# NTSB CEN18LA328: Piper PA32R, N9894K, South Beloit, IL, August 12, 2018 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: August 12, 2018, 08:32 local (13:32 UTC) - Place: South Beloit, IL - Coordinates: 42.492221, -88.983612 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.4922&lon=-88.9836&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Serious injuries - Injuries: 1 serious, 2 minor - Status: Completed, report April 13, 2020 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Flight Standards District Office - NTSB case key (mKey): 98060 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA328 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98060/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98060 - Page: https://openairdocs.org/ntsb/CEN18LA328 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-32R-300, 14 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103213), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Attention/monitoring: attention](https://openairdocs.org/ntsb-findings/02021510): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-32R-300, 2 cases](https://openairdocs.org/ntsb-findings/02021510/cases.md?model=7103213), [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. - [Initial climb: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338); cases with it: [Piper PA-32R-300, 1 case](https://openairdocs.org/ntsb-events/338/sequence.md?model=7103213), [All aircraft, 563 cases](https://openairdocs.org/ntsb-events/338/sequence.md) - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-32R-300, 7 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7103213), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Emergency descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-32R-300, 32 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103213), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N9894K-2021-07-31), registration cancelled 2021-07-31, S/N 32R-7880041 (OpenAirDocs) - Reported make and model: Piper PA32R (300) - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7880041 - Year built: 1978 - Airframe hours: 3414 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: minor; 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 ## 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 20180812011039A](https://openairdocs.org/incident/20180812011039A), Aug 12, 2018: Piper PA-32R-300, South Beloit, IL, Substantial damage. N9894K departed runway 25 at the Beloit Airport, Beloit, Wisconsin (44C). The pilot stated that he heard a loud ?bang? Shortly after rotation and that the… ## Docket (3 files) The files NTSB released with the investigation on November 21, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98060. 1.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 714 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478214&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation with FAA Inspector and Pilot (item 2, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478215&FileExtension=.PDF&FileName=Record%20of%20Conversation%20with%20FAA%20Inspector%20and%20Pilot-Master.PDF - FAA Safety Briefing - Startle Response (item 3, .PDF, 658 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478216&FileExtension=.PDF&FileName=FAA%20Safety%20Briefing%20-%20Startle%20Response-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.