# NTSB CHI98LA061: Piper PA-28-140, N5454S, Sturtevant, WI, December 13, 1997 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: December 13, 1997, 15:45 local (21:45 UTC) - Place: Sturtevant, WI - Coordinates: 42.700904, -87.889244 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.7009&lon=-87.8892&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report August 20, 1999 - Report: Approved by Office Director - NTSB case key (mKey): 10804 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI98LA061 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/10804/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=10804 - Page: https://openairdocs.org/ntsb/CHI98LA061 ## 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 In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with object, approach - vfr pattern - final approach - object - vehicle - altitude/clearance - inadequate, pilot in command (cause) - visual lookout - inadequate, pilot in command (cause) - visual illusion, pilot in command (contributing factor) - In flight collision with terrain/water, descent - 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](https://openairdocs.org/deregistered/N5454S-2017-06-07), registration cancelled 2017-06-07, S/N 28-7125120, built 1971 (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: 28-7125120 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 20; 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 ## 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 19971213038569A](https://openairdocs.org/incident/19971213038569A), Dec 13, 1997: Piper PA28140, Sturtevant, WI, Destroyed, 1 fatal. Student pilot was on approach to RY26 when acft struck a semi truck on interstate 94, Sylvania, WI. (.4)witnesses reported the airplane approached the runway… ## Other investigations on N5454S (1) 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 FTW78FPM09](https://openairdocs.org/ntsb/FTW78FPM09), May 20, 1978: Piper PA-28 (N5454S), Tulsa, OK, substantial damage ## Docket (30 files) The files NTSB released with the investigation on August 13, 1999, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=10804. 9.9 MB in all. - Survival Factors Group Factual Report of Investigation (item 1, .PDF, 223 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436494&FileExtension=.PDF&FileName=Survival%20Factors%20Group%20Factual%20Report%20of%20Investigation-Redacted.PDF - Survival Factors Appendix A - Photo 1. View of N5454S at the Accident Site. Note: The Cockpit and Cabin Area Remained Intact. (item 2, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109461&FileExtension=.PDF&FileName=Survival%20Factors%20Appendix%20A%20-%20Photo%201.%20%20View%20of%20N5454S%20at%20the%20Accident%20Site.%20%20Note%3A%20%20The%20Cockpit%20and%20Cabin%20Area%20Remained%20Intact.-Master.PDF - Survival 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 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109462&FileExtension=.PDF&FileName=Survival%20Factors%20Appendix%20A%20-%20Photo%202.%20%20View%20of%20Occupant%20Seated%20in%20the%20Same%20Seat%20Where%20the%20Pilot%20Had%20Been%20Seated.%20%20Note%3A%20%20Location%20of%20Shoulder%20Harness%20Mount.-Master.PDF - Survival Factors Appendix A - Photo 3. View of Shoulder Harness Mounting Holes. (item 4, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109463&FileExtension=.PDF&FileName=Survival%20Factors%20Appendix%20A%20-%20Photo%203.%20%20View%20of%20Shoulder%20Harness%20Mounting%20Holes.-Master.PDF - Survival Factors Appendix A - Photo 4. View Looking Inboard at Pilot's Seat. Note: Abraded Sheep Skin Seat Cover. (item 5, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109464&FileExtension=.PDF&FileName=Survival%20Factors%20Appendix%20A%20-%20Photo%204.%20%20View%20Looking%20Inboard%20at%20Pilot%27s%20Seat.%20%20Note%3A%20%20Abraded%20Sheep%20Skin%20Seat%20Cover.-Master.PDF - Survival 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 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109465&FileExtension=.PDF&FileName=Survival%20Factors%20Appendix%20A%20-%20Photo%205.%20%20View%20of%20Damaged%20Instrument%20Panel%20and%20Broken%20Control%20Yoke.%20%20Note%3A%20%20Arrows%20Point%20to%20Compressed%20Instrument%20Panel%20and%20Broken%20Yoke.-Master.PDF - Survival Factors Appendix A - Photo 6. View of Damaged Nose Cowling. Note: Damage is in the Upwards and Aft Direction. (item 7, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109466&FileExtension=.PDF&FileName=Survival%20Factors%20Appendix%20A%20-%20Photo%206.%20%20View%20of%20Damaged%20Nose%20Cowling.%20%20Note%3A%20%20Damage%20is%20in%20the%20Upwards%20and%20Aft%20Direction.-Master.PDF - Airport Diagram (item 8, .PDF, 133 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109467&FileExtension=.PDF&FileName=Airport%20Diagram-Master.PDF - FAA Inspector's Report (item 9, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436495&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Report-Redacted.PDF - Racine County Sheriff's Department Report (item 10, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436496&FileExtension=.PDF&FileName=Racine%20County%20Sheriff%27s%20Department%20Report-Redacted.PDF - NTSB Airframe and Engine Examination Report (item 11, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436497&FileExtension=.PDF&FileName=NTSB%20Airframe%20and%20Engine%20Examination%20Report-Redacted.PDF - Pilot's Logbook Endorsement Page, Medical Certificate with Endorsement (item 12, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436498&FileExtension=.PDF&FileName=Pilot%27s%20Logbook%20Endorsement%20Page,%20Medical%20Certificate%20with%20Endorsement-Redacted.PDF - Trucking Company Accident Report (Excerpt) (item 13, .PDF, 965 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436499&FileExtension=.PDF&FileName=Trucking%20Company%20Accident%20Report%20(Excerpt)-Redacted.PDF - Commitment Letter, Wisconsin Department of Transportation, Bureau of Aeronautics (item 14, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436500&FileExtension=.PDF&FileName=Commitment%20Letter,%20Wisconsin%20Department%20of%20Transportation,%20Bureau%20of%20Aeronautics-Redacted.PDF - Piper Service Bulletin #896 (item 15, .PDF, 905 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109474&FileExtension=.PDF&FileName=Piper%20Service%20Bulletin%20%23896-Master.PDF - Piper Shoulder Harness Kit Instruction Excerpt (item 16, .PDF, 411 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109475&FileExtension=.PDF&FileName=Piper%20Shoulder%20Harness%20Kit%20Instruction%20Excerpt-Master.PDF - FAA Advisory Circular AC Number 21-34 Excerpt (item 17, .PDF, 734 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109476&FileExtension=.PDF&FileName=FAA%20Advisory%20Circular%20AC%20Number%2021-34%20Excerpt-Master.PDF - "Flight Deck Performance" Book Excerpt (item 18, .PDF, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109477&FileExtension=.PDF&FileName=%22Flight%20Deck%20Performance%22%20Book%20Excerpt-Master.PDF - "Human Factors in Flight" Book Excerpt (item 19, .PDF, 426 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109478&FileExtension=.PDF&FileName=%22Human%20Factors%20in%20Flight%22%20Book%20Excerpt-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 20, .PDF, 432 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436501&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 21, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436502&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 22, .PDF, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40436503&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photo 1. N5454S, Right Front View Looking South-Southwest. ( Racine County Sheriff's Office Photo ) (item 23, .PDF, 210 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109482&FileExtension=.PDF&FileName=Photo%201.%20%20N5454S,%20Right%20Front%20View%20Looking%20South-Southwest.%20%20(%20Racine%20County%20Sheriff%27s%20Office%20Photo%20)-Master.PDF - Photo 2. N5454S, Right Side, Looking West. (Racine County Sheriff's office Photo ) (item 24, .PDF, 162 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109483&FileExtension=.PDF&FileName=Photo%202.%20%20N5454S,%20Right%20Side,%20Looking%20West.%20%20(Racine%20County%20Sheriff%27s%20office%20Photo%20)-Master.PDF - Photo 3. N5454S, Right Rear View, Looking North-Northwest. ( Racine County Sheriff's Office Photo ) (item 25, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109484&FileExtension=.PDF&FileName=Photo%203.%20%20N5454S,%20Right%20Rear%20View,%20Looking%20North-Northwest.%20%20(%20Racine%20County%20Sheriff%27s%20Office%20Photo%20)-Master.PDF - Photo 4. N5454S, Detail of Fuselage Left Side, Cockpit Forward. ( Racine County Sheriff's Office Photo ) (item 26, .PDF, 218 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109485&FileExtension=.PDF&FileName=Photo%204.%20%20N5454S,%20Detail%20of%20Fuselage%20Left%20Side,%20Cockpit%20Forward.%20%20(%20Racine%20County%20Sheriff%27s%20Office%20Photo%20)-Master.PDF - Photo 5. N5454S, Detail of Fuselage Right Side, Cockpit Forward. ( Racine County Sheriff's Office Photo ) (item 27, .PDF, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109486&FileExtension=.PDF&FileName=Photo%205.%20%20N5454S,%20Detail%20of%20Fuselage%20Right%20Side,%20Cockpit%20Forward.%20%20(%20Racine%20County%20Sheriff%27s%20Office%20Photo%20)-Master.PDF - Photo 6. N5454S's Engine Propeller Flange. (item 28, .PDF, 257 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109487&FileExtension=.PDF&FileName=Photo%206.%20%20N5454S%27s%20Engine%20Propeller%20Flange.-Master.PDF - Photo 7. N5454S, Cockpit/Instrument Panel as Viewed from Pilot Seat. ( FAA Photo ) (item 29, .PDF, 230 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109488&FileExtension=.PDF&FileName=Photo%207.%20%20N5454S,%20Cockpit%2FInstrument%20Panel%20as%20Viewed%20from%20Pilot%20Seat.%20%20(%20FAA%20Photo%20)-Master.PDF - Photo 8. N5454S's Pilot Seat Shoulder Harness Mount. (item 30, .PDF, 223 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40109489&FileExtension=.PDF&FileName=Photo%208.%20%20N5454S%27s%20Pilot%20Seat%20Shoulder%20Harness%20Mount.-Master.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.