# NTSB CEN18LA378: Piper PA32, N4078W, Hereford, TX, September 9, 2018

- Type: NTSB accident investigation
- Classification: Accident · Serious injuries · Limited investigation · Final report
- Date: September 9, 2018, 11:17 local (16:17 UTC)
- Place: Hereford, TX
- Coordinates: 34.856388, -102.325836
- Nearby events: https://openairdocs.org/map.md?lat=34.8564&lon=-102.3258&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240)
- Highest injury: Serious injuries
- Injuries: 4 serious
- Status: Completed, report November 19, 2019
- Report: Approved by Office Director
- NTSB office: Central Region
- Parties: FAA -- Flight Standards
- NTSB case key (mKey): 98272
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN18LA378
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98272/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98272
- Page: https://openairdocs.org/ntsb/CEN18LA378

## Probable cause

The pilot’s exceedance of the airplane’s critical angle of attack during takeoff, which resulted in an aerodynamic stall.

## 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-32-300, 25 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103212), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Piper PA-32-300, 3 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7103212), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-32-300, 12 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7103212), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Piper PA-32-300, 5 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7103212), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md)
- [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-32-300, 43 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103212), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The private pilot lost control of the airplane during takeoff; it subsequently impacted the ground near the departure end of the runway and was destroyed. The pilot reported that she had no memory of her preflight activity or takeoff. A witness observed the airplane in a nose-high, tail-low attitude during the takeoff but lost sight of the airplane behind hangars. He noted that the engine sounded like it was at full power. Postaccident examination of the airplane did not reveal any evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Data recovered from an onboard engine monitor did not reveal any indication of a loss of engine power during takeoff. The airplane was loaded within the gross weight and center-of-gravity limits. Performance data indicated that the available runway length was sufficient for takeoff. It is likely that the pilot overrotated during takeoff and the airplane entered an aerodynamic stall, which resulted in the airplane departing controlled flight and impacting the ground.

## Factual narrative

On September 9, 2018, at 1117 central daylight time, a Piper PA-32-300 airplane, N4078W, impacted terrain after takeoff from runway 20 at the Hereford Municipal Airport (HRX), Hereford, Texas. The pilot and three passengers were seriously injured and the airplane was destroyed. The airplane was registered to and operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed for the personal flight that was not being operated on a flight plan. The flight was originating at the time of the accident and was destined for the Reagan County Airport (E41), Big Lake, Texas.The pilot reported that she had no memory of any portion of the accident flight, including her arrival at the airport that morning and the pre-flight activity. A witness reported that he was in a T-hangar on the airport when he observed a portion of the takeoff. He stated that the airplane was in a nose high, tail low attitude before he lost sight of it behind a line of hangars. The engine sounded like it was operating at full power. The airplane came to rest in a grass field about 350 yards southeast of the departure end of the runway. The main wreckage consisted of the fuselage, engine/propeller, right wing and empennage. The fuselage came to rest on its right side. The right wing had separated at the root and was located immediately adjacent to the fuselage. The left wing was separated at the root and was located about 50 yards north of the main wreckage. A postrecovery examination of the airplane did not reveal any anomalies consistent with a preimpact failure or malfunction. The airplane was equipped with an engine monitor which was downloaded. The data did not reveal any indication of a loss of engine power during takeoff. The data indicated that the takeoff began about 1116:40 as the engine speed increased to 2,659 rpm. The engine speed remained at or above 2,643 rpm until the penultimate data point, which was recorded at 1117:34. The final data point was recorded at 1117:40; the corresponding engine speed at that time was 2,209 rpm. The rated engine speed was 2,700 rpm. The remaining engine parameters were within normal operating limits during the engine run-up and takeoff. A weight and balance calculation based on the available loading information revealed that the takeoff gross weight was approximately 3,249 lbs. and the center-of-gravity location was about 92.59 inches. This was within the allowable loading envelope for the airplane. A current airplane weight and balance record was not available to the investigation. The calculation used a previous airplane empty weight noted in the Federal Aviation Administration airworthiness records. Performance information contained in the airplane owner's manual indicated that the expected takeoff ground roll with 10° flaps was about 1,800 ft and about 2,900 ft required to clear a 50 ft obstacle. With 25° flaps, the takeoff ground roll was expected to be about 1,700ft and about 2,700 ft required to clear a 50 ft obstacle. The density altitude at the time of the accident was about 5,647 ft. The available runway length was 6,100 ft. The airplane owner's manual stated that during takeoff the airplane should be allowed to accelerate to 65 to 70 mph. The manual noted, "premature raising of the nose, or raising it to an excessive angle will result in a delayed take-off." The manual recommended a normal takeoff flap setting of 10° (first notch), and a short-field takeoff flap setting of 25° (second notch).

## Aircraft

- Registration: [N4078W](https://openairdocs.org/deregistered/N4078W-2021-05-08), registration cancelled 2021-05-08, S/N 32-40121, built 1966 (OpenAirDocs)
- Reported make and model: Piper PA32 (300)
- Registry model: [Piper PA-32-300](https://openairdocs.org/model/piper-pa-32-300) (registry code 7103212) (OpenAirDocs)
- Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 32-40121
- Year built: 1966
- Airframe hours: 6953
- Engines: Lycoming IO-540-K1A5 300 horsepower reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, March 11, 2018, 21 hours before
- Departed: HRX, Hereford, TX
- Destination: E41, Big Lake, TX
- Airport: HRX, Hereford Muni, runway 20, 6,100 × 100 ft, concrete
- Equipment: Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 30; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review November 12, 2017; seat: left; restraint: lap only; flight hours: 272 total, 44 in this make and model, 213 as pilot in command, 15 in the last 90 days, 4 in the last 30 days, 0 in the last 24 hours

## Weather

- Conditions: Visual (VMC), Day
- Wind: 210° at 8 knots
- Visibility: 10 statute miles
- Lowest ceiling: 3,000 ft broken
- Temperature: 73 °F, dew point 63 °F
- Altimeter: 30.11 inHg
- Observed at: HRX, 1 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 20180909015669A](https://openairdocs.org/incident/20180909015669A), Sep 9, 2018: Piper PA-32-300, Hereford, TX, Destroyed. On September 9, 2018, at approximately 1100 am local time, N4078W, a Piper PA-32-300 impacted the ground shortly after takeoff coming to rest approximately 200…

## Docket (14 files)

The files NTSB released with the investigation on March 19, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98272. 14.5 MB in all.

- Pilot Statement (item 1, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471232&FileExtension=.PDF&FileName=Pilot%20Statement-Master.PDF
- Conversation Summary - FAA Inspector (item 2, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471233&FileExtension=.PDF&FileName=Conversation%20Summary%20-%20FAA%20Inspector-Master.PDF
- Conversation Summary - Insurance Representative (item 3, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471234&FileExtension=.PDF&FileName=Conversation%20Summary%20-%20Insurance%20Representative-Master.PDF
- Maintenance Records - Airframe (Excerpt) (item 4, .PDF, 430 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471235&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Airframe%20(Excerpt)-Master.PDF
- Maintenance Records - Engine (Excerpt) (item 5, .PDF, 422 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471236&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Engine%20(Excerpt)-Master.PDF
- Maintenance Records - Propeller (Excerpt) (item 6, .PDF, 280 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471237&FileExtension=.PDF&FileName=Maintenance%20Records%20-%20Propeller%20(Excerpt)-Master.PDF
- Pilot's Logbook (item 7, .PDF, 11.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471238&FileExtension=.PDF&FileName=Pilot%27s%20Logbook-Master.PDF
- Weight and Balance Calculation (item 8, .PDF, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471239&FileExtension=.PDF&FileName=Weight%20and%20Balance%20Calculation-Master.PDF
- Density Altitude Calculation (item 9, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471240&FileExtension=.PDF&FileName=Density%20Altitude%20Calculation-Master.PDF
- Weather Observation - Hereford Municipal (item 10, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471241&FileExtension=.PDF&FileName=Weather%20Observation%20-%20Hereford%20Municipal-Master.PDF
- Airplane Owner's Manual (Excerpt) (item 11, .PDF, 765 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471242&FileExtension=.PDF&FileName=Airplane%20Owner%27s%20Manual%20(Excerpt)-Master.PDF
- Airplane Flight Manual (Excerpt) (item 12, .PDF, 447 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471244&FileExtension=.PDF&FileName=Airplane%20Flight%20Manual%20(Excerpt)-Master.PDF
- Plot of Engine Data (item 13, .PDF, 288 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471243&FileExtension=.PDF&FileName=Plot%20of%20Engine%20Data-Master.PDF
- Engine Monitor Data File (item 14, .CSV, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471245&FileExtension=.csv&FileName=Engine%20Monitor%20Data%20File-Master.csv

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.