# NTSB ERA10LA092: Piper PA-32R, N5319J, Hatteras, NC, December 6, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: December 6, 2009, 10:37 local (15:37 UTC) - Place: Hatteras, NC - Coordinates: 35.232776, -75.628051 - Nearby events: https://openairdocs.org/map.md?lat=35.2328&lon=-75.6281&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: No injuries - Injuries: 1 uninjured - Status: Completed, report April 12, 2011 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 75149 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA10LA092 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75149/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75149 - Page: https://openairdocs.org/ntsb/ERA10LA092 ## Probable cause The pilot's inability to maintain directional control during an aborted takeoff for undetermined reasons. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: powerplant parameters](https://openairdocs.org/ntsb-findings/01062050): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation; cases with it: [Piper PA-32R-301T, 1 case](https://openairdocs.org/ntsb-findings/01062050/cases.md?model=7103220), [All aircraft, 81 cases](https://openairdocs.org/ntsb-findings/01062050/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-32R-301T, 8 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103220), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Wind: variable wind](https://openairdocs.org/ntsb-findings/03034025): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Piper PA-32R-301T, 1 case](https://openairdocs.org/ntsb-findings/03034025/cases.md?model=7103220), [All aircraft, 113 cases](https://openairdocs.org/ntsb-findings/03034025/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: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Piper PA-32R-301T, 4 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7103220), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff-rejected takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Piper PA-32R-301T, 6 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7103220), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## Analysis The pilot reported that just prior to becoming airborne, a cockpit aural alarm sounded and the manifold pressure was approximately one inch above its maximum limit. He elected to abort the takeoff and applied the brakes. The airplane veered to the left and he concluded that the right brake was not functioning correctly. In response, he attempted to correct the drift using right rudder application. The airplane exited the left side of the runway and collided with sand dunes and vegetation. The reported failure of the right brake was not able to be confirmed and no cause for such a failure was observed. ## Factual narrative HISTORY OF FLIGHT On December 6, 2009, about 1037 eastern standard time, a turbocharged Piper PA-32R-301, N5319J, was substantially damaged during an aborted takeoff from Billy Mitchell Airport (HSE), Hatteras, North Carolina. The private pilot/owner was not injured. The personal flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed. According to the pilot, he flew the airplane from Norfolk, Virginia to HSE two days earlier, and the accident flight was to be his return trip. The airplane was equipped with an aftermarket alerting system that monitored several parameters. The system was designed to sound an alarm when any parameter limit was exceeded, and the alarm tone was the same for all parameters. The pilot conducted the preflight inspection, engine start, and engine run up; he reported that all were "normal." He obtained weather information from the HSE automated surface observation system (ASOS), and based on the reported winds, he selected runway 7 as the departure runway. He advanced the throttle, and initiated the takeoff roll; the pilot stated that the engine response and takeoff roll were "normal.' At an indicated airspeed of approximately 85 to 90 knots, the pilot applied back pressure on the yoke to begin the liftoff. About the same time, he heard an aural alarm from the monitoring/alerting system. When the alarm sounded, the pilot glanced at some of the instrument indications, and he believed that the digital display of the manifold pressure indicated 39 inches of mercury, which was in excess of the allowable manifold pressure limit of 38 inches. The pilot decided to abort the takeoff, and he pushed the yoke forward and retarded the throttle. He then applied the toe brakes, and the airplane veered to the left, but remained on the runway. The pilot concluded that the right brake was not functioning properly, so he subsequently applied right rudder to correct the airplane's path, and used only the left brake to decelerate the airplane. As the speed decreased, the rudder effectiveness also decreased, and the pilot reduced his pressure on the left brake in order to maintain directional control. Several hundred feet before the end of the runway, the airplane departed the left side of the runway into the surrounding sand, and it continued to decelerate while paralleling to the runway. After the airplane had traveled approximately 200 to 300 feet across the sand, the left wing struck a sand dune, the airplane "rotated 90 degrees to the left," and came to rest against bushes and sand dunes. The pilot shut down the airplane and exited safely. There were no witnesses to the accident. The first responders to the accident were park rangers from the National Park Service (NPS) and personnel from the local volunteer fire department. PERSONNEL INFORMATION Federal Aviation Administration (FAA) records indicated that the pilot held a privatepilot certificate with an airplane single-engine land rating. The pilot reported that his most recent FAA third-class medical certificate was issued in March 2009, and that he had 215 total hours of flight experience, including approximately 155 hours in the accident airplane. His practical test for the private pilot certificate, which was also his most recent flight review, was successfully completed in May 2009. AIRCRAFT INFORMATION According to FAA records, the airplane was manufactured in 2001, and it was equipped with a Lycoming TIO-540 series piston engine. In December 2006, while it was registered to a previous owner, the airplane was involved in a landing overrun accident in Crystal Beach, Texas. In June 2007 the airplane was sold to a salvage facility, and the current owner/pilot purchased it from the salvage facility in March 2009. According to the pilot, the airplane's most recent annual inspection was completed in March 2009, at which time the airplane had approximately 990 total hours in service. At the time of the accident, the airplane had approximately 1,141 total hours in service. METEOROLOGICAL INFORMATION The 1020 recorded weather observation at HSE included winds from 010 degrees, variable from 330 to 040 degrees, at 8 knots, with gusts to 16 knots. The 1051 observation included winds from 010 degrees, variable from 340 to 050 degrees, at 11 knots, with gusts to 19 knots. Both observations indicated 10 miles visibility, temperature of approximately 7 degrees C, and an altimeter setting of 30.32 inches of mercury. AIRPORT INFORMATION FAA records indicated that HSE was equipped with a single asphalt runway, designated 07-25, that measured 3,000 feet by 75 feet. Airport elevation was listed as 17 feet above mean sea level. The airport was owned by the NPS, but maintained and managed by the North Carolina Department of Transportation (NCDOT). The airport was normally unattended, but NPS facilities and park rangers were based in the local area. In contrast, NCDOT offices and personnel were based approximately 260 miles away. Due to their proximity, NPS park rangers were the first responders to the accident, and they enlisted the assistance of the local volunteer fire department (VFD). However, at the time of the accident, neither the NPS nor the VFD had any established aircraft accident response protocols. This contributed to their inability to temporarily close the airport while the rescue and recovery operations were conducted. As a direct result of the difficulties that NPS and VFD personnel encountered in their response to this accident, NCDOT and NPS jointly implemented multiple safety improvements at HSE. These included the development of NPS accident response protocols, the implementation of regularly scheduled training and coordination sessions for the affected agencies (NPS, NCDOT, FAA, first responders, etc), and the purchase and installation of safety-related equipment. These included fire extinguishers, runway closuresigns, and land-line and radio communications devices. In addition, NCDOT established a new HSE website (www.billymitchellairport.com) that was intended to improve dissemination of safety-related information to pilots. WRECKAGE AND IMPACT INFORMATION According to information provided by the FAA, the airplane came to rest several hundred feet from the point where it departed the paved surface, and approximately 200 feet prior to the runway end. The airplane remained upright, facing approximately north. Both wings, the cowl, the forward fuselage, and the nose landing gear incurred substantial impact damage. The reported failure of the right brake was not able to be confirmed, and no cause(s) for such a failure were observed. ## Aircraft - Registration: [N5319J](https://openairdocs.org/aircraft/N5319J), registered now, S/N 3257213 (OpenAirDocs) - Reported make and model: PIPER PA-32R (301) - Registry model: [Piper PA-32R-301T](https://openairdocs.org/model/piper-pa-32r-301t) (registry code 7103220) (OpenAirDocs) - Category: Airplane - Serial number: 3257213 - Airframe hours: 1141 - Engines: Lycoming IO-540 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 5, 2009, 151 hours before - Departed: HSE, Hatteras, NC - Destination: ORF, Norfolk, VA - Airport: HSE, Billy Mitchell, runway 07, 3,000 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: none; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review May 20, 2009; seat: left; flight hours: 215 total, 155 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: variable at 11 knots, gusting 19 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 46 °F, dew point 37 °F - Altimeter: 30.31 inHg - Observed at: HSE ## 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 20091206051989A](https://openairdocs.org/incident/20091206051989A), Dec 6, 2009: Piper PA-32R-301T, Cape Hatteras, NC, Substantial damage. During takeoff roll Mr. Charles f. cole observed a turbocharger overboost indication on the cockpit instrument panel and aborted the takeoff. According to Mr.… ## Other investigations on N5319J (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 DFW07CA047](https://openairdocs.org/ntsb/DFW07CA047), Dec 31, 2006: Piper PA 32R 301T (N5319J), Crystal Beach, TX, substantial damage. Probable cause: The pilot's touchdown too far down the runway resulting in an overrun. Factors were the wet grass runway and the trailer. ## Docket (7 files) The files NTSB released with the investigation on December 23, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75149. 2.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40340870&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Pilot Interview Summary (item 2, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40340768&FileExtension=.PDF&FileName=Pilot%20Interview%20Summary-Redacted.PDF - Park Ranger Statement (item 3, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40340841&FileExtension=.PDF&FileName=Park%20Ranger%20Statement-Redacted.PDF - Compiled Photographs (4 total) (item 4, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40340861&FileExtension=.PDF&FileName=Compiled%20Photographs%20(4%20total)-Master.PDF - Pilot Log Excerpts (item 5, .PDF, 420 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40340767&FileExtension=.PDF&FileName=Pilot%20Log%20Excerpts-Redacted.PDF - NCDOT Interview Summary (item 6, .PDF, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40340770&FileExtension=.PDF&FileName=NCDOT%20Interview%20Summary-Redacted.PDF - Safety Improvements to HSE Airport (item 7, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40340771&FileExtension=.PDF&FileName=Safety%20Improvements%20to%20HSE%20Airport-Redacted.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.