# NTSB ERA12LA250: Piper PA46, N21EP, Wellington, FL, March 23, 2012 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: March 23, 2012, 17:45 local (21:45 UTC) - Place: Wellington, FL - Coordinates: 26.465555, -80.149719 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.4656&lon=-80.1497&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) - Highest injury: Serious injuries - Injuries: 1 serious - Status: Completed, report June 11, 2014 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Piper, FAA/FSDO - NTSB case key (mKey): 83204 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA12LA250 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/83204/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=83204 - Page: https://openairdocs.org/ntsb/ERA12LA250 ## Probable cause The pilot's failure to maintain directional control of the airplane during the takeoff roll, which resulted in a collision with a tree. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action sequence](https://openairdocs.org/ntsb-findings/02041020): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA46-500TP, 1 case](https://openairdocs.org/ntsb-findings/02041020/cases.md?model=7104622), [All aircraft, 77 cases](https://openairdocs.org/ntsb-findings/02041020/cases.md) - [Aircraft capability: takeoff distance](https://openairdocs.org/ntsb-findings/01061025): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation; cases with it: [Piper PA46-500TP, 1 case](https://openairdocs.org/ntsb-findings/01061025/cases.md?model=7104622), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/01061025/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA46-500TP, 6 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7104622), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/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 PA46-500TP, 11 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7104622), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230); cases with it: [Piper PA46-500TP, 6 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7104622), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Piper PA46-500TP, 2 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=7104622), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md) ## Analysis A witness reported that the airplane veered left during the takeoff roll and headed toward a large ditch that surrounded the runway. It appeared that the pilot did not attempt to stop the airplane or abort the takeoff. The airplane continued toward the ditch, and, upon reaching the ditch's edge, the airplane rotated and reached an altitude of about 50 feet. The airplane's left wing collided with trees. The airplane rolled left and then right before stalling and crashing. The pilot stated that the airplane seemed to pull left on takeoff, possibly due to a right quartering tailwind, and that he did not realize where he was positioned on the runway. Examination of the airplane and engine did not reveal any preimpact anomalies that would have precluded normal operation. ## Factual narrative On March 23, 2012, about 1745 eastern daylight time, a Piper PA-46-500TP, N21EP, was substantially damaged following a collision with trees at the Wellington Aero Club Airport (FD38), West Palm Beach, Florida. The airline transport pilot was seriously injured. The airplane was registered to Mascaro Air LLC and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and no flight plan was filed. The flight was originating at the time of the accident. A witness reported that they watched as the airplane began its takeoff roll on runway 33. The witness stated that the winds favored runway 15. As the airplane continued its takeoff roll, it veered to the left and headed towards a large ditch that surrounded the runway. It appeared that no attempts were made to stop the airplane or abort the takeoff. The airplane continued towards the ditch and upon reaching the ditch's edge, the airplane took off, reaching an altitude of approximately 50 feet. The airplane's left wing collided with trees, and the airplane rolled to the left and then right before stalling. According to the owner of the airplane, the pilot was hired to give him instruction in the airplane. He stated that the airplane had approximately 40 hours of flight time since delivered. The purpose of the flight on the day of the accident was to fly the airplane to another airport for an avionics check. The owner watched as the pilot taxied to the turf runway for takeoff. The airplane lifted off approximately midfield and appeared to have directional and control problems. The airplane climbed to a height of 60-80 feet before brushing into palm trees. The airplane entered a steep downward left turn before impacting the ground. In a statement from the pilot, he stated that after the accident he had no recollection of the flight due to a concussion. In the months that followed after the accident, knowing the circumstances he stated, that after lining up on runway 33, he applied power and was unable to maintain the airplane on the centerline, since it was not marked. He went on to say that the airplane seemed to pull to the left of the grass runway. He felt that the reason he did not abort the takeoff was because he was not aware of how far left of the centerline the airplane had gone. He also believed that the airplane reached the rotation speed for a soft field takeoff and he decided to lift off. Not realizing how far left he was of the centerline and with a nose high attitude right after takeoff, apparently the airplane brushed the top of a palm tree with the left wing tip and caused the airplane to yaw to the left and he lost control of the airplane. The Wellington Aero Club Airport is a private airport located 5 miles west of West Palm Beach, Florida. The 4,000 foot by 100 foot lighted turf runway features short, firm Bermuda grass. The runway is oriented 33/15 and is at an elevation of 20 feet. At1753 EDT the Palm Beach, FL weather reporting station, located approximately 11 nautical miles east of the accident site, reported winds were 130 degrees at 9 gusting to 16 knots with 10 statute miles of visibility. Examination of the airplane by the Federal Aviation Administration (FAA) and a representative from Piper revealed that the airplane came to rest inverted on a 320-degree heading on the patio decking of a residential home. All major aircraft components and control surfaces were identified and located at the wreckage site. Flight control continuity was established to all flight control surfaces except for impact and recovery-related cable separations. Fuel was noted around the wreckage site and in the swimming pool. On initial examination the FAA inspector noted that the elevator trim was positioned near maximum nose up. It was also noted that the flaps were in the neutral position for takeoff; review of the flight manual recommends 20 degrees for grass runways. Examination of the engine revealed that the firewall structure, engine mounts, exhaust stubs, starter/generator, auxiliary alternator, air conditioning pump, torque system, and the cowling remained attached with impact damage and deformation. All airframe to engine connections were connected and intact. Examination of the engine revealed that contact signatures within the internal components showed that it was developing power at the time of impact. Examination of the engine revealed no indications of any preimpact anomalies or distress that would of precluded normal engine operation prior to impact. ## Aircraft - Registration: [N21EP](https://openairdocs.org/deregistered/N21EP-2012-07-18), registration cancelled 2012-07-18, S/N 4697479, built 2012 (OpenAirDocs) - Reported make and model: PIPER PA46 (500TP) - Registry model: [Piper PA46-500TP](https://openairdocs.org/model/piper-pa46-500tp) (registry code 7104623) (OpenAirDocs) - Registry engine: [Pratt & Whitney Canada PT6A-42A](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-42a) (registry code 52268, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 4697479 - Airframe hours: 40 - Engines: PRATT AND WHITNEY PT6A 1940 horsepower turbo prop - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Mascaro Air LLC. - Registered owner: Mascaro Air LLC. - Airworthiness certificate: Standard, Normal - Departed: FD38, Wellington, FL - Destination: VRB, Vero Beach, FL - Airport: FD38, Wellington, runway 33, 4,000 × 100 ft, grass/turf ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: serious; airline transport, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; flight hours: 10,651 total, 10,418 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 63 °F - Altimeter: 30.06 inHg - Observed at: BCT, 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 20120323005329A](https://openairdocs.org/incident/20120323005329A), Mar 23, 2012: Piper Aircraft Inc PA46-500TP, Wellington, FL, Destroyed. At approximately 1700 March 28, 2012 pilot took off in PA-46TP downwind on grass strip at Wellington Air Park, palm beach county, Florida. Flaps were up and… ## Docket (19 files) The files NTSB released with the investigation on May 21, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=83204. 11.5 MB in all. - Pilot statement and information (item 1, .PDF, 850 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400257&FileExtension=.PDF&FileName=Pilot%20statement%20and%20information-Redacted.PDF - Pilot statement-Second statement (item 2, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398515&FileExtension=.PDF&FileName=Pilot%20statement-Second%20statement-Redacted.PDF - Pilot statement-Third statement (item 3, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398520&FileExtension=.PDF&FileName=Pilot%20statement-Third%20statement-Redacted.PDF - Owner statement (item 4, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398521&FileExtension=.PDF&FileName=Owner%20statement-Redacted.PDF - Witness Statement (item 5, .PDF, 40 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398525&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Reports from Federal Agencies-FAA initial observations (item 6, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398511&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies-FAA%20initial%20observations-Redacted.PDF - Reports from Local Agencies-Palm Beach County Sheriff report (item 7, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398527&FileExtension=.PDF&FileName=Reports%20from%20Local%20Agencies-Palm%20Beach%20County%20Sheriff%20report-Redacted.PDF - Miscellaneous-Excerpts from pilot operating handbook (item 8, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398549&FileExtension=.PDF&FileName=Miscellaneous-Excerpts%20from%20pilot%20operating%20handbook-Master.PDF - Statement of Party Representatives to NTSB Investigation-P&W Brian Lingis (item 9, .PDF, 309 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398546&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-P%26W%20Brian%20Lingis-Redacted.PDF - Statement of Party Representatives to NTSB Investigation-Piper Ron Maynard (item 10, .PDF, 102 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398547&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Piper%20Ron%20Maynard-Redacted.PDF - Statement of Party Representatives to NTSB Investigation-P&W Thomas Berthe (item 11, .PDF, 569 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398548&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-P%26W%20Thomas%20Berthe-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 12, .PDF, 440 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398554&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1-Courtesy of FAA- Runway marks (item 13, .PDF, 373 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398570&FileExtension=.PDF&FileName=Photo%201-Courtesy%20of%20%20FAA-%20Runway%20marks-Master.PDF - Photo 2- Courtesy of FAA- Runway 33 (item 14, .PDF, 154 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398572&FileExtension=.PDF&FileName=Photo%202-%20Courtesy%20of%20FAA-%20Runway%2033-Master.PDF - Photo 3-Courtesy of FAA-View of ditch on side of runway 33 (item 15, .PDF, 227 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398573&FileExtension=.PDF&FileName=Photo%203-Courtesy%20of%20FAA-View%20of%20ditch%20on%20side%20of%20runway%2033-Master.PDF - Photo 4-Courtesy of Piper-Main wreckage forward view (item 16, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398574&FileExtension=.PDF&FileName=Photo%204-Courtesy%20of%20Piper-Main%20wreckage%20forward%20view-Master.PDF - Photo 5-Courtesy of Piper-Side view of main wreckage (item 17, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398576&FileExtension=.PDF&FileName=Photo%205-Courtesy%20of%20Piper-Side%20view%20of%20main%20wreckage-Master.PDF - Photo 6-Courtesy of FAA-View of trim control wheel (item 18, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398578&FileExtension=.PDF&FileName=Photo%206-Courtesy%20of%20FAA-View%20of%20trim%20control%20wheel-Master.PDF - Photo 7-Courtesy of FAA-Flap handle in neutral position (item 19, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40398581&FileExtension=.PDF&FileName=Photo%207-Courtesy%20of%20FAA-Flap%20handle%20in%20neutral%20position-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.