# NTSB CEN20FA072: Piper PA28, N5969W, Florence, CO, February 2, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: February 2, 2020, 13:55 local (20:55 UTC) - Place: Florence, CO - Coordinates: 38.430831, -105.118057 - Nearby events: https://openairdocs.org/map.md?lat=38.4308&lon=-105.1181&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal, 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO, Lycoming Engines, Piper Aircraft - NTSB case key (mKey): 100891 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20FA072 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100891/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100891 - Page: https://openairdocs.org/ntsb/CEN20FA072 ## Probable cause The pilot’s decision to continue the takeoff with reduced airplane performance due to high density altitude ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-150, 1 case](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7102804), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Piper PA-28-150, 1 case](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=7102804), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-150, 4 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102804), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-28-150, 3 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102804), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28-150, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102804), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis During takeoff for a local flight, the flight instructor rotated the airplane, but it failed to lift off from the runway. The flight instructor continued the takeoff and rotated the airplane a second time; at that point, the airplane was located near the midpoint of the runway. A witness reported that the airplane’s climb performance was weak. During the climb, the flight instructor recognized that something was wrong and made a 180° turn to land on the runway. The airplane impacted terrain resulting in substantial damage to both wings and the fuselage. Postaccident examination of the airframe and engine found no preimpact anomalies that would have precluded normal operations. A review of meteorological data revealed that the temperature at the time of the accident was the warmest that the pilot had encountered since he purchased the airplane 1 month before the accident. The weather conditions at the time of the accident were consistent with a high density altitude; well above the threshold indicated in guidance at which leaning the fuel mixture is recommended to maintain airplane performance. Postaccident calculations showed that, in the weather conditions at the time, the airplane would have experienced a takeoff distance increase of 140% and a climb performance decrease of 65%. It is not possible to determine, based on the available evidence, whether the instructor adequately leaned the airplane’s fuel mixture for departure and whether that contributed to degraded airplane performance. During a previous flight, the airplane exhibited reduced performance while operating in lower density altitude conditions than those on the day of the accident. ## Factual narrative FAA-P-8740-2, “Density Altitude” The Federal Aviation Administration’s density altitude document (FAA-P-8740-2), dated 2008, stated the following: Whether due to high altitude, high temperature, or both, reduced air density (reported in terms of density altitude) adversely affects aerodynamic performance and decreases the engine’s horsepower output. Takeoff distance, power available (in normally aspirated engines), and climb rate are all adversely affected. Landing distance is affected as well; although the indicated airspeed (IAS) remains the same, the true airspeed (TAS) increases. From the pilot’s point of view, therefore, an increase in density altitude results in the following: • Increased takeoff distance. • Reduced rate of climb. • Increased TAS (but same IAS) on approach and landing. • Increased landing roll distance. In addition:If the airplane flight manual (AFM)/POH [Pilot’s Operating Handbook] is not available, use the Koch Chart to calculate the approximate temperature and altitude adjustments for aircraft takeoff distance and rate of climb. At power settings of less than 75 percent, or at density altitude above 5,000 feet, it is also essential to lean normally aspirated engines for maximum power on takeoff (unless the aircraft is equipped with an automatic altitude mixture control). Otherwise, the excessively rich mixture is another detriment to overall performance. Video of Earlier Flight A student pilot, who had flown in the accident airplane with the flight instructor about 1 month before the accident, provided a video of that flight. The student said that the flight included the flight instructor, himself, and a passenger. The airplane was fueled with 20 gallons. The video showed that, when the airplane was rotated at a speed of about 72 mph, the stall warning light illuminated and continued to flicker as the airplane climbed and accelerated toward 85 mph. The student pilot then asked if “that” was normal; the flight instructor replied, “yeah, it’s pretty sensitive but we are nowhere near a stall.” Later during the climbout, the flight instructor remarked that the airplane “is not climbing today.” A review of weather information for that flight showed that the temperature was 46.4°F with a pressure altitude of 5,122 ft. The Koch Chart showed a decrease in climb performance of about 50%. According to the most recent weight and balance information, the accident airplane was operated about 100 pounds below maximum gross weight. On February 2, 2020, about 1355 mountain daylight time, a Piper PA28-150 airplane, N5969W, was substantially damaged when it was involved in an accident near Florence, Colorado. The flight instructor and one passenger were seriously injured, and one passenger was fatally injured. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. The flight was a second exploration flight for the passenger seated in the front left seat. The brother ofthat person was seated in the aft right seat, and the flight instructor was seated in the front right seat. The flight instructor reported that he rotated the airplane using about 2,000 ft of the 5,399-ft-long runway. The airplane climbed and then settled back down to the runway. About 2,500 ft down the runway, the flight instructor rotated the airplane again and entered ground effect. He did not recall the climbout but remembered that he flew a 180° turn to land on runway 11. The airplane descended and impacted rolling terrain about 1,000 ft southwest of the departure end of runway 29. An eyewitness saw the accident airplane depart from about midfield. He recalled that the airplane sounded as if it were making the expected power but that the subsequent climb was “anemic.” The calculated density altitude at the airport was 7,931 ft. At the time of the accident, the weather observation at the airport indicated a temperature of 24ºC/75ºF. According to the flight instructor, it was the highest temperature at 1V6 since his purchase of the accident airplane. The recorded dewpoint was -15ºC/5 ºF and the barometric pressure was 29.78 in of mercury. Using the Koch Chart located in the Federal Aviation Administration’s Density Altitude document, the airplane would be expected to experience a takeoff distance increase of 140% and a climb performance reduction of 65%. The flight instructor purchased the airplane on December 31, 2019, about 1 month before the accident. In addition to logging flight time in the accident airplane the flight instructor had logged time in Cessna 210-5A, Piper PA28-180, and Cessna 182T airplanes. Figure 1 Accident Site Plots The initial impact point was determined to be scuffing along the ground that went up an embankment along a 125° magnetic heading. The airplane came to rest upright on a 347° magnetic heading. The left wing had separated and was broken in several locations. The left wing fuel tank was breached but contained some fuel. The right wing remained attached to the airplane, and the fuel tank contained fuel. About 20 to 25 gallons of fuel was drained from airplane. The tachometer displayed 2,995.81 hours, and the Hobbs meter showed 610.4 hours. Flight control continuity was traced from the flight controls to the control surfaces. The flap handle was set to the first notch, which corresponded to 10° flap extension. The trim screw displayed about 1 inch (7 threads visible) approximating a neutral-to-nose-up pitch trim setting. The propeller remained mounted to the engine crankshaft flange. The spinner was crushed aft against the propeller hub. One propeller blade was bent aft about 90° with chordwise polishing observed, and some leading-edge denting and chipping were noted. The other blade was straight and showed no evidence of scraping and chipping. All engine filters and screens were clear of debris. Valve train continuity and thumb compression were obtained for each cylinder. The magnetos produced spark at eachterminal. The carburetor had separated and showed signatures of hydraulic pressure to one of the floats, consistent with fluid (fuel) being present in the carburetor at impact. No preimpact anomalies were detected with the airframe or engine. ## Aircraft - Registration: [N5969W](https://openairdocs.org/deregistered/N5969W-2020-10-31), registration cancelled 2020-10-31, S/N 28-3957, built 1967 (OpenAirDocs) - Reported make and model: Piper PA28 (150) - Registry model: [Piper PA-28-150](https://openairdocs.org/model/piper-pa-28-150) (registry code 7102804) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-3957 - Year built: 1967 - Airframe hours: 2995.81 - Engines: Lycoming O-320 SERIES reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, December 26, 2019, 9.92 hours before - Departed: 1V6, Florence, CO - Destination: 1V6, Florence, CO - Airport: 1V6, Fremont County, runway 29, 5,399 × 75 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 22; injuries: serious; commercial, flight instructor; airplane ratings: single-engine land, multi-engine sea; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review February 16, 2019; seat: right; restraint: lap only; flight hours: 469.6 total, 9.5 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 75 °F, dew point 5 °F - Altimeter: 29.78 inHg - Observed at: K1V6, 30 nm away - METAR: METAR K1V6 022050Z AUTO 28006KT 10SM CLR 24/M15 A2978 RMK AO2= ## 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 20200202000799A](https://openairdocs.org/incident/20200202000799A), Feb 2, 2020: Piper PA-28-150, Florence, CO, Substantial damage, 1 fatal. On 02/02/2020 the pilot took off from runway 29 at freemont airport in Florence Colorado. The winds were 250 at 7 knots, temp was 75 degrees and it was clear.… ## Other investigations on N5969W (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 MKC86LA180](https://openairdocs.org/ntsb/MKC86LA180), Aug 27, 1986: Piper PA-28-150C (N5969W), Junction City, KS, substantial damage ## Docket (13 files) The files NTSB released with the investigation on June 1, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100891. 70.0 MB in all. - Case findings (item 1, PDF, 5 pages, 256 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13963526&FileExtension=pdf&FileName=FA072%20CASE%20FINDINGS-Rel.pdf - Pilot emails (item 2, PDF, 7 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13930019&FileExtension=pdf&FileName=pilot%20emails_Redacted-Rel.pdf - Photos (item 3, PDF, 7 pages, 8 photos, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13662289&FileExtension=pdf&FileName=Photos%207-Rel.pdf - Airplane log books pages (item 4, PDF, 3 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13930337&FileExtension=pdf&FileName=Logbook%20Pages_Redacted-Rel.pdf - Pilot log books (item 5, PDF, 10 pages, 9.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13646110&FileExtension=pdf&FileName=p%20logs%20reduced_Redacted-Rel.pdf - Accident density altitude and performance calculations (item 6, PDF, 6 pages, 775 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13647071&FileExtension=pdf&FileName=Accident%20Density%20Altitude%20calculations-Rel.pdf - Witness email (item 7, PDF, 1 page, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13647429&FileExtension=pdf&FileName=witness%20email_Redacted-Rel.pdf - Previous flight video (item 8, MP4, 22.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13647533&FileExtension=mp4&FileName=20200105_134734_001-Rel.mp4 - Takeoff video (item 9, MP4, 20.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13648043&FileExtension=mp4&FileName=Takeoff%20Video-Rel.mp4 - Eyewitnesses (item 10, PDF, 3 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13663732&FileExtension=pdf&FileName=Witness%20Statements_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 11, PDF, 1 page, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13664637&FileExtension=pdf&FileName=N5969W%20Retention-Release-of-Wreckage-Form_Redacted-Rel.pdf - Record of conversation benker (item 12, PDF, 1 page, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13962481&FileExtension=pdf&FileName=Record%20of%20Conversation%20Benker-Rel.pdf - Dispatch log (item 13, PDF, 2 pages, 7.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13963634&FileExtension=pdf&FileName=Dispatch%20Log_Redacted-Rel.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.