# NTSB ERA16CA237: Piper PA 28-161, N8237Z, Honesdale, PA, June 29, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: June 29, 2016, 17:29 local (21:29 UTC) - Place: Honesdale, PA - Coordinates: 41.515556, -75.251663 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.5156&lon=-75.2517&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: 4 uninjured - Status: Completed, report July 5, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 93506 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16CA237 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93506/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93506 - Page: https://openairdocs.org/ntsb/ERA16CA237 ## Probable cause The pilot's inadequate preflight planning, which resulted in his attempt to take off near the airplane’s maximum gross weight in high-density altitude conditions that degraded the airplane’s takeoff and climb performance and resulted in an aborted takeoff and subsequent runway excursion. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: performance calculations](https://openairdocs.org/ntsb-findings/02061010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-161, 3 cases](https://openairdocs.org/ntsb-findings/02061010/cases.md?model=7102803), [All aircraft, 114 cases](https://openairdocs.org/ntsb-findings/02061010/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=7102803), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) - [Planning/preparation: weight/balance calculations](https://openairdocs.org/ntsb-findings/02061015): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-28-161, 2 cases](https://openairdocs.org/ntsb-findings/02061015/cases.md?model=7102803), [All aircraft, 110 cases](https://openairdocs.org/ntsb-findings/02061015/cases.md) - [Object/animal/substance](https://openairdocs.org/ntsb-findings/03022000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/03022000/cases.md?model=7102803), [All aircraft, 224 cases](https://openairdocs.org/ntsb-findings/03022000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Abnormal runway contact](https://openairdocs.org/ntsb-events/090); cases with it: [Piper PA-28-161, 8 cases](https://openairdocs.org/ntsb-events/090/sequence.md?model=7102803), [All aircraft, 1,506 cases](https://openairdocs.org/ntsb-events/090/sequence.md) - [Takeoff-rejected takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Piper PA-28-161, 30 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102803), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Takeoff-rejected takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-161, 58 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102803), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis At an airport with a field elevation of 1,357 ft above mean sea level, where the temperature was 23°C, the pilot loaded the airplane with passengers, luggage, and fuel, to near its maximum gross weight. He then initiated a takeoff on a 2,986-ft-long runway, which had an approximate 500-ft displaced threshold on each end, a 0.6-percent uphill gradient, and trees off the departure end. While attempting to take off, the airplane failed to become airborne, and the pilot aborted the takeoff. The airplane traveled off the right side of the runway and was substantially damaged when it struck vegetation and terrain. The pilot and the three passengers were not injured. Review of airport security camera footage revealed that the pilot had initiated a rolling, 0-flap takeoff from an intersection with about 200 ft of usable pavement behind him. Review of the weather conditions present at the time of the accident indicated that the density altitude was 2,805 ft. Review of weather information and a Koch chart also indicated that with the density altitude that existed at the time of the accident, a 30 percent increase in takeoff distance should have been anticipated by the pilot along with a 23 percent decrease in climb rate. Review of the information manual for the airplane revealed that it contained performance information. When asked if he had checked the density altitude before takeoff, the pilot replied that he had not. ## Factual narrative At an airport with a field elevation of 1,357 feet above mean sea level, where the temperature was 23 degrees Celsius, the pilot loaded the airplane with passengers, luggage, and fuel, to near its maximum gross weight He then initiated a takeoff on a 2,986-foot-long runway, which had an approximate 500-foot displaced threshold on each end, a 0.6 percent uphill gradient, and obstructions in the form of trees off the departure end. During the takeoff, the airplane failed to become airborne and the pilot aborted the takeoff. The airplane traveled off the right side of the runway, and was substantially damaged when it struck vegetation and terrain. The pilot and the three passengers were not injured. Review of airport security camera footage revealed that the pilot had initiated a rolling, zero flap takeoff from an intersection with approximately 200 feet of usable pavement behind him. Review of the weather conditions present at the time of the accident indicated that the density altitude was 2,805 feet. Review of weather information and a Koch chart also indicated that with the density altitude that existed at the time of the accident, a 30 percent increase in takeoff distance should have been anticipated by the pilot along with a 23 percent decrease in rate of climb. Review of the information manual for the airplane revealed that it did contain published performance information. When asked if he had checked the density altitude prior to takeoff the pilot advised that he had not. ## Aircraft - Registration: [N8237Z](https://openairdocs.org/deregistered/N8237Z-2017-10-26), registration cancelled 2017-10-26, S/N 28-8216177, built 1982 (OpenAirDocs) - Reported make and model: PIPER PA 28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8216177 - Year built: 1982 - Airframe hours: 7314.3 - Engines: LYCOMING O-320-E2D 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 7, 2016 - Departed: N30, Honesdale, PA - Destination: MKL, JACKSON, TN - Airport: N30, Cherry Ridge, runway 36, 2,986 × 50 ft, asphalt - Equipment: Stall warning system, Electronic flight bag or handheld device, Handheld GPS, Satellite tracking device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: none; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review August 14, 2014; seat: left; restraint: 3-point; flight hours: 270 total, 77 in this make and model, 152 as pilot in command, 28 in the last 90 days, 20 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 59 °F - Altimeter: 29.95 inHg - Observed at: N30 ## 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 20160629013499A](https://openairdocs.org/incident/20160629013499A), Jun 29, 2016: Piper PA-28-161, Honesdale, PA, Substantial damage. N8237Z was attempting takeoff from the N30 airport at approximately 1730 local time from runway 36. He had himself and family on board which included his… ## Docket (9 files) The files NTSB released with the investigation on June 8, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93506. 7.2 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=40452995&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Witness Statements and Interview Summaries (item 2, .PDF, 841 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452996&FileExtension=.PDF&FileName=Witness%20Statements%20and%20Interview%20Summaries-Master.PDF - Satellite Image of Accident Location (item 3, .PDF, 267 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452997&FileExtension=.PDF&FileName=Satellite%20Image%20of%20Accident%20Location-Master.PDF - Weather Reports and Records (item 4, .PDF, 846 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452998&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Excerpts from Piper PA-28-161 Information Manual (Performance) (item 5, .PDF, 330 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40452999&FileExtension=.PDF&FileName=Excerpts%20from%20Piper%20PA-28-161%20Information%20Manual%20(Performance)-Master.PDF - NOAA Density Altitude Calculator (item 6, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453000&FileExtension=.PDF&FileName=NOAA%20Density%20Altitude%20Calculator-Master.PDF - FAA Koch Chart (item 7, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453001&FileExtension=.PDF&FileName=FAA%20Koch%20Chart-Master.PDF - Photo Array (item 8, .PDF, 7 photos, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453002&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Security Camera Videos (Shelf Item) (item 9, .PDF, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40453003&FileExtension=.PDF&FileName=Security%20Camera%20Videos%20(Shelf%20Item)-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.