# NTSB CEN20LA305: Piper PA28, N716RL, San Antonio, TX, July 25, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: July 25, 2020, 09:10 local (14:10 UTC) - Place: San Antonio, TX - Coordinates: 29.331388, -98.464164 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.3314&lon=-98.4642&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) - Highest injury: Fatal - Injuries: 1 fatal, 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming Engines, Piper Aircraft Company, FAA FSDO - NTSB case key (mKey): 101667 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA305 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101667/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101667 - Page: https://openairdocs.org/ntsb/CEN20LA305 ## Probable cause The pilot’s improper decision to take off in an airplane over maximum gross weight and with a tailwind, which prevented the airplane from climbing. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-140, 43 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102802), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Aircraft capability: maximum weight](https://openairdocs.org/ntsb-findings/01061035): Aircraft › Aircraft oper/perf/capability · Capability exceeded; cases with it: [Piper PA-28-140, 4 cases](https://openairdocs.org/ntsb-findings/01061035/cases.md?model=7102802), [All aircraft, 152 cases](https://openairdocs.org/ntsb-findings/01061035/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Piper PA-28-140, 7 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=7102802), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) - [Environmental issues](https://openairdocs.org/ntsb-findings/03020000): Environmental issues › Physical environment · Effect on operation; cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/03020000/cases.md?model=7102802), [All aircraft, 24 cases](https://openairdocs.org/ntsb-findings/03020000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft loading event](https://openairdocs.org/ntsb-events/010); cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-events/010/sequence.md?model=7102802), [All aircraft, 84 cases](https://openairdocs.org/ntsb-events/010/sequence.md) - [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) (defining event); cases with it: [Piper PA-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot, a flight instructor who operated a business at the airport, was taking the two passengers on a local discovery flight to see if they wanted to pursue flight lessons. After takeoff, the pilot was unable to climb the airplane above the tall trees at the end of the runway, obstacles he was likely aware of due to his familiarity with the airport. Airport surveillance video showed that the airplane lifted off after a 1,700-ft-long ground roll and was in a nose-high attitude but not climbing and headed toward the trees, after which the airplane was out of the camera’s view. The airplane impacted trees and terrain about 2,400 ft from the departure end of the runway and was destroyed by impact damage and a postimpact fire. A postaccident examination of the airplane revealed no anomalies that would have precluded normal operation of the airplane. A weight and balance calculation for the accident flight showed that the airplane was operating about 73 lbs over its maximum gross weight of 2,150 lbs. The pilot elected to depart on a runway with a gusty tailwind component of 4 to 7 knots. The airplane’s observed takeoff ground roll of 1,700 ft was 50% longer than the 1,125 ft ground roll predicted by the airplane’s performance charts for a no-wind takeoff at gross weight, indicating that the over gross weight condition and the tail wind significantly degraded the airplane’s performance. It is likely that the pilot’s decision to take off with the airplane over maximum gross weight and a gusty tailwind prevented the airplane from climbing or maintaining altitude. ## Factual narrative Airplane Owner’s Handbook Performance Charts Using the performance charts listed in the handbook for the airplane, at gross weight and a density altitude of 2,300 ft, the takeoff distance was about 1,125 ft, and the airplane was capable of a 550 ft per minute climb rate. Pilot’s Handbook of Aeronautical Knowledge In the Federal Aviation Administration publication, The Pilot’s Handbook of Aeronautical Knowledge (FAA-H-8083-25B), dated 2016, Chapter 11, Aircraft Performance, states that if “the pilot attempts to climb out of ground effect without first attaining normal climb pitch attitude and airspeed, the airplane may inadvertently enter the region of reversed command at a dangerously low altitude. Even with full power, the airplane may be incapable of climbing or even maintaining altitude. The pilot’s only recourse in this situation is to lower the pitch attitude in order to increase airspeed, which inevitably results in a loss of altitude. The airplane was certified to operate as a normal or utility category airplane. The airplane was found configured with four seats and according to its Federal Aviation Administration (FAA) Type Certificate Data Sheet, a four place PA-28-140 can only operate in the normal category with a maximum gross weight of 2,150 lbs. A pilot that also flew N716RL reported filling the airplane with fuel the day before and flew about a 0.9-hour flight. He also remarked that there was a full box of oil cans in the back seat of the airplane. The airplane’s weight at takeoff was estimated to be 2,222.5 lbs or 72.5 lbs over maximum gross weight. It could not be determined if the pilot performed a weight and balance calculation before the flight. Stinson Municipal Airport is serviced by two runways: 9/27 and 14/32. The pilot departed from runway 14. According to the departure procedures listed for Stinson Municipal Airport, there are trees up to 70 ft tall starting 72 ft from the departure end of the runway. The pilot routinely flew from SSF. On July 25, 2020, about 0910 central daylight time, a Piper PA-28-140 airplane, N716RL, was destroyed when it was involved in an accident near Stinson Municipal Airport (SSF), San Antonio, Texas. The pilot and two passengers sustained fatal injuries. The airplane was operated under the provisions of Title 14 Code of Federal Regulations Part 91 as an instructional flight. The pilot was a flight instructor who operated a flight school at SSF, and the two passengers were taking part in a local discovery flight to see if they wanted to pursue flight lessons. The pilot contacted the tower controller and reported that he had received weather information. The pilot then requested to depart runway 14 and perform one lap in the traffic pattern. The controller cleared the airplane for takeoff and reported that the wind was from 030° at 12 knots gusting to 20 knots. Airport surveillance video showed the airplane roll down the runway and take off as the airplane was about abeam the intersection of therunway with taxiway C, a takeoff roll of about 1,700 ft. As the airplane lifted off, it rolled slightly to the right. Another camera angle showed that the airplane’s wings rocked several times, and that the airplane did not climb. The airplane was in a nose-high attitude and was headed toward trees, after which the airplane was out of the camera’s view. The airplane subsequently collided with the trees and terrain, and a postimpact fire ensued. A witness, who was a police officer and a private pilot, observed the airplane take off and noticed that the airplane was flying low. He continued to watch the airplane and stated that the nose of the airplane “kept popping up every 2 or 3 seconds but [the airplane] was still descending.” The witness stated that the engine sounded normal. He saw the airplane descend behind the tree line, heard the crash, and notified the police emergency dispatch. Using the tower controller’s report of wind from 030° at 12 knots gusting to 20 knots, the calculated tailwind component for takeoff on runway 14 was about 4 knots gusting to about 7 knots. Using the reported temperature at SSF of 28°C, the calculated density altitude was about 2,300 ft. The pilot’s logbook was not available during the course of the investigation. On the pilot’s most recent application for medical certificate, dated January 9, 2019, the pilot reported accruing 330 total hours with 200 hours logged in the preceding 6 months. The pilot’s total flight experience could not be determined. The airplane impacted a residential backyard about 2,400 ft southeast of the departure end of runway 14. The first identified point of impact was a damaged tree along the northern fence line of the backyard. The portion of the right-wing fuel tank skin was located below the tree. The fiberglass right wingtip was located between the fuel tank and main wreckage. The main wreckage was located at the center of the backyard. Scorch marks extended to the southern edge of the yard and charring was observed to a wood fence. An examination of the wreckage found that all flight controls were continuous except for the aileron balance cable which was fractured with broomstrawing. The flap handle was found in the first notch which corresponds with 10° flaps. Pitch trim was set to a partial nose-up setting. Engine controls were found full throttle and full rich mixture and the carburetor heat was off. An engine examination revealed no preimpact anomalies that would have precluded normal operations. ## Aircraft - Registration: [N716RL](https://openairdocs.org/aircraft/N716RL), registered now, S/N 28-7225365, built 1972 (OpenAirDocs) - Reported make and model: Piper PA28 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7225365 - Year built: 1972 - Airframe hours: 9010.4 - Engines: Lycoming O-320-E2A 150 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Robert Cole Perguson - Registered owner: Robert Cole Perguson - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 10, 2020 - Departed: SSF, San Antonio, TX - Destination: SSF, San Antonio, TX - Airport: SSF, Stinson Muni, runway 14, 4,128 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 28; injuries: fatal; commercial, flight instructor; airplane ratings: single-engine sea, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review January 19, 2019; seat: left; flight hours: 330 total ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 12 knots, gusting 19 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 73 °F - Altimeter: 29.88 inHg - Observed at: KSSF, 1 nm away - METAR: SPECI KSSF 251418Z 03012G19KT 10SM CLR 28/23 A2988 RMK AO2 T02780228= ## 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 20200725006449A](https://openairdocs.org/incident/20200725006449A), Jul 25, 2020: Piper PA-28-140, San Antonio, TX, Destroyed, 3 fatal. On July 25, 2020 N716RL a Piper cherokee PA-28-140 serial number 28-7225365 departed runway 14 at Stinson airport (kssf) under visual flight rules at 1412 UTC… ## Docket (11 files) The files NTSB released with the investigation on September 22, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101667. 13.1 MB in all. - Case findings (item 1, PDF, 5 pages, 165 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14379397&FileExtension=pdf&FileName=case%20findings%20cen20la305-Rel.pdf - Photos (item 2, PDF, 3 pages, 3 photos, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13938796&FileExtension=pdf&FileName=CEN20LA305%20Photos-Rel.pdf - Video of takeoff (item 3, MP4, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14379379&FileExtension=mp4&FileName=N716RL%20takeoff%20video-Rel.mp4 - Witness information (item 4, PDF, 1 page, 480 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13938806&FileExtension=pdf&FileName=N716RL%20Witness%20Information_Redacted-Rel.pdf - Engine examination summary (item 5, PDF, 2 pages, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13938903&FileExtension=pdf&FileName=Examination%20Summary%20-%20CEN20LA305-Rel.pdf - Weather and performance calculations (item 6, PDF, 8 pages, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14393564&FileExtension=pdf&FileName=Weather%20and%20Performance%202-Rel.pdf - (Obstacle) departure procedures excerpt (item 7, PDF, 2 pages, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13938251&FileExtension=pdf&FileName=Takeoff%20Mins,%20Dept%20Procedures-Rel.pdf - Logbook entries (item 8, PDF, 2 pages, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13938605&FileExtension=pdf&FileName=logbooks%20entries_Redacted-Rel.pdf - Phak excerpt (item 9, PDF, 1 page, 396 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13938988&FileExtension=pdf&FileName=PHAK%20Chapter%2011%20excerpt-Rel.pdf - Party form - Piper aircraft (item 10, PDF, 1 page, 302 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14185832&FileExtension=pdf&FileName=Party%20Form%20N716RL_Redacted-Rel.pdf - Party form Lycoming engines (item 11, PDF, 1 page, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14378971&FileExtension=pdf&FileName=NTSB%20party%20form_Lycoming-CEN20LA305_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.