ERA11LA229

NTSB accident investigation · Piper PA-28R-180 · Ridgely, MD · April 4, 2011

Accident · Serious injuriesLimited investigationFinal report
Date
April 4, 2011, 18:00 local (22:00 UTC)
Place
Ridgely, MD
Injuries
3 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N7619JPiper PA-28R-180
Defining event
Approach-VFR pattern final: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report February 23, 2012
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20110404006629A
Case key
78790

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 receiving instruction's inadequate compensation for the wind during landing and delay in executing a go-around, which resulted in a loss of airspeed, low final approach, and subsequent collision with the ground short of the runway. Contributing to the accident was the flight instructor's inadequate surveillance and remedial action.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Wind: gustsEnvironmental issues › Conditions/weather/phenomena · Response/compensationPiper PA-28R-180: 4 casesAll aircraft: 1,199 casesProbable cause
Action: delayed actionPersonnel issues › Action/decision · PilotPiper PA-28R-180: 2 casesAll aircraft: 894 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · Instructor/check pilotPiper PA-28R-180: 2 casesAll aircraft: 792 casesProbable cause
Performance/control parametersAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28R-180: 3 casesAll aircraft: 1,269 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The certified flight instructor and two commercial pilots departed on a training flight to practice maneuvers in preparation for the commercial pilots' flight instructor practical tests. One of the commercial pilots (pilot receiving instruction) was manipulating the controls at the time of the accident. The pilot receiving instruction entered the airport traffic pattern and configured the airplane to perform a power-off approach and landing. While on final approach, the airplane's airspeed deteriorated and the airplane began to sink. The pilot receiving instruction applied full engine power to initiate a go-around, but the airplane continued to sink and impacted the ground short of the runway. A postaccident examination of the airplane revealed no evidence of any preimpact mechanical malfunctions or anomalies. The nearest weather facility reported about a 70-degree left crosswind at 22 knots, gusting to 27 knots.

Factual narrative

The airplane was recovered from the accident scene and examined in a storage facility in Clayton, Delaware on June 2, 2011. The wings were separated during the crash sequence, and parts and components were stored inside the cockpit and cabin area. Control cable continuity was established from the control yoke to the elevator and the wing roots. The rudder pedals were jammed due to impact damage, and rudder cable continuity was established from the rudder to the cabin area. The propeller and crankshaft propeller flange were separated by impact. The fracture surface displayed evidence of overload fracture. The vacuum pump was removed, and an attempt to rotate the engine through the vacuum pump drive was unsuccessful. Closer inspection revealed that the crankshaft appeared bent and the case halves appeared displaced at the front crankshaft main bearing. Borescope examination of each cylinder revealed no evidence of abnormal wear or deposits. Both propeller blades displayed chordwise and spanwise scratches. The top four spark plugs were removed, and were light tan and gray in color. The right magneto was secure in its mount, and the left magneto mount was broken by impact. The magnetos were removed and placed in a test stand. Both magnetos produced spark on the stand through all terminal towers. According to FAA records, the airplane was manufactured in 1968, and was powered by a Lycoming IO-360, 180 horsepower reciprocating engine. The most recent 100-hour inspection was completed on January 21, 2011, at a total airframe time of 6,108 hours. On April 4, 2011, about 1800 eastern daylight time, a Piper PA-28R-180, N7619J, was substantially damaged when it impacted terrain while approaching to land at Ridgely Airpark (RJD), Ridgely, Maryland. The certificated flight instructor (CFI), commercial pilot receiving instruction, and commercial pilot-rated passenger were seriously injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local instructional flight, which was conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the flight school that operated the airplane, the CFI was providing instruction to the two commercial pilots, who were both training towards their flight instructor certificates. They departed Bay Bridge Airport (W29), Stevensville, Maryland about 1720 on a local training flight. The pilots did not provide any information about the lesson itinerary, or if they would be landing at any outlying airports, but the flight school reported that it was common for many of their instructors to practice landings at RJD. The CFI stated that the purpose of the flight was to practice maneuvers for the commercial pilots' flight instructor practical tests. The commercial pilot receiving instruction was flying the airplane at the time of the accident. The CFI stated that they approached RJD with the intention of practicing a "Power-Off 180 Approach and Landing." He stated that thecommercial pilot entered the downwind leg of the traffic pattern for runway 12 and extended the airplane's landing gear. Abeam the intended touchdown point, the commercial pilot reduced engine power to idle and established a glide. The CFI stated that the traffic pattern was "tight," and that on final approach, the airplane's airspeed deteriorated below its best glide speed and the airplane began to sink. The commercial pilot applied full engine power to initiate a go-around, but the airplane continued to sink and impacted the ground short of the runway. The commercial pilot stated that the airplane encountered wind shear on final approach, and the only thing he could remember from the accident sequence was applying full engine power as the airspeed deteriorated. The commercial-pilot rated passenger did not respond to requests from the NTSB requesting he supply a statement about the accident. A witness who was driving past the airport and observed the accident reported to a Federal Aviation Administration (FAA) inspector that he saw the airplane making a "tight" left approach to runway 12, and was "very low." Prior to reaching the runway, the left wing impacted the ground, and the airplane "cartwheeled." He called 911, and then ran to the airplane to help extricate the individuals inside. The witness stated that the winds were gusting at the time of the accident. The 1755 weather observation at Dover Air Force Base (DOV), Dover, Delaware, located approximately 21 nm northeast of the accident site, included winds from 180 degrees true at 22 knots gusting to 27 knots, 10 statute miles visibility, temperature 26 degrees C, dew point 8 degrees C, and an altimeter setting of 29.49 inches of mercury. Peak winds of 28 knots from 180 degrees were noted at 1758. The CFI held a commercial pilot certificate with ratings for airplane single- and multiengine land, and a flight instructor certificate with ratings for airplane single- and multiengine land and instrument airplane. His most recent flight review was conducted on September 2, 2010. His most recent first class FAA medical certificate was issued in December 2010. He reported 1,280 total hours of flight experience, but did not report his total flight experience in the accident airplane make and model. The pilot receiving instruction held a commercial pilot certificate with ratings for airplane single- and multiengine land, and an instrument rating. His most recent flight review was conducted on February 16, 2011. His most recent first class FAA medical certificate was issued in May 2008. He reported 312 total hours of flight experience but did not report his total flight experience in the accident airplane make and model. An FAA inspector examined the airplane at the site, and stated that the initial impact point was approximately 200 feet prior to the approach end of runway 12. A wreckage path approximately 65 feet in length extended to where the airplane came to rest on its right side, about 60feet left of the runway centerline. Both wings were separated at their roots, the propeller was separated from the engine, and the fuselage exhibited extensive damage.

Aircraft

Registration
N7619J
Reported as
Piper PA-28R-180
Category
Airplane
Serial number
28R-31013
Airframe hours
6,108
Engine
Lycoming IO-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Galdieri Aviation Inc
Registered owner
Galdieri Aviation Inc
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · January 21, 2011
Departed
W29 · Stevensville, MD
Destination
W29 · Stevensville, MD
Airport
RJD · Ridgely Airpark, runway 12, 3,214 × 50 ft

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
23
Injuries
Serious
Certificates
Commercial, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
September 2, 2010
Seat
Left
Flight hours
1,280 total · 1,195 as pilot in command · 244 in the last 90 days · 106 in the last 30 days · 4 in the last 24 hours
Role
Pilot
Age
24
Injuries
Serious
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
February 16, 2011
Seat
Right
Flight hours
312 total · 215 as pilot in command · 42 in the last 90 days · 8 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 22 knots, gusting 27
Visibility
10 statute miles
Temperature
79 °F, dew point 46 °F
Altimeter
29.48 inHg
Observed at
DOV, 21 nm away

Docket · 8

The files NTSB released with the investigation on December 27, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.0 MB in all.

FAA reports on this event · 1

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