# NTSB CEN23FA304: Piper PA28, N8225N, Osage Beach, MO, July 13, 2023

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Field · Final report
- Date: July 13, 2023, 11:57 local (16:57 UTC)
- Place: Osage Beach, MO · Heavily wooded area on private property.
- Coordinates: 38.121106, -92.68833 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=38.1211&lon=-92.6883&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: Fatal
- Injuries: 2 fatal, 1 serious
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Central Region
- Parties: Lycoming Engines, FAA Kansas City FSDO, Piper Aircraft
- NTSB case key (mKey): 192625
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23FA304
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192625/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192625
- Page: https://openairdocs.org/ntsb/CEN23FA304

## Probable cause

The pilot’s failure to properly set the stabilator trim before takeoff, which resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall during takeoff.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Flight control system: elevator control system](https://openairdocs.org/ntsb-findings/01022730): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/01022730/cases.md?model=7102802), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022730/cases.md)
- [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-140, 6 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=7102802), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md)
- [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Piper PA-28-140, 14 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7102802), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-140, 103 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102802), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Attention/monitoring: task monitoring/vigilance](https://openairdocs.org/ntsb-findings/02021520): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28-140, 5 cases](https://openairdocs.org/ntsb-findings/02021520/cases.md?model=7102802), [All aircraft, 330 cases](https://openairdocs.org/ntsb-findings/02021520/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: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-28-140, 14 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102802), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md)
- [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28-140, 44 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102802), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Takeoff: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-28-140, 19 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7102802), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md)
- [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Piper PA-28-140, 21 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7102802), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md)
- [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); 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 surviving passenger reported that the airplane did not seem to be climbing as well as it should have during the takeoff for the local sightseeing flight. The passenger believed the pilot was perhaps fighting the flight controls for an unknown reason. Shortly after takeoff, the airplane made a “violent turn” to the right, and it seemed like the airplane went straight down. The turn to the right and the airplane going straight down seemed to happen at the same time. The airplane came to rest nose down near multiple large trees. The accident site was about 0.55 mile from the departure end of the runway. The airplane sustained substantial damage to the fuselage, both wings, and the empennage. Two witnesses reported observing the airplane during the takeoff with its nose “pitched up in the air” and “the tail was lower than the nose.” A review of local area surveillance video recordings showed the airplane in flight with a nose-up attitude. Examination of the wreckage did not reveal any preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. During the examination, the stabilator trim was found in the full nose-up position. The takeoff checklist for the airplane included instructions to properly set the stabilator trim before takeoff. The passenger did not recall if the pilot used the checklist or adjusted the stabilator trim once before takeoff. It is likely that the stabilator trim position resulted in the airplane's extreme nose-up attitude, which led to an exceedance of the airplane's critical angle of attack and an aerodynamic stall during the takeoff. It is also likely the stabilator trim was left at the setting from when the airplane landed at the airport the day before. It was undetermined why the pilot did not set the stabilator trim before takeoff.

## Factual narrative

The FAA Airplane Flying Handbook FAA-H-8083-3C discusses when an elevator stall may occur and states in part: This situation may occur during a go-around procedure from a normal landing approach or a simulated, forced-landing approach, or immediately after a takeoff, with the trim set for a normal landing approach glide at idle power. The owner of the airplane reported there were no known mechanical issues with the airplane. A review of the airframe and engine maintenance records revealed no outstanding mechanical anomalies with the airplane. The airplane had a manual trim system. The manual trim control was located on the top of the cockpit, on the interior roof. The airplane was equipped with a stall warning system that includes a red light that illuminates on the left side of the instrument panel between 5 and 10 mph above the stall speed. A calculation of weight and balance numbers showed the airplane was within limitations for the accident flight. According to the Piper Cherokee 140 B Owner’s Handbook, the takeoff checklist states, “trim tab set.” The airplane was equipped with a stabilator, as opposed to a stabilizer-elevator configuration. On July 13, 2023, about 1157 central daylight time, a Piper PA-28-140 airplane, N8225N, sustained substantial damage when it was involved in an accident in Osage Beach, Missouri. The pilot and one passenger sustained fatal injuries. One passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot flew the airplane from its home base at the Carrollton Memorial Airport (K26), Carrollton, Missouri, to the Grand Glaize-Osage Beach Airport (K15), Osage Beach, Missouri. The airplane arrived at K15 on July 12, 2023, about 1030. According to the airport manager, the airplane did not refuel at the airport. The purpose of the flight was to take the two passengers on a sightseeing flight in the local area to view scenery around the Lake of the Ozarks. According to the owner of the airplane, the airplane should have had about 25 gallons of fuel onboard for the flight. The surviving passenger reported that the flight was going to last about 30 minutes. During the preflight inspection of the airplane, the pilot did not mention any concerns with the airplane to the passenger. The pilot did not ask the two passengers for their weights before departing, nor did the pilot conduct a safety briefing with the two passengers. The pilot was sitting in the front left seat, the surviving passenger was in the front right seat, and the other passenger was in the rear left seat. The two passengers did not use the available lap belt restraint systems for the flight. The passenger stated that he did not recall if the pilot used a checklist after they boarded the airplane. He also stated that he does not recall if the pilot adjusted the manual trim before or during the takeoff. The airplane departed from runway 32 at K15. During the takeoff, it seemedlike the airplane was not climbing as much as it should have according to the passenger. Also, during the takeoff, it seemed that the pilot was perhaps fighting the flight controls for an unknown reason. The pilot then said, “what the [expletive].” The passenger did not know what the pilot meant by saying that. Shortly after the pilot said that statement out loud, the passenger reported the airplane entered a “violent turn” to the right, and it seemed like it went straight down. The turn to the right and the airplane going straight down seemed to happen at the same time. The pilot did not say anything else after the “what the [expletive]” statement. The passenger reported that he and the other passenger did not touch the flight controls in the airplane at any time, nor did he hear any sputtering or coughing noises from the engine during the runup or the takeoff. The passenger did not recall seeing any cockpit lights illuminate or hear any cockpit alarms activate during the takeoff. The passenger did not recall any events after the descending right turn. The airplane came to rest nose down near multiple large trees. The accident site was about 0.55 mile from the departure end of runway 32. The airplane sustained substantial damage to the fuselage, both wings, and the empennage. Two witnesses reported observing the airplane during the takeoff with its nose “pitched up in the air” and “the tail was lower than the nose.” A review of local area surveillance video recordings showed the airplane in flight with a nose-up attitude. An autopsy of the pilot was performed by Southwest Missouri Forensics, Ozark, Missouri. The autopsy report was reviewed by the NTSB Investigator-In-Charge. According to the autopsy report, the cause of death was blunt force injuries, and the manner of death was accident. Toxicology testing was performed at the Federal Aviation Administration Forensic Sciences Laboratory. The test results were negative for substances tested. The estimated density altitude for the closest meteorological reporting station was 3,552 ft above mean sea level. The father of the pilot reported that his son was scheduled to take his certificated flight instructor check ride on July 18, 2023. A review of Federal Aviation Administration (FAA) records showed that the pilot had successfully passed the Fundamentals of Instructing examination on March 31, 2023, and the Flight Instructor Airplane examination on May 26, 2023. An examination of the airframe confirmed flight control continuity. The trim tab jackscrew was found extended above the drum, with about 17 threads exposed (about 1 and ¾ inch), that corresponded to a full nose-up stabilator trim setting. The stall warning system lift detector was intact, and the switch was heard to make an audible “click” when actuated. The engine crankshaft was rotated by turning the crankshaft propeller mounting flange and continuity of the crankshaft to the rear gears and to the valvetrain was observed. Compressionand suction were observed from all four cylinders. The interiors of the cylinders were observed using a lighted borescope and no anomalies were noted. The two-blade aluminum propeller was found separated from the engine. The propeller bolts were found broken, and the propeller and starter ring gear separated from the engine crankshaft flange. The propeller showed some chordwise scratching on both blades, on both the forward and aft faces. One blade was found with slight aft bending and the other blade was bent, about ¾ span from the root, rearward about 80 degrees. There were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation.

## Aircraft

- Registration: [N8225N](https://openairdocs.org/deregistered/N8225N-2023-12-05), registration cancelled 2023-12-05, S/N 28-25430, built 1969 (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: 28-25430
- Year built: 1969
- Airframe hours: 5444.24
- Engines: Lycoming Engines O-320-E2A 150 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, August 19, 2022, 36.57 hours before
- Equipment: Electronic flight bag or handheld device, Stall warning system

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 22; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review March 15, 2023; seat: left; restraint: lap only; toxicology performed; flight hours: 240 total, 165 as pilot in command

## Weather

- Conditions: Visual (VMC), Day
- Wind: 270° at 6 knots
- Visibility: 9 statute miles
- Lowest ceiling: 2,600 ft broken
- Temperature: 86 °F, dew point 72 °F
- Altimeter: 29.86 inHg
- Observed at: KTBN, 34 nm away
- METAR: KTBN 131655Z AUTO 27006KT 9SM BKN026 30/22 A2986 RMK AO2 SLP101 T03020221 $

## 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 20230713010389A](https://openairdocs.org/incident/20230713010389A), Jul 13, 2023: Piper PA-28-140, Osage Beach, MO, Destroyed, 2 fatal. During climb out on runway 32, the aircraft lost engine power. The aircraft right wing stalled and rolled right. The aircraft impacted trees and then the…

## Other investigations on N8225N (2)

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 CHI74FEE24](https://openairdocs.org/ntsb/CHI74FEE24), Sep 30, 1973: Piper PA-28 (N8225N), Plainfield, IL, substantial damage
- [NTSB CHI71DEE91](https://openairdocs.org/ntsb/CHI71DEE91), Jun 27, 1971: Piper PA-28 (N8225N), Midlothian, IL, substantial damage

## Docket (25 files)

The files NTSB released with the investigation on November 21, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192625. 3.5 GB in all.

- Accident photographs (item 1, PDF, 16 pages, 7.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17464307&FileExtension=pdf&FileName=Accident%20Photographs-Rel.pdf
- Grand glaize airport - video footage 1 (.avi file) (item 2, AVI, 67.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17460736&FileExtension=avi&FileName=Airport%20Video%201-Rel.avi
- Grand glaize airport - video footage 2 (.avi file) (item 3, AVI, 579 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17460371&FileExtension=avi&FileName=Airport%20Video%202-Rel.avi
- Grand glaize airport - video footage 3 (.avi file) (item 4, AVI, 144 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17460746&FileExtension=avi&FileName=Airport%20Video%203-Rel.avi
- Grand glaize airport - video footage 4 (.avi file) (item 5, AVI, 22.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17460381&FileExtension=avi&FileName=Airport%20Video%204-Rel.avi
- Lake regional hospital - additional parking lot video footage (.avi file) (item 6, AVI, 1.0 GB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17459293&FileExtension=avi&FileName=Lake%20Regional%20Hospital%20-%20Additional%20Parking%20Lot%207_13_2023%2011_57_37%20(UTC-05_00)-Rel.avi
- Lake regional hospital - emergency room parking lot video footage (.avi file) (item 7, AVI, 1.5 GB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17459303&FileExtension=avi&FileName=Lake%20Regional%20Hospital%20-%20ER%20Parking%20Lot%207_13_2023%2011_57_45%20(UTC-05_00)-Rel.avi
- Accident sequence witness statements (item 8, PDF, 11 pages, 28.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17370377&FileExtension=pdf&FileName=Accident%20Sequence%20Witness%20Statements_Redacted-Rel.pdf
- Additional accident sequence witness statements (item 9, PDF, 2 pages, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17370530&FileExtension=pdf&FileName=Additional%20Accident%20Sequence%20Witness%20Statements-Rel.pdf
- Additional statements (item 10, PDF, 5 pages, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17370665&FileExtension=pdf&FileName=Additional%20Statements-Rel.pdf
- Pilot logbook excerpts (item 11, PDF, 12 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17369452&FileExtension=pdf&FileName=Pilot%20Logbook%20Excerpts_Redacted-Rel.pdf
- Additional pilot information (item 12, PDF, 1 page, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17460990&FileExtension=pdf&FileName=CEN23FA304%20Pilot%20Information%20MOR-Rel.pdf
- N8225N airframe and engine examination report (item 13, PDF, 8 pages, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17464547&FileExtension=pdf&FileName=CEN23FA304%20Airframe%20and%20Engine%20Examination%20Report-Rel.pdf
- N8225N recent airframe maintenance records (item 14, PDF, 5 pages, 7.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17370215&FileExtension=pdf&FileName=N8225N%20Recent%20Airframe%20Maintenance%20Records_Redacted-Rel.pdf
- N8225N recent engine maintenance records (item 15, PDF, 6 pages, 13.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17370470&FileExtension=pdf&FileName=N8225N%20Recent%20Engine%20Maintenance%20Records_Redacted-Rel.pdf
- N8225N recent propeller maintenance records (item 16, PDF, 2 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17370939&FileExtension=pdf&FileName=N8225N%20Recent%20Propeller%20Maintenance%20Records_Redacted-Rel.pdf
- Airplane weight and balance sheet (item 17, PDF, 1 page, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17367908&FileExtension=pdf&FileName=Airplane%20Weight%20and%20Balance%20Sheet_Redacted-Rel.pdf
- Airplane weight and balance calculations (item 18, PDF, 4 pages, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17367273&FileExtension=pdf&FileName=Airplane%20Weight%20and%20Balance%20Calculations_Redacted-Rel.pdf
- N8225N cockpit checklist placard (item 19, PDF, 1 page, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17464075&FileExtension=pdf&FileName=N8225N%20Cockpit%20Checklist%20Placard-Rel.pdf
- Piper cherokee 140B owner's handbook - excerpts (item 20, PDF, 4 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17367763&FileExtension=pdf&FileName=Piper%20Cherokee%20140B%20Owner%27s%20Handbook%20-%20Excerpts-Rel.pdf
- Additional Piper PA-28-140 cherokee checklist (item 21, PDF, 2 pages, 5.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17367773&FileExtension=pdf&FileName=Additional%20Piper%20PA-28-140%20Cherokee%20Checklist-Rel.pdf
- Weather information (item 22, PDF, 2 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17370323&FileExtension=pdf&FileName=CEN23FA304%20Weather%20Information_Redacted-Rel.pdf
- FAA forensic toxicology report (item 23, PDF, 1 page, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17364254&FileExtension=pdf&FileName=FAA%20Forensic%20Toxicology%20Report_Redacted-Rel.pdf
- Release of aircraft wreckage, NTSB form 6120.15 (item 24, PDF, 2 pages, 421 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17461043&FileExtension=pdf&FileName=N8225N%20NTSB%20Wreckage%20Release%20Form_Redacted-Rel.pdf
- NTSB party member forms (item 25, PDF, 2 pages, 430 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17364078&FileExtension=pdf&FileName=NTSB%20Party%20Member%20Forms_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.

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