# NTSB ERA15LA237: Piper PA28, N43078, Hampton, NH, June 14, 2015 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: June 14, 2015, 09:30 local (13:30 UTC) - Place: Hampton, NH - Coordinates: 42.968334, -70.82833 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.9683&lon=-70.8283&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed, report September 11, 2018 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Lycoming Engines, Federal Aviation Administration - NTSB case key (mKey): 91366 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA15LA237 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/91366/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=91366 - Page: https://openairdocs.org/ntsb/ERA15LA237 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Flight control system: elevator control system](https://openairdocs.org/ntsb-findings/01022730): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/01022730/cases.md?model=7102802), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022730/cases.md) - [Action: incorrect action selection](https://openairdocs.org/ntsb-findings/02041010): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-140, 6 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md?model=7102802), [All aircraft, 397 cases](https://openairdocs.org/ntsb-findings/02041010/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Piper PA-28-140, 14 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7102802), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/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-28-140, 103 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102802), [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. - [Prior to flight: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-28-140, 14 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102802), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Piper PA-28-140, 21 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7102802), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/deregistered/N43078-2017-08-29), registration cancelled 2017-08-29, S/N 28-7425332, built 1974 (OpenAirDocs) - Reported make and model: PIPER PA28 (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: 28-7425332 - Year built: 1974 - Airframe hours: 4520 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: serious; 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 ## 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 20150614018509A](https://openairdocs.org/incident/20150614018509A), Jun 14, 2015: Piper PA-28-140, North Hampton, NH, Destroyed. Departed rnwy 02 at 7BE at 0940 LCL time. Takeoff roll was observed to be normal. Witnesses observed the aircraft abruptly leave the ground and on climb out… ## Other investigations on N43078 (3) 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 NYC94LA149](https://openairdocs.org/ntsb/NYC94LA149), Jul 29, 1994: Piper PA-28-140 (N43078), Towanda, PA, substantial damage. Probable cause: The pilot's improper recovery from a bounced landing. - [NTSB BFO90LA049](https://openairdocs.org/ntsb/BFO90LA049), May 26, 1990: Piper PA-28-140 (N43078), Lusby, MD, substantial damage. Probable cause: THE PILOT MISJUDGED THE DISTANCE NEEDED TO TOUCHDOWN AND STOP HIS AIRCRAFT BEFORE RUNNING OFF THE END OF THE RUNWAY. THE PILOT FAILED TO USE ALL OF THE AVAILABLE RUNWAY DURING THE LANDING SEQUENCE. - [NTSB NYC75DHD20](https://openairdocs.org/ntsb/NYC75DHD20), Sep 25, 1974: Piper PA-28 (N43078), Vincetown, NJ, substantial damage ## Docket (8 files) The files NTSB released with the investigation on June 19, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=91366. 5.4 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 796 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464170&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Record of Conversation With Pilot (item 2, .PDF, 214 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464171&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation%20With%20Pilot-Master.PDF - Witness Statements (item 3, .PDF, 361 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464172&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Airport Video (20 seconds long, MP4, 1.7MB) (item 4, MP4, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464173&FileExtension=mp4&FileName=Airport%20Video%20(20%20seconds%20long,%20MP4,%201.7MB)-Master - Excerpt From Pilot Operating Manual (item 5, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464174&FileExtension=.PDF&FileName=Excerpt%20From%20Pilot%20Operating%20Manual-Master.PDF - Photo Array (item 6, .PDF, 5 photos, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464175&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Statement of Party Representatives to NTSB Investigation (Lycoming) (item 7, .PDF, 327 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464176&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20(Lycoming)-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 179 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40464177&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.