# NTSB CHI04LA201: Piper PA-28-140, N4345J, Custer, SD, July 31, 2004 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: July 31, 2004, 09:50 local (15:50 UTC) - Place: Custer, SD - Coordinates: 43.733333, -103.617774 - Nearby events: https://openairdocs.org/map.md?lat=43.7333&lon=-103.6178&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report June 8, 2005 - Report: Approved by Office Director - Parties: FAA, Rapid City, SD FSDO - NTSB case key (mKey): 59806 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI04LA201 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/59806/pdf - Page: https://openairdocs.org/ntsb/CHI04LA201 ## Probable cause The pilot's poor preflight planning/preparation and the pilot used improper aborted takeoff procedures by not reducing the throttle. Factors associated with the accident were the high density altitude and the tailwind. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Overrun, takeoff - aborted - preflight planning/preparation - poor, pilot in command (cause) - wrong runway - used, pilot in command (contributing factor) - weather condition - high density altitude (contributing factor) - weather condition - tailwind (contributing factor) - aborted takeoff - improper, pilot in command (cause) - throttle/power control - improper use of, pilot in command (cause) - On ground/water encounter with terrain/water, takeoff - aborted - terrain condition - ground ## Analysis The airplane collided with rough terrain when it overran the end of the runway during an aborted takeoff. The certificated flight instructor (CFI) was demonstrating a "ground effect acceleration takeoff" when the accident occurred. The CFI stated the airplane did not accelerate in ground effect to his target speed of 90 miles per hours so he initiated an aborted takeoff about 1,500 feet prior to the end of the runway. The CFI stated that upon touchdown, the braking action was poor. He stated he reduced back pressure and applied brakes firmly, before applying back pressure again, but the airplane did not stop. The CFI stated the airplane departed the end of the runway at a speed of about 70 mph. The student pilot stated the CFI "... cut power immediately, and began to flare. When it was evident that the aircraft was not slowing at a sufficient rate, the instructor dropped the nose and both instructor and student applied full brakes." The airport manager who witnessed the accident reported the airplane was about 10 feet above the runway when it settled back to the runway. He stated the airplane was "... still under full power all the remaining way to the white marks at the end of runway eight." He stated the engine power was then reduced and the airplane skidded between the runway end lights. The manager stated, "From the point of impact to the point where the throttle was fully retarded, there was a continuous cloud of blue smoke." The airplane came to rest in the grass approximately 250 feet from the departure end of the runway. Black skid marks and metallic scrape marks were visible on the runway. These marks began about 300 feet prior to the departure end of the runway and continued to the end of the runway. Density altitude at the time of the takeoff was 8,110 feet. The takeoff was being made on runway 08 and the wind was from 250 degrees at 9 knots. The PA-28-140 Owner's Handbook provides a takeoff distance versus density altitude chart. The chart contains information for density altitudes up to 7,000 feet. The chart states "Extrapolation of chart above 7000 ft. is invalid." The landing distance versus density altitude chart indicates that at a density altitude of 7,000 feet, with 40 degrees of flaps, at gross weight with no wind, the landing distance would be 1,250 feet. ## Factual narrative On July 31, 2004, at 0950 mountain daylight time, a Piper PA-28-140, N4345J, collided with rough terrain when it overran the departure end of runway 08 (5,500 feet by 60 feet, dry asphalt) during an aborted takeoff, at the Custer County Airport (CUT), Custer, South Dakota. The certified flight instructor (CFI) and the student pilot were not injured. The airplane was substantially damaged. The 14 CFR Part 91 instructional flight was operating in visual meteorological conditions without a flight plan. The local flight was originating at the time of the accident. The CFI reported he was demonstrating a "ground effect acceleration takeoff" to his student when the accident occurred. The CFI reported the density altitude at the time of the accident was 7,800 feet. The CFI stated the airplane did not accelerate in ground effect to his target speed of 90 miles per hour (mph) so he initiated an aborted takeoff about 1,500 feet prior to the end of the runway. The CFI stated that upon touchdown, the braking action was poor. He stated, "I reduced back pressure for a more positive traction and applied brakes firmly, before applying back pressure again. It wasn't until this point that I was concerned as it became obvious that there was virtually no braking action. Moments later I asked the student to assist me in braking with her toe brakes." The CFI stated the airplane departed the end of the runway at a speed of about 70 mph. The student pilot reported the target speed was not achieved, so the takeoff was aborted. She stated the CFI "... cut power immediately, and began to flare. When it was evident that the aircraft was not slowing at a sufficient rate, the instructor dropped the nose and both instructor and student applied full brakes." The airport manager who witnessed the takeoff reported the airplane "... appeared to hit the runway from a height of approximately 10', two thirds of the way down runway eight. From which point, the 140 was still under full power all the remaining way to the white marks at the end of runway eight." He stated the engine power was then reduced and the airplane skidded between the runway end lights. The manager stated, "From the point of impact to the point where the throttle was fully retarded, there was a continuous cloud of blue smoke." The airplane came to rest in the grass approximately 250 feet from the departure end of the runway. Black skid marks and metallic scrape marks were visible on the runway. These marks began about 300 feet prior to the departure end of the runway and continued to the end of the runway. The airplane came to a stop with both main landing gear turned sideways. The scissors mechanisms on both main landing gear separated and the gear were turned sideways. The right wing was pulled away from the fuselage and the bottom of both wings were wrinkled near the landing gear attach points. The weather reporting station at CUT reported the conditions at 0953 were: wind 250 at 9 knots; 10 statute miles visibility; clear skies; temperature 26 degrees Celsius; dew point 5 degrees Celsius; and a barometric pressure of 30.04 inches of mercury. Using the current weather information along with a field elevation of 5,602 feet mean sea level (msl), the density altitude was calculated to be 8,110 feet. The takeoff was being made on runway 08 and the wind was from 250 degrees at 9 knots. The PA-28-140 Owner's Handbook provides a takeoff distance versus density altitude chart. The chart contains information for density altitudes up to 7,000 feet. The chart states "Extrapolation of chart above 7000 ft. is invalid." The landing distance versus density altitude chart indicates that at a density altitude of 7,000 feet, with 40 degrees of flaps, at gross weight with no wind, the landing distance would be 1,250 feet. ## Aircraft - Registration: [N4345J](https://openairdocs.org/aircraft/N4345J), registered now, S/N 28-22721 (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: 28-22721 - Airframe hours: 3553 - Engines: Lycoming O-320-E2A 150 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: Flight Training Adventure Camps - Registered owner: Dominik J. Strobel - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 2, 2004, 50 hours before - Departed: CUT, Custer, SD - Destination: CUT, Custer, SD - Airport: CUT, Custer County, runway 08, 5,500 × 60 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, valid medical--w/ waivers/lim; last flight review July 29, 2004; seat: right; flight hours: 2,500 total, 1,000 in this make and model, 2,450 as pilot in command, 8 in the last 90 days, 8 in the last 30 days, 2 in the last 24 hours - Student pilot; age 20; injuries: none; student; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 5 total, 5 in this make and model, 5 in the last 90 days, 5 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 9 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 41 °F - Altimeter: 30.04 inHg - Observed at: CUT ## 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 20040731018169A](https://openairdocs.org/incident/20040731018169A), Jul 31, 2004: Piper PA28140, Custer, SD, Substantial damage. (-23) On July 31, 2004, at approximately 0950 local time, Mr. Strobel and his student departed from Custer, SD (cut) on rwy 8. The weather was clear, the wind… 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.