# NTSB CEN21LA293: Piper PA-28-140, N4216J, Porter, TX, June 25, 2021 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 3 · Limited · Final report - Date: June 25, 2021, 10:00 local (15:00 UTC) - Place: Porter, TX - Coordinates: 30.153375, -95.321989 - Nearby events: https://openairdocs.org/map.md?lat=30.1534&lon=-95.3220&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO - NTSB case key (mKey): 103353 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21LA293 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103353/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103353 - Page: https://openairdocs.org/ntsb/CEN21LA293 ## Probable cause The pilot’s decision to continue the takeoff with degraded engine performance, which resulted in an inability to climb and a subsequent forced landing. The reason for the engine’s degraded performance could not be determined based on available information. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Unknown/Not determined (probable cause); cases with it: [Piper PA-28-140, 10 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=7102802), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Personality/attitude: motivation/respond to pressure](https://openairdocs.org/ntsb-findings/02021025): Personnel issues › Psychological · Pilot; cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/02021025/cases.md?model=7102802), [All aircraft, 53 cases](https://openairdocs.org/ntsb-findings/02021025/cases.md) - [Aircraft capability: climb capability](https://openairdocs.org/ntsb-findings/01061010): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Piper PA-28-140, 7 cases](https://openairdocs.org/ntsb-findings/01061010/cases.md?model=7102802), [All aircraft, 183 cases](https://openairdocs.org/ntsb-findings/01061010/cases.md) - [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) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28-140, 47 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102802), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-140, 56 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102802), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## Analysis According to the pilot and pilot-rated passenger, the airspeed did not increase during the initial climb. The pilot discontinued the climb and made a right turn to avoid trees. The pilot landed the airplane in a nearby construction site, and the airplane struck an embankment, which substantially damaged the fuselage and left wing. Neither the pilot nor the pilot-rated passenger reported noticing any deficiencies with the airplane during the preflight, taxi, or engine run-up. A witness heard the engine run-up and stated that the engine ran rough when the magneto check was performed. This witness and another witness reported that the engine did not sound as if it were producing full power when the airplane began to take off. They reported that the airplane did not become airborne until it was about half way down the runway. A postaccident examination of the airplane did not reveal any anomalies that could be attributed to a loss of engine power. Based on the available evidence, the airplane’s engine was likely not producing full power, which was evident during the pre-takeoff engine run-up. The pilot elected to continue the takeoff with degraded engine power, resulting in an inability to climb and a subsequent forced landing during which the airplane was damaged. The reason for the engine’s degraded performance could not be determined based on available information. At the time of the accident flight, the departure airport was scheduled to be permanently closed the following day, and the purpose of the flight was to relocate the airplane to a nearby airport. The pilot’s self-induced pressure to move the airplane likely contributed to his decision to continue the flight with degraded engine performance. ## Factual narrative On June 25, 2021, about 1000 central daylight time, a Piper PA-28-140, N4216J, was substantially damaged when it was involved in an accident near North Houston Airport (9X1), Porter, Texas. The pilot and passenger were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot and the pilot-rated passenger the preflight, taxi, and run-up checks were normal. The airplane was lined up on the runway for takeoff, full engine power was applied with the brakes held, and the engine instruments were checked before takeoff. After the brakes were released, the airplane accelerated to takeoff speed, and they rotated and began to climb. During the initial climb, the airspeed was not increasing, and the pilot made a right turn to avoid trees. The pilot subsequently landed on a nearby construction site, and the airplane struck an embankment, which damaged the fuselage and left wing. A flight school owner was on the airport ramp and heard the airplane take off. He estimated the engine was only making about 2,000 rpm during the takeoff roll. He wondered why the airplane was taking off under partial engine power and noted that the airplane rotated about 1,800 ft down the runway. It climbed into ground effect and stayed in ground effect. He lost sight of the airplane and did not hear or see the accident. He also noted that he did not see or hear the pre-takeoff engine check. The airport manager heard the engine run-up and thought the engine ran rough during the magneto check. He noted that the engine did not sound unusual except when the magneto check was performed and then it would run rough. He reported that the airplane’s flaps were extended but he could not tell how much. He watched the airplane as it took off and noted that the takeoff started with non-aggressive throttle application and the airplane moving slowly down the runway. He thought that the pilot might have been taxiing the airplane back to the ramp area, but the takeoff continued. He did not think it was at full power and thought the pilot was attempting to clear the magnetos. He stated that the airplane became airborne about midfield and he continued to watch thinking the pilot would land straight ahead. The airplane continued to climb slowly, and he did not think it would clear the trees on the south end of the airport property. The airplane started a right turn toward the west and disappeared from his view. It was reported that the purpose of the flight was to relocate the airplane to another airport since 9X1 was to be permanently closed. The airport permanently ceased operations the day after the accident. A postaccident examination showed that the front of the airplane incurred heavy impact damage. The engine was tilted down, and the carburetor was partially broken from the engine sump due to impact. A visual inspection of the engine did not reveal any preimpact anomalies. One propeller blade had gentle bending in the aftdirection. The engine could be rotated by hand and continuity of the engine valve train and accessory section was confirmed. The upper set of spark plugs was removed and appeared normal. with a light gray color. The engine produced suction and compression during rotation. The engine-driven fuel pump was removed and actuated by hand and appeared to function. The gascolator was damaged and was open due to the accident but had a small amount of debris present. The throttle and mixture controls were connected at the carburetor. The left magneto impulse coupling was very faint when rotated. Spark was observed on the top set of spark plugs. Engine ignition timing was checked and was found to be 25° before top center (BTC) on the right magneto, and about 20° BTC on the left magneto. There was a “SCAT” tube on the engine induction that was crushed. It could not be determined if the SCAT tubing had collapsed before the accident or if the crush-damage was solely a result of impact. The examination of the airplane did not reveal any anomalies that the reported loss of engine power could be attributed to. According to the Lycoming Operator’s Manual for the O-320 series engine, the ignition timing specification was 25° BTC, for an O-320-E2A, as was installed on the accident airplane The weather conditions about the time of the accident included a temperature of 31° Celsius (C), dewpoint 24° C, and an altimeter setting of 29.99 inches of mercury. Based on this data and the airport elevation of 125 ft msl, the calculated density altitude at the time of the accident was 1,985 ft. These weather conditions were conducive for light induction icing at cruise and descent power settings. ## Aircraft - Registration: [N4216J](https://openairdocs.org/deregistered/N4216J-2023-09-22), registration cancelled 2023-09-22, S/N 28-22564, built 1966 (OpenAirDocs) - Reported make and model: PIPER PA-28-140 - 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: 28-22564 - Year built: 1966 - Airframe hours: 3175 - Engines: Lycoming O-320-E2A 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 11, 2021, 10 hours before - Destination: KCXO, Conroe, TX - Airport: 9X1, North Houston, runway 17, 3,594 × 46 ft, asphalt - Equipment: Handheld GPS, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: none; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review November 1, 2019; seat: left; restraint: 3-point; flight hours: 500 total - Pilot-rated passenger; injuries: none; private; airplane ratings: single-engine land; medical: class 2, without waivers/limitations; last flight review June 15, 2021; seat: right; restraint: 3-point ## Weather - Conditions: Visual (VMC), Day - Wind: 190° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 1,700 ft broken - Temperature: 88 °F, dew point 75 °F - Altimeter: 29.99 inHg - Observed at: KDWH, 13 nm away - METAR: METAR KDWH 251453Z 19008KT 10SM BKN017 BKN023 BKN032 31/24 A2999 RMK AO2 SLP154 T03060244 50008= ## 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 20210625010399A](https://openairdocs.org/incident/20210625010399A), Jun 25, 2021: Piper PA-28-140, Porter, TX, Substantial damage. On 6/25/2021 at 1000 CDT, a Piper PA-28-140, s/n 28-22564, N4216J, was attempting to take off on runway 17 at north houston airport (9X1), when the aircraft… ## Docket (12 files) The files NTSB released with the investigation on October 11, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103353. 588 MB in all. - Lycoming engine operator's manual excerpt (item 1, PDF, 1 page, 37 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13194293&FileExtension=pdf&FileName=pa28-lycoming-o-320-operator-s-manual%20excerpt-Rel.pdf - Airplane examination summary (item 2, PDF, 3 pages, 573 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13194205&FileExtension=pdf&FileName=Examination%20Summary%20--Rel.pdf - Pilot statement (item 3, PDF, 1 page, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13193491&FileExtension=pdf&FileName=June%2025%20N4216J%20Omar%20Signed%20Statement_Redacted-Rel.pdf - Pilot rated passenger statement (item 4, PDF, 1 page, 321 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13194739&FileExtension=pdf&FileName=Mohammad%20N4216J%20Statement%20(signed)_Redacted-Rel.pdf - Witness statements (item 5, PDF, 2 pages, 135 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13194544&FileExtension=pdf&FileName=Witness%20statements_Redacted-Rel.pdf - Photo array (item 6, PDF, 4 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13195003&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Pilot logbook (item 7, PDF, 13 pages, 156 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13196184&FileExtension=pdf&FileName=Pilot%20logbook_Redacted-Rel.pdf - Maintenance records (item 8, PDF, 34 pages, 427 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13195735&FileExtension=pdf&FileName=Maintenance%20records_Redacted-Rel.pdf - Carburetor icing probability chart from FAA SAIB CE-09-35 (item 9, PDF, 1 page, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13199967&FileExtension=pdf&FileName=Carb%20ice%20chart%20from%20SAIB-Rel.pdf - Weather METAR reports (item 10, PDF, 1 page, 116 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13199977&FileExtension=pdf&FileName=METARS-Rel.pdf - Airport information (item 11, PDF, 3 pages, 867 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13200373&FileExtension=pdf&FileName=Airport%20information-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 12, PDF, 1 page, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14361552&FileExtension=pdf&FileName=Attachment_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.