pilot, Electronic flight bag or handheld device

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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
62
Injuries
Minor
Certificate
Private
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
April 25, 2018
Seat
Left
Restraint
Lap only
Flight hours
1,593 total · 1,235 in this make and model · 4 in the last 90 days · 2 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
6 statute miles
Lowest ceiling
None
Temperature
75 °F, dew point 70 °F
Altimeter
30.13 inHg
Observed at
KJVL, 8 nm away

Docket · 3

The files NTSB released with the investigation on November 21, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.5 MB 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.