ERA15LA237

NTSB accident investigation · Piper PA28 · Hampton, NH · June 14, 2015

Accident · Serious injuriesLimited investigationFinal report
Date
June 14, 2015, 09:30 local (13:30 UTC)
Place
Hampton, NH
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N43078Piper PA28
Defining event
Takeoff: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report September 11, 2018
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Lycoming Engines, Federal Aviation Administration
FAA report
20150614018509A
Case key
91366

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

On this page

Probable cause

The pilot’s failure to properly set the stabilator trim prior to takeoff, which resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall during takeoff.

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.

Flight control system: elevator control systemAircraft › Aircraft systems · Incorrect use/operationPiper PA-28-140: 2 casesAll aircraft: 74 casesProbable cause
Action: incorrect action selectionPersonnel issues › Action/decision · PilotPiper PA-28-140: 6 casesAll aircraft: 397 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededPiper PA-28-140: 14 casesAll aircraft: 990 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-28-140: 103 casesAll aircraft: 9,295 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 private pilot reported that the airplane lifted off normally but would not climb. The airplane cleared trees at the end of the runway before descending and impacting a wooded area. Two witnesses reported and airport surveillance video confirmed that the airplane lifted off in an extreme nose-up attitude and remained in that attitude as it descended below trees at the end of the runway. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. During the examination, the stabilator trim was found in the full nose-up position. The pre-takeoff checklist for the airplane included instructions to properly set the stabilator trim prior to takeoff. It is likely that the stabilator trim position resulted in the airplane's extreme nose-up attitude, which led to an exceedance of the airplane's critical angle of attack during the initial climb and an aerodynamic stall.

Factual narrative

On June 14, 2015, about 0930 eastern daylight time, a Piper PA-28-140, N43078, impacted trees and terrain shortly after takeoff from Hampton Airfield (7B3), Hampton, New Hampshire. The private pilot and one passenger received serious injuries. The airplane was substantially damaged by impact forces and a postcrash fire. Visual meteorological conditions prevailed and no flight plan was filed for the planned flight to Biddeford Airport (B19), Biddeford, Maine. The airplane was owned and operated by the private pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight.According to the pilot, on the morning of the accident he had fueled the airplane at B19, and performed a "full run-up and normal takeoff" for the flight to 7B3. The takeoff, all systems, and flight characteristics appeared normal. After landing at 7B3, he taxied to the ramp and shut the airplane down. He did not refuel at 7B3, and a short time later he and his passenger embarked and taxied to runway 02, where he performed another engine run-up, with no anomalies noted. He indicated that the takeoff, and all systems including the airspeed, appeared normal. He said that the airplane lifted off at 65 knots, but it would not climb. He asked the passenger to read the emergency checklist, and verified that the mixture was rich, the throttle was full, the fuel selector was on the fullest tank, the fuel pump was on, and the carburetor heat was off. He attempted to keep the airplane level; however, he raised the nose at the last minute as they approached a tree line. The airplane cleared the initial tree line; however, subsequently descended into the wooded area. According to a witness, as the airplane lifted off from the runway, it appeared to have a "high angle of attack," and it looked as though it was "mushing through the air" after takeoff. During the initial climb the pitch attitude decreased briefly, and then increased before the airplane reached a tree line. After clearing the trees, the nose lowered and the airplane disappeared out of sight. The witness further stated that he did not hear a loss of engine power at any time. Another witness stated that when the airplane lifted off the ground, its "nose was too vertical." The witness thought the airplane would not climb above the trees in the nose-up position; however, it cleared the tree tops and was "nearly vertical" when it began to lose altitude. Review of airport surveillance video also revealed that the airplane lifted off and remained in a nose-up attitude. Examination of the wreckage, at the scene, by a Federal Aviation Administration (FAA) inspector revealed that the airplane impacted a wooded area about 2,000 feet from the departure end of the runway and slightly right of the extended runway centerline. The fuselage came to rest upright in a nose down attitude with the engine and nose section embedded in soil. Both wings were separated from the fuselage. A postaccident examination of theairplane and engine was conducted by an FAA inspector and representative from the engine manufacturer. One propeller blade exhibited chordwise scratching and leading-edge gouging. When the engine crankshaft was rotated by hand, continuity was confirmed on all cylinders, valves, and accessory gears. Thumb compression and suction was verified on each cylinder. The spark plugs were removed and examined; each displayed little or no wear and were light gray/black/oily in color. The carburetor bowl was removed and was found to be free of debris. Control cable continuity was established from each aileron though fractures, consistent with tensile overload, to the cockpit area. The stabilator and rudder were removed during salvage recovery efforts, and the flight control cables were cut by recovery personnel. However, cable continuity was confirmed from the cockpit area to the rudder and stabilator. Examination of the stabilator trim indicator in the cockpit revealed that the trim was in the full nose up position. Examination of the stabilator trim jackscrew revealed 16 exposed threads, which equated to a full nose-up position. Review of a takeoff checklist from a make and model pilot operating manual revealed "Trim tab – set."

Aircraft

Registration
N43078
Reported as
Piper PA28 (140)
Category
Airplane
Serial number
28-7425332
Built
1974
Airframe hours
4,520
Engine
Lycoming O-320-D3G, 160 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 1, 2015 · 2 hours before
Departed
7B3 · Hampton, NH
Destination
B19 · Biddeford, ME
Airport
7B3 · Hampton Airfield, runway 02, 2,100 × 170 ft, grass/turf
Equipment
Stall warning system, Handheld GPS

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
56
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
May 24, 2014
Seat
Left
Restraint
3-point
Flight hours
182 total · 182 in this make and model · 129 as pilot in command · 3 in the last 90 days · 2 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
60° at 8 knots
Visibility
10 statute miles
Lowest ceiling
25,000 ft broken
Temperature
73 °F, dew point 48 °F
Altimeter
30.05 inHg
Observed at
KPSM, 7 nm away

Docket · 8

The files NTSB released with the investigation on June 19, 2018, on NTSB’s docket system: statements, records, photos and specialists’ reports. 5.4 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.

Other investigations on N43078 · 3

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