# NTSB ERA16FA186: Piper PA28, N7031R, Homestead, FL, May 16, 2016 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Field investigation · Final report - Date: May 16, 2016, 16:46 local (20:46 UTC) - Place: Homestead, FL - Coordinates: 25.498056, -80.558334 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=25.4981&lon=-80.5583&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-flare/touchdown: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report August 28, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Piper, FAA FSDO, Lycoming - NTSB case key (mKey): 93178 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16FA186 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93178/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93178 - Page: https://openairdocs.org/ntsb/ERA16FA186 ## Probable cause The pilot's improper decision to allow the passenger to attempt a landing, which resulted in a loss of control during landing with a quartering tailwind. Contributing to the severity of the pilot's injuries was the separation of the deteriorated shoulder harness. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-140, 43 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102802), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Passenger (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) - [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 PA-28-140, 40 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7102802), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Passenger (probable cause); cases with it: [Piper PA-28-140, 6 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=7102802), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Piper PA-28-140, 7 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=7102802), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) - [Equipment/furnishings: flight compartment equipment](https://openairdocs.org/ntsb-findings/01022510): Aircraft › Aircraft systems · Failure (probable cause); cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/01022510/cases.md?model=7102802), [All aircraft, 37 cases](https://openairdocs.org/ntsb-findings/01022510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-flare/touchdown: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28-140, 44 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102802), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Landing-flare/touchdown: 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 and the passenger, a friend who was previously a student pilot but never completed his training, were making their first flight together. The pilot, who sustained serious injuries, did not recall the accident. The passenger reported that the pilot took off from the departure airport and then transferred the controls to him and let him fly for a while. They flew to another airport, and the pilot made one touch-and-go landing on runway 36. During departure, the pilot again transferred control to the passenger and stated, "you make the next landing and I will watch you." The passenger reported that he was trying to fly the airplane straight to the runway but drifting left due to a quartering tailwind, which was reported as 14 knots, gusting to 22 knots. The passenger tried to correct the flight path but was unable to align the airplane with the runway centerline. He did not remember if the pilot tried to help or not at any point before the airplane impacted the ground. The airplane came to rest near midfield and about 340 ft left of the runway edge. Examination of the wreckage did not reveal evidence of any preimpact mechanical malfunctions that would have precluded normal operation. The pilot's (left front seat's) shoulder harness was torn in half at its midpoint. The distal 24 inches (the portion that did not normally retract into the inertia reel) of the webbing showed significant discoloration, fading, and stiffness. A significant section of abrasive wear was noted on the edges of the webbing about 15 to 21 inches from the distal end fitting; the shoulder harness separated in this worn section. The passenger's (right front seat's) shoulder harness was also discolored, faded, and stiff. The manufacturer's maintenance manual for the airplane stated that an inspection of the seat belts is required during the annual and/or 100-hour inspection. The manual indicated that the belts are to be replaced if deteriorated or worn. Review of the airplane's maintenance logbooks found no records indicating that the seat belts were ever inspected or replaced. If the pilot's shoulder harness had been replaced, it would likely have secured him in his seat and minimized the severity of the injuries that he incurred. ## Factual narrative The left and right front seatbelts and shoulder harnesses were retained for further examination by an NTSB survival factors specialist. The shoulder harnesses were manufactured by Pacific Scientific, and the lap belts were manufactured by Davis Aircraft Products, Inc. Both shoulder harnesses were equipped with an inertia reel and an end fitting designed to secure to a standoff button on the separate lapbelt, and the belt webbing's total extended length was about 53 inches. The left shoulder harness webbing retracted normally into the inertia reel. The distal 24 inches (the portion that did not normally retract into the inertia reel) of the webbing showed significant discoloration and fading. The yellowed material in the discolored area was noticeably stiffer and less pliable than the material that retracted into the inertia reel, which appeared to be black in color. Some minor wear was noted on the edges of the webbing that retracted into the inertia reel, and there was a 6-inch section of significant abrasive wear about 15 to21 inches from the distal end fitting. In this section, about 6 longitudinally woven threads (or 1/8 inch) were compromised at the wear's deepest intrusion into the webbing. A complete transverse, frayed separation of the webbing was present at the point of deepest intrusion, about 20 inches from the distal end fitting. The webbing of the right shoulder harness did not retract normally into the inertia reel and about 48 inches of webbing remained exposed. The distal 44 inches of the webbing showed discoloration and fading and appeared an orangish color. The discolored material was slightly stiffer and less pliable than the webbing of both lapbelts, but less so than the webbing of the left shoulder harness. The most significant area of discoloration appeared between 14 and 42 inches from the distal end fitting. There was very minor abrasive wear on the edges of a small portion of the webbing that would normally have retracted into the inertia reel, but no thread integrity was compromised. There was no noted wear to the edges of the remainder of the webbing. Both the lapbelts were in good condition, and the buckles functioned as designed. The webbing was appropriately supple and showed no evidence of fading or damage. The adjustable, insert tab portions of the belts were in similarly good condition. They were adjusted to a length of about 34 inches. The manufacturer's maintenance manual for the airplane stated that an inspection of the seat belts is required during the annual and/or 100-hour inspection. The manual indicated that the belts are to be replaced if deteriorated or worn. Review of the airplane's maintenance logbooks found no records indicating that the seat belts were ever inspected or replaced. The four-seat, low-wing, fixed-tricycle-gear airplane was manufactured in 1966. It was powered by a 150-horsepower Lycoming O-320-E2A engine and equipped with a two-bladed, fixed-pitch Sensenich propeller. A review ofmaintenance records revealed that the airplane's most recent annual inspection was completed on September 20, 2015. At that time, the airframe had accumulated 3,630 total flight hours, and the engine had accumulated 1,453.7 flight hours since major overhaul. On May 16, 2016, about 1646 eastern daylight time, a Piper PA-28-140, N7031R, impacted terrain during landing at Homestead General Aviation Airport (X51), Homestead, Florida. The airplane sustained substantial damage; the private pilot was seriously injured, and the passenger sustained minor injuries. The airplane was registered to and operated by the pilot as a personal flight conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and no flight plan was filed for the flight that departed Miami Executive Airport (TMB) en route to X51. The pilot's wife reported that he does not have any recollection of the accident. The passenger stated that the pilot was a friend of his, and the accident flight was their first flight together. The passenger also stated that he was previously a student pilot but never completed his training and let his medical certificate expire. Soon after departing TMB, the pilot transferred control to passenger and let him fly around and make a couple of turns before he transferred control back to the pilot. They flew to X51, and the pilot made one touch-and-go landing. During departure, the pilot transferred control to the passenger and stated, "you make the next landing and I will watch you." According to the passenger, the pilot then asked him if he wanted "one notch" of flaps, which equated to 10° flap extension, and the passenger responded that he did. The passenger reported that he was trying to fly the airplane straight to the runway, but it kept drifting left due to the quartering tailwind. The passenger tried to correct the flight path but could not get the airplane aligned with the centerline of runway 36. The passenger further stated that he was having difficulty controlling the airplane and did not remember if the pilot tried to help or not. The passenger recalled the airplane veering to the left of the runway centerline and the ground coming up on them quickly. He then braced for impact. The 1645 recorded weather at X51 was wind from 120° true at 14 knots, gusting to 22 knots, visibility 10 statute miles, temperature 29°C, dew point 23°C, and altimeter setting 30.07 inches of mercury. According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with an airplane single-engine land rating, which was issued on May 4, 2012. He also held an FAA third-class medical certificate, issued September 23, 2015. At the time of the medical examination, the pilot reported 2,100 total hours of flight experience. The pilot's logbook could not be located. According to FAA records, the passenger held a student pilot certificate. He also held an FAA first-class medicalcertificate, issued December 4, 2014. At the time of the medical examination, the passenger reported no hours of flight experience. The student pilot's logbook could not be located. Examination of the accident site revealed that the wreckage was located near midfield and about 340 ft off the left side of runway 36. Ground scars that corresponded with damage to the airplane's left-wing tip were between the runway and a canal. Another ground scar that corresponded to damage to the propeller was located on the far bank of the canal. The ground scars were orientated on a heading of 295°. The airplane came to rest on a heading of 200° about 40 ft from the canal bank. The nose gear was bent aft, and both main landing gear were sheared off. Cable continuity was established to all flight controls. The left-wing tank was full of fuel, and the right wing tank was half-full of fuel. The fuel was consistent in color and odor to 100LL aviation type gasoline and had no visible signs of water contamination. The nose section of the airplane was crushed down and aft, and the engine was tilted up about 30°. The left wing main spar was fractured at the fuselage, and the rear attachment point bolt separated and was not located within the wreckage area. The left wing pulled away from the fuselage about 6 inches but remained attached to the flap torque tube assembly. The flaps were in the 10° position. The ailerons, fuselage, and right wing were intact. The fuel selector was selected to the left tank. Both control yokes were bent to the right and downward. The left front seat's (pilot's) shoulder harness was torn in half at its midpoint. The aft attachment points of the pilot's seat remained attached to the seat rails; however, the forward attach points were separated from the seat rails, consistent with impact forces. The right front seat's (passenger's) shoulder harness was intact, and the seat was attached at all four corners to the seat rails. ## Aircraft - Registration: [N7031R](https://openairdocs.org/deregistered/N7031R-2018-03-16), registration cancelled 2018-03-16, S/N 28-21728, built 1966 (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: 28-21728 - Year built: 1966 - Airframe hours: 3673.86 - Engines: LYCOMING O-320-E2A 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 20, 2015, 44 hours before - Departed: TMB, Miami, FL - Destination: X51, Homestead, FL - Airport: X51, Homestead General Aviation, runway 36, 4,000 × 100 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: serious; private; airplane ratings: single-engine land; medical: class 2, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 2,100 total, 999,999 in this make and model - Student pilot; age 48; injuries: minor; student; medical: class 1; seat: right; restraint: 3-point; flight hours: 45 total, 99,999 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 120° at 14 knots, gusting 22 - Visibility: 10 statute miles - Lowest ceiling: 10,000 ft broken - Temperature: 84 °F, dew point 73 °F - Altimeter: 30.06 inHg - Observed at: X51 ## 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 20160516005439A](https://openairdocs.org/incident/20160516005439A), May 16, 2016: Piper PA-28-140, Homestead, FL, Destroyed. A Piper PA28-140 aircraft, N7031R, departed kendall-tamiami executive airport (tmb). The pilot of the aircraft attempted a touch and go on runway 36 at… ## Docket (11 files) The files NTSB released with the investigation on August 7, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93178. 13.2 MB in all. - Memorandum for Record – Telephone Interview, Passenger (item 1, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454935&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Passenger-Master.PDF - Memorandum for Record – Telephone Interview, Wife (item 2, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454936&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Wife-Master.PDF - Maintenance Records (item 3, .PDF, 9.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454937&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Excerpt of Piper Cherokee Service Manual (item 4, .PDF, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454938&FileExtension=.PDF&FileName=Excerpt%20of%20Piper%20Cherokee%20Service%20Manual-Master.PDF - Weather Reports and Records (item 5, .PDF, 271 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454939&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Wreckage Diagram (item 6, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454940&FileExtension=.PDF&FileName=Wreckage%20Diagram-Master.PDF - Investigative Photos (item 7, .PDF, 4 photos, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454941&FileExtension=.PDF&FileName=Investigative%20Photos-Master.PDF - Survival Factors Specialist's Factual Report (item 8, .PDF, 9 photos, 755 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454942&FileExtension=.PDF&FileName=Survival%20Factors%20Specialist%27s%20Factual%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 520 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454943&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454944&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Evidence Control Form (item 11, .PDF, 277 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40454945&FileExtension=.PDF&FileName=Evidence%20Control%20Form-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.