CHI98LA061

NTSB accident investigation · Piper PA-28-140 · Sturtevant, WI · December 13, 1997

Accident · FatalLimited investigationFinal report
Date
December 13, 1997, 15:45 local (21:45 UTC)
Place
Sturtevant, WI
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N5454SPiper PA-28-140
Weather
Visual (VMC) · Day
Status
Completed · report August 20, 1999
Report
Approved by Office Director
FAA report
19971213038569A
Case key
10804

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's misjudgment of altitude/distance and her failure to maintain adequate visual lookout. Also causal was the pilot's failure to maintain adequate obstacle clearance. A contributing factor was the pilot experiencing a visual illusion.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with objectApproach - vfr pattern - final approach
Object - vehicle
Altitude/clearance - inadequatePilot in commandCause
Visual lookout - inadequatePilot in commandCause
Visual illusionPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - ground

Analysis

Witnesses reported the airplane approached the runway at a '...very low angle... .' The airplane crossed a 4-lane highway that was perpendicular to the runway and final approach course. The landing gear struck the top of a southbound semi-trailer truck's air deflector and trailer, then the airplane collided with the ground about 140-feet west of the truck collision point. According to the pilot's logbook, she had accumulated over 37 hours of total flight experience. She had flown about 26 hours at an airport that had runways 100 and 150-feet wide, and about 11 hours at the accident airport runway, 33 feet wide. According to a Human Performance Specialist at the FAA's Civil Aeromedical Institute, runway width differences may be a source of distortion in perception during landing. When the runway is narrower than normal, the pilot may experience an illusion that causes them to fly a lower than normal final approach path.

Factual narrative

History of flight

On December 13, 1997, at 1545 central standard time (cst), a Piper PA-28-140, N5454S, piloted by a student pilot, was destroyed during a collision with a moving tractor-trailer truck and terrain while on short final approach to runway 26L (2,300' X 33' dry/asphalt) at the Sylvania Airport, Sturtevant, Wisconsin. Visual meteorological conditions prevailed at the time of the accident. The 14 CFR Part 91 instructional flight was not operating on a flight plan. The pilot was fatally injured. The flight departed Sturtevant, Wisconsin, at 1540 cst.

Witnesses said N5454S's main landing gear struck the semi-trailer truck's trailer. They said the airplane was approaching the runway from the east "...at a very low angle," according to the Racine County Wisconsin Sheriff's Department report. One witness said the airplane "...had a slight up and down jerky movement as it crossed the northbound traffic just before hitting the semi [that was driving in the southbound lane]." Another witness said that the "...airplane was flying low toward the ground and as it got closer it looked as if it hit turbulence because it sort of swerved lower and hit the top right of a semi-truck. Then its wing skidded off the truck... ."

Witnesses reported that the airplane collided with the ground in a pitch down attitude with the right wing lower than the left wing. They said the airplane rebounded and slid backward about 20-feet from its impact point. The initial ground collision point was about 100-feet west of the highway where the truck was operating.

Other damage

The air deflector on the semi-trailer truck cab roof was cracked and had black marks on it. The trailer's front had a black imprint on it. The imprint consisted of two main sections. One section had the letters N, E, and R. These were arranged next to each other in a curved line. The second transfer mark paralleled the three letter's curve. The top of the trailer had 3 cuts in it. These cuts were between 6 and 12-inches long. The driver side of the trailer had an inward bend that was about 2-inches out of alignment with the trailer's side. The center of this was next to the area of cut marks.

Personnel information

The pilot was a student pilot who began her flight training on April 26, 1997. At the time of the accident, the pilot's logbook showed she had 37.3 hours of flight time. The pilot's logbook showed she had 26.6-hours of flight instruction and no solo flight time in a Cessna 150 before transitioning to the Piper PA-28-150 (PA-28). She had 1.6-hours of solo flight time in the PA-28. The pilot had 9.1-hours of dual instruction in the PA-28 series airplanes. She soloed the PA-28 after she had received 3.1- hours of flight instruction. The logbook showed she had received instruction in the following areas and sequence: "Touch-goes, stalls, aircraft system orientation (.9-hour flight instruction), crosswinds [takeoff and landings], 190/18 with gusts, go-around (.7- hour flight instruction), simulated power failure with landing, landings and takeoffs- looking good (1.0-hour flight instruction), 5 dual [takeoff and landings], 5 solo landings (1.0-hour total time, .5-hour solo)."

Aircraft information

N5454S was a 1971 model of the Piper PA-28-140 series airplane. According to its airframe logbook, the airplane's main landing gear tires were installed "new" on it during June 21, 1996. According to the mechanic who changed the tires, they were an "Aero Trainer" brand. The airplane was delivered from the factory with the shoulder harness mounted as found in the wreckage. The airplane was certified under Civil Air Regulations Part 3 on October 31, 1960. A review of CAR 3 revealed no requirements for shoulder harness mounting. A review of 14 CFR Part 23 revealed no mounting requirements for a shoulder harness.

Piper Aircraft Corporation issued Service Bulletin Number 896 on November 28, 1988. Piper stated it "...considers compliance mandatory." According to the bulletin, the compliance time should "...not exceed 1 calendar year from the date of this Service Bulletin." The Bulletin's purpose says that Piper supports the use of shoulder harnesses with lap belts. The Service Bulletin said that Piper is issuing the "...Mandatory Service Bulletin and strongly urges you to install and use a complete restraint system of both seat belts and shoulder harnesses... ." A copy of this Bulletin is appended to this report.

The shoulder harness kit directions for airplane serial numbers that N5454S is part of shows that the harness should be installed in the cockpit ceiling about 14-inches aft of the fuselage's side window post. A search of Service Bulletins, Service Letters, did not reveal any that addresses changing the factory installed belts that were mounted similar to the one found on N5454S. A copy of the shoulder harness kit instructions is appended to this report.

Wreckage and impact information

The on-scene investigation revealed that N5454S's landing gear legs were sheared off at the wing's main spar attachment point. The nose landing gear oleo strut separated at the strut mount. The trailer's top was about 14-feet above the highway. N5454S's collision point with the trailer was about 300-feet east of the runway's threshold. The runway has a displaced threshold that is 140-feet in length. See illustration appended to this report.

N5454S's right leading edge of its wing tip was crushed aft and up from the chord line. The fuselage, forward of the firewall, was bent to the right about 15-degrees and crushed up about 8-inches above the top of the firewall. This area was pointing downward at an approximate 30-degree angle from the firewall. The crush area was on the bottom of the nose bowl and right side of the cowl. The right side of the fuselage was crushed inward about 8-inches midway between the wing's trailing edge and the stabilator's leading edge. The stabilator's right side was twisted upward from its tip to root area. The assembly was crushed aft about 6-inches.

The left side of the instrument panel was compressed inboard and forward about 4-inches. The right handle of the pilots control yoke was broken off at the hub of the yoke. No other deformation of the instrument panel or occupiable space within the cockpit was observed.

The propeller had gouges in its leading edge from the tip to about 7-inches in toward the blades root. The gouges varied in depth from about 1/8-inch to 3/4-inch. The lengths of these gouges were between 1/4-inch and about 1-inch. No anomalies with the airframe, flight control system or engine were found that would prevent flight.

Meteorological information

Weather reported at the Kenosha Municipal Airport, Kenosha, Wisconsin, on December 13, 1997, at 1550 central standard time were a clear sky, visibility of 10-statute miles with winds from 260-degrees magnetic at 6-knots. According to an astronomer from the Adler Planetarium, Chicago, Illinois, the sun's position at the time of the accident was 235-degrees from magnetic north and was 4.2-degrees above the horizon. The astronomer's statement is appended to this report.

Aerodrome information

The accident airport is privately owned but open to public use. The State of Wisconsin has designated the airport as a reliever airport for general aviation aircraft using Mitchell International Airport located in Milwaukee, Wisconsin.

The Milwaukee, Wisconsin, Federal Aviation Administration Flight Standards District Office Principal Operations Inspector said his office has had complaints of low flying airplanes by drivers on the interstate highway that is about 300-feet from the runway's threshold. The displaced threshold begins about 160-feet from the interstate highway. During subsequent investigation activity, the IIC observed airplanes flying about 20 to 50-feet above the vehicles that were using the highw

Aircraft

Registration
N5454S
Reported as
Piper PA-28-140
Category
Airplane
Serial number
28-7125120
Engine
Lycoming O-320, 150 horsepower, reciprocating
Damage
Destroyed
Flight
Instructional · Part 91
Registered owner
Sylvania Flying Club, Inc.
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
100 hour · September 18, 1998
Departed
C89
Destination
C89
Airport
C89 · Sylvania Airport, runway 26L, 2,300 × 33 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
20
Certificate
Student
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
37 total · 11 in this make and model · 2 as pilot in command · 8 in the last 90 days · 5 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
260° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
43 °F
Altimeter
29.00 inHg
Observed at
ENW, 6 nm away

Docket · 30

The files NTSB released with the investigation on August 13, 1999, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.9 MB in all.

Survival Factors Group Factual Report of InvestigationItem 1 · .PDF · 223 KBSurvival Factors Appendix A - Photo 1. View of N5454S at the Accident Site. Note: The Cockpit and Cabin Area Remained Intact.Item 2 · .PDF · 49 KBSurvival Factors Appendix A - Photo 2. View of Occupant Seated in the Same Seat Where the Pilot Had Been Seated. Note: Location of Shoulder Harness Mount.Item 3 · .PDF · 49 KBSurvival Factors Appendix A - Photo 3. View of Shoulder Harness Mounting Holes.Item 4 · .PDF · 46 KBSurvival Factors Appendix A - Photo 4. View Looking Inboard at Pilot's Seat. Note: Abraded Sheep Skin Seat Cover.Item 5 · .PDF · 38 KBSurvival Factors Appendix A - Photo 5. View of Damaged Instrument Panel and Broken Control Yoke. Note: Arrows Point to Compressed Instrument Panel and Broken Yoke.Item 6 · .PDF · 48 KBSurvival Factors Appendix A - Photo 6. View of Damaged Nose Cowling. Note: Damage is in the Upwards and Aft Direction.Item 7 · .PDF · 48 KBAirport DiagramItem 8 · .PDF · 133 KBFAA Inspector's ReportItem 9 · .PDF · 117 KBRacine County Sheriff's Department ReportItem 10 · .PDF · 1.6 MBNTSB Airframe and Engine Examination ReportItem 11 · .PDF · 155 KBPilot's Logbook Endorsement Page, Medical Certificate with EndorsementItem 12 · .PDF · 1.4 MBTrucking Company Accident Report (Excerpt)Item 13 · .PDF · 965 KBCommitment Letter, Wisconsin Department of Transportation, Bureau of AeronauticsItem 14 · .PDF · 68 KBPiper Service Bulletin #896Item 15 · .PDF · 905 KBPiper Shoulder Harness Kit Instruction ExcerptItem 16 · .PDF · 411 KBFAA Advisory Circular AC Number 21-34 ExcerptItem 17 · .PDF · 734 KB"Flight Deck Performance" Book ExcerptItem 18 · .PDF · 306 KB"Human Factors in Flight" Book ExcerptItem 19 · .PDF · 426 KBStatement of Party Representatives to NTSB InvestigationItem 20 · .PDF · 432 KBRelease of Aircraft Wreckage, NTSB Form 6120.15Item 21 · .PDF · 81 KBToxicological ReportItem 22 · .PDF · 75 KBPhoto 1. N5454S, Right Front View Looking South-Southwest. ( Racine County Sheriff's Office Photo )Item 23 · .PDF · 210 KBPhoto 2. N5454S, Right Side, Looking West. (Racine County Sheriff's office Photo )Item 24 · .PDF · 162 KBPhoto 3. N5454S, Right Rear View, Looking North-Northwest. ( Racine County Sheriff's Office Photo )Item 25 · .PDF · 203 KBPhoto 4. N5454S, Detail of Fuselage Left Side, Cockpit Forward. ( Racine County Sheriff's Office Photo )Item 26 · .PDF · 218 KBPhoto 5. N5454S, Detail of Fuselage Right Side, Cockpit Forward. ( Racine County Sheriff's Office Photo )Item 27 · .PDF · 200 KBPhoto 6. N5454S's Engine Propeller Flange.Item 28 · .PDF · 257 KBPhoto 7. N5454S, Cockpit/Instrument Panel as Viewed from Pilot Seat. ( FAA Photo )Item 29 · .PDF · 230 KBPhoto 8. N5454S's Pilot Seat Shoulder Harness Mount.Item 30 · .PDF · 223 KB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N5454S · 1

Matched to the same aircraft by N-number and date.