# NTSB CHI08LA197: Piper PA-28-161, N2133V, Sparta, WI, July 19, 2008 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: July 18, 2008, 22:30 local (Jul 19, 2008, 03:30 UTC) - Place: Sparta, WI - Coordinates: 43.958332, -90.737777 - Nearby events: https://openairdocs.org/map.md?lat=43.9583&lon=-90.7378&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff-rejected takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: Serious injuries - Injuries: 1 serious, 3 uninjured - Status: Completed, report May 12, 2009 - Report: Approved by Office Director - Parties: FAA Milwaukee FSDO - NTSB case key (mKey): 68861 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI08LA197 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/68861/pdf - Page: https://openairdocs.org/ntsb/CHI08LA197 ## Probable cause The pilot's inadequate preflight planning and the pilot's delay in aborting the takeoff. Contributing to the accident was the airplane's overgross weight condition. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: flight planning/navigation](https://openairdocs.org/ntsb-findings/02061025): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/02061025/cases.md?model=7102803), [All aircraft, 179 cases](https://openairdocs.org/ntsb-findings/02061025/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-161, 10 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7102803), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Planning/preparation: weight/balance calculations](https://openairdocs.org/ntsb-findings/02061015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-161, 2 cases](https://openairdocs.org/ntsb-findings/02061015/cases.md?model=7102803), [All aircraft, 110 cases](https://openairdocs.org/ntsb-findings/02061015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff-rejected takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Piper PA-28-161, 30 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102803), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Takeoff-rejected takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-161, 58 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102803), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that he had landed at the airport to refuel, and the accident occured during an aborted takeoff when it departed the end of the 4,708-foot by 100 feet, asphalt runway. He reported that he "filled the tanks to 28 gallons total via visual inspection." After another preflight that included "sumping" the fuel tanks, he conducted a full power engine run with the brakes held at the threshold of runway 29. He reported that the engine was performing normally during full power ground roll as the airplane's airspeed increased. He reported, "Entering ground effect in order to achieve airspeed for safe climb performance I observed only partial power." He lowered the nose and applied brakes; however, the airplane went off the end of runway 29 at about 15 mph. The pilot reported that the terrain sloped downward about 15 degrees and the grass was wet with dew. He was unable to stop the airplane before the landing gear collapsed and the wing spar was bent. The engine was test run after the accident, and it produced 2,375 RPM. The total weight of the airplane at the accident site was about 2,486 pounds. The maximum gross weight limit of the airplane was 2,440 pounds. ## Factual narrative On July 18, 2008, about 2230 central daylight time, a Piper PA-28-161, N2133V, sustained substantial damage during an aborted takeoff when it departed the end of runway 11 (4,708 feet by 100 feet, asphalt) at the Sparta/Fort McCoy Airport (CMY), Sparta, Wisconsin. The pilot and two of the passengers were not injured, but one of the passengers received serious injuries. The 14 Code of Federal Regulations Part 91 personal flight was departing CMY and its destination was the Dane County Regional Airport - Truax Field (MSN), Madison, Wisconsin. Visual meteorological conditions prevailed at the time of the accident. No flight plan was filed. The pilot reported that the flight had originally departed from the South St Paul Municipal Airport (SGS), St Paul, Minnesota, at 2000, with MSN as the final destination. He reported that prior to departure, he conducted a weight and balance, performance evaluation, preflight, and received a standard weather briefing. After takeoff, he utilized visual flight rules (VFR) flight following and en route in-flight weather service. He landed at CMY for fuel and a weather update. He reported that he "filled the tanks to 28 gallons total via visual inspection." After another preflight that included "sumping" the fuel tanks, he conducted a full power engine run with the brakes held at the threshold of runway 29. He reported that the engine was performing normally during full power ground roll as the airplane's airspeed increased. He reported, "Entering ground effect in order to achieve airspeed for safe climb performance I observed only partial power." He lowered the nose and applied brakes, however, the airplane went off the end of runway 29 at about 15 mph. The pilot reported that the terrain sloped downward about 15 degrees and the grass was wet with dew. He was unable to stop the airplane before the landing gear collapsed and the wing spar was bent. A firefighter based at the Fort McCoy Airport Fire Station reported that he observed the airplane as it taxied up to the JP-8 fueling pumps. The pilot was informed that the AVGAS fuel pumps were located on the civilian side of the airport and he taxied the airplane to the other side of the airport. The firefighter reported that about 20 minutes later he heard the airplane departing. He looked out his window and saw the airplane on the runway, traveling west to east. He reported, "As he was straight out from my room I thought he was taking a lot further than most small planes to lift off. It appeared he had enough speed to do so." He stated further, "As he passed the painted numbers on the runway, he began to slow down. He was unable to stop before he reached the end of the runway and ran off." The CMY airport manager reported that the accident scene was off the departure end of runway 11. He met the pilot and three passengers. Emergency personnel transported the passenger who was seriously injured to the hospital. The airport manager reported that the following items were removed from the airplane and put into his vehicle: A tent with tent poles, several (3) backpacks as he recalled, 2 bags of groceries, blankets, pillows, sandals, a small cooler, and an unopened case of beer. The items were not weighed. The passenger who was seriously injured reported that she brought a tote bag for clothes and toiletries that weighed about 10 lbs and a blanket that weighed about 5 lbs. She remembered there also being a case of beer, two pillows, a bag for the pilot's gear, a bag of clothes for each person on board, a cooler, and a tent. A Federal Aviation Administration (FAA) inspector examined the airplane at the accident site on July 19, 2008. His inspection of the airplane revealed continuity of the flight controls. He checked the fuel for water contamination and none was present. The brakes showed evidence of high temperature as indicated by smell, warping discs, and discoloration. The flaps were retracted and the control surface trims were in the normal takeoff range. The fuel selector was on the left tank. The left fuel tank was full up to the top of the wing. The right wing fuel was about 1 - 2 inches from the top of the wing. The airplane was lying on the ground tilted about 4 degrees to the left. The fuel was removed from the wing tanks during the recovery of the airplane at the accident site. 24 gallons were removed from the left tank, and 15-20 gallons were removed from the right tank. Fuel receipts from MCY showed that pilot had 23.19 gallons of fuel put on the airplane on July 18, 2008. The engine was run at the aircraft salvage facility with an inspector from the FAA's Minneapolis Flight Standards District Office (FSDO) providing oversight. The inspector reported the engine run results as: "Full power 2,375 RPM, oil pres good, oil temp good, plenty of throttle left but it didn't increase RPM. Mag drops 100 rpm both left and right. The engine sounded smooth with throttle response, of course, there was a lot of vibration from the prop." The inspector reported that factors that affected the performance of the engine during the run included: the carburetor air box was partially crushed, the inlet tube was disconnected from the inlet filter, the propeller was slightly bent, and the lower 1/3 of the propeller was blowing against the trailer the engine was mounted on. The airplane was a single-engine Piper PA-28-161, serial number 28-7916323. The maximum gross weight when it was originally manufactured was 2,325 lbs. As a result of a Supplemental Type Certificate, the maximum gross weight of the airplane was increased to 2,440 lbs. The weight of the airplane as found by the FAA at the accident site was as follows: Empty aircraft weight: 1,492 lbs Front seat passengers: 405 lbs Rear seat passengers: 295 lbs Fuel (39 gallons x 6 lbs/gal): 234 lbs Baggage (Provided by Pilot): 60 lbs Total: 2,486 lbs The moment of the airplane as found by the FAA at the accident site was as follows: Empty aircraft weight: 129,362 inch lbs Front seat passengers: 32,603 inch lbs Rear seat passengers: 34,840 inch lbs Fuel (39 gallons x 6 lbs/gal): 22,230 inch lbs Baggage (Provided by Pilot): 8,568 inch lbs Total: 227,603 inch lbs The Center of Gravity (CG) of the accident airplane was: 91.6 inches. According to the operator's Weight and Balance Computation chart, the forward limit of the CG was 83.0 inches and the aft limit was 93.0 inches. The Piper PA-28-161 Warrior II Pilot's Operating Handbook (POH), Revised July 11, 1977, Section 5, Performance Figure 5-5, page 5-15, "Normal Short Field Ground Roll Distance - No Obstacle" provided a chart to calculate the expected ground roll distance during takeoff. The expected ground roll distance was about 1,300 feet for a 2,325-pound airplane at a 1,000-foot pressure altitude with a temperature of 70 degrees Fahrenheit on a no wind day with a lift off airspeed of 50 knots. The pilot was a 23-year-old private pilot with a single-engine land rating. He held a third class medical certificate that was issued on July 6, 2005. He reported a total of 317 flight hours with 111 hours in the PA-28-161. He had flown 34 hours in the last 90 days, and 17 hours in the last 30 days. He had logged a total of 34 night hours, and had flown 2 hours at night within the last 30 days. ## Aircraft - Registration: [N2133V](https://openairdocs.org/deregistered/N2133V-2009-03-09), registration cancelled 2009-03-09, S/N 28-7916323, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA-28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7916323 - Airframe hours: 7167 - Engines: Lycoming O-320-036 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: John Linder - Registered owner: Prescott Flying Club - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 14, 2008 - Departed: CMY, Fort McCoy, WI - Destination: MSN, Madison, WI - Airport: CMY, Fort McCoy Airport, runway 29, 4,708 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 23; injuries: none; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review June 22, 2008; seat: left; flight hours: 317 total, 111 in this make and model, 240 as pilot in command, 34 in the last 90 days, 17 in the last 30 days ## Weather - Conditions: Visual (VMC), Night/dark - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 68 °F - Altimeter: 29.95 inHg - Observed at: MCY ## 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 20080718846109A](https://openairdocs.org/incident/20080718846109A), Jul 18, 2008: Piper PA28161, Sparta, WI, Destroyed. (-23) July 18, 2008 N2133V piloted by [privacy data omitted] departed st. paul municipal (sgs) on a personal pleasure flight and laned at Sparta fort mccoy… 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.