# NTSB ERA16FA257: Piper PA 28R-201, N2241Q, Esperance, NY, July 16, 2016

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: July 16, 2016, 18:45 local (22:45 UTC)
- Place: Esperance, NY
- Coordinates: 42.780555, -74.331947
- Nearby events: https://openairdocs.org/map.md?lat=42.7806&lon=-74.3319&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490)
- Highest injury: Fatal
- Injuries: 3 fatal, 1 serious
- Status: Completed, report December 11, 2017
- Report: Approved by Office Director
- NTSB office: Eastern Region Aviation
- Parties: FAA/FSDO, Lycoming Engines, Piper Aircraft Inc.
- NTSB case key (mKey): 93610
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16FA257
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93610/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93610
- Page: https://openairdocs.org/ntsb/ERA16FA257

## Probable cause

The pilot's inadequate preflight weight and balance and performance planning, which resulted in the airplane being over gross weight. Also causal were the pilot's decision not to use the entire runway for takeoff, his premature liftoff, and his failure to attain adequate airspeed, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall.

## 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-28R-201, 2 cases](https://openairdocs.org/ntsb-findings/02061010/cases.md?model=7102816), [All aircraft, 114 cases](https://openairdocs.org/ntsb-findings/02061010/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-28R-201, 3 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102816), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Aircraft capability: maximum weight](https://openairdocs.org/ntsb-findings/01061035): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Piper PA-28R-201, 1 case](https://openairdocs.org/ntsb-findings/01061035/cases.md?model=7102816), [All aircraft, 152 cases](https://openairdocs.org/ntsb-findings/01061035/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28R-201, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102816), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Aircraft capability: takeoff distance](https://openairdocs.org/ntsb-findings/01061025): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28R-201, 2 cases](https://openairdocs.org/ntsb-findings/01061025/cases.md?model=7102816), [All aircraft, 67 cases](https://openairdocs.org/ntsb-findings/01061025/cases.md)
- [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28R-201, 3 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7102816), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/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-28R-201, 1 case](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7102816), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md)
- [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28R-201, 1 case](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=7102816), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md)
- [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28R-201, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7102816), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-201, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102816), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)
- [Initial climb: Collision during takeoff/land](https://openairdocs.org/ntsb-events/490) (defining event); cases with it: [Piper PA-28R-201, 2 cases](https://openairdocs.org/ntsb-events/490/sequence.md?model=7102816), [All aircraft, 1,309 cases](https://openairdocs.org/ntsb-events/490/sequence.md)

## Analysis

The private pilot and three passengers departed in the airplane from a 3,000-ft-long runway with a density altitude of about 3,000 ft and a light wind. Surveillance video showed that the airplane did not use the entire length of the runway for takeoff; the pilot began his takeoff roll where the paved section of the part turf/part asphalt runway began, resulting in 2,400 ft of available runway. During the ground roll, the nose of the airplane lifted off and then settled back onto the runway, and the airplane became airborne at 1,500 ft. Witnesses described the takeoff and initial climb as "slow" and "sluggish." The wings rocked, and the airplane climbed to about 100 ft in a continuous left turn before descending into trees 1,000 ft left of the runway centerline. Examination of the airplane and its engine revealed no evidence of preimpact mechanical malfunction or anomaly. An estimate of the airplane's takeoff weight indicated that it was about 66 lbs over the maximum allowable takeoff weight of 2,750 pounds. Review of performance charts revealed that the takeoff ground roll distance for the airplane at the maximum allowable gross weight was about 2,180 ft. Review of radar data showed that from rotation to the final radar target, the airplane's groundspeed (which was about the same as its airspeed given the light wind) varied between 61 and 67 knots, which was about the airplane's calculated stall speed of 60 knots. Further, the witness observations were consistent with the pilot failing to attain sufficient airspeed, which resulted in the airplane's wing exceeding its critical angle of attack and an aerodynamic stall. It is likely that the pilot lifted off prematurely at a speed lower than normal and was unable to accelerate or climb the airplane once it exited ground effect. A premature liftoff and a climb attempt at a speed significantly below best angle of climb speed (78 knots) placed the airplane in a situation where the power required for level flight was very near or exceeded the available power. To recover from this situation the pilot needed to lower the airplane's nose in order to accelerate the airplane to obtain a positive rate of climb. However, such an action is counterintuitive when low to the ground and requires accurate problem recognition, knowledge of the correct solution, and sufficient terrain clearance to accomplish.

## Factual narrative

According to FAA Pamphlet FAA-P-8740-2, Density Altitude: Whether due to high altitude, high temperature, or both, reduced air density (reported in terms of density altitude) adversely affects aerodynamic performance and decreases the engine's horsepower output. Takeoff distance, power available (in normally aspirated engines), and climb rate are all adversely affected. Landing distance is affected as well; although the indicated airspeed (IAS) remains the same, the true airspeed (TAS) increases. From the pilot's point of view, therefore, an increase in density altitude results in the following: • Increased takeoff distance. • Reduced rate of climb. • Increased TAS (but same IAS) on approach and landing. • Increased landing roll distance. Because high density altitude has particular implications for takeoff/climb performance and landing distance, pilots must be sure to determine the reported density altitude and check the appropriate aircraft performance charts carefully during preflight preparation. A pilot's first reference for aircraft performance information should be the operational data section of the aircraft owner's manual or the Pilot's Operating Handbook developed by the aircraft manufacturer. In the example given in the previous text, the pilot may be operating from an airport at 500 ft MSL, but he or she must calculate performance as if the airport were located at 5,000 ft. A pilot who is complacent or careless in using the charts may find that density altitude effects create an unexpected –and unwelcome – element of suspense during takeoff and climb or during landing. According to the Pilot's Handbook of Aeronautical Information, Chapter 3 (pg. 3-3, para. 1) per the section entitled Density Altitude (DA): DA is the vertical distance above sea level in the standard atmosphere at which a given density is to be found. The density of air has significant effects on the aircraft's performance because as air becomes less dense, it reduces: • Power because the engine takes in less air. • Thrust because a propeller is less efficient in thin air. • Lift because the thin air exerts less force on the air foils. The four-seat, low-wing, retractable-gear airplane was manufactured in 1977. It was powered by a 200-horsepower Lycoming IO-360 engine driving a McCauley two-blade, constant-speed propeller. The airplane's most recent annual inspection was completed on March 1, 2016, at 6,573.6 total aircraft hours. The airplane's weight and balance condition at the time of takeoff was calculated based on the estimated fuel onboard the airplane and the estimated weights of the passengers. According to the information provided by the fixed base operator at HVN, the airplane departed HVN with about 25 gallons or about 300 lbs of usable fuel. Fuel burn from HVN to NY05 was estimated to be about 8 gallons or 48 lbs. The airplane's takeoff weight at NY05 was calculated to be 2,816.5 lbs, which was 66.5 lbs above the maximum allowable gross weight of 2,750lbs. There are no performance charts for any weight above the maximum gross weight. The performance charts indicated that at the airplane's maximum allowable gross weight, the estimated takeoff ground roll was 2,180 ft and the total distance to clear a 50-ft obstacle was 2,750 ft. According to the pilot's operating handbook for the airplane, the rotation speed for a normal takeoff was between 65 and 75 knots indicated airspeed (KIAS). With a flap setting of 25°, the rotation speed for a short-field takeoff was between 50 and 60 KIAS. After liftoff, the pilot was to increase airspeed to 55 to 65 KIAS. There are no performance charts or procedures for a 10° flap setting during takeoff. The performance charts do not consider the effects of a grass runway surface on takeoff and landing performance. The gross weight stalling speed with power off and full flaps is 55 KIAS, and, with flaps up, this speed is increased 5 knots. Loss of altitude during stall can be as great as 400 ft depending on configuration and power. The manufacturer did not publish power-on stall speeds for the airplane. The best rate of climb speed at gross weight is 90 KIAS, and the best angle of climb speed is 78 KIAS. NY05 was a private-use airport at 1,260 ft elevation, configured with two parallel runways, each of which was 3,000 ft long. Runway 12R/30L was a turf runway, and runway 12L/30R combined both asphalt and turf surfaces. The elevation of HVN was 12.4 ft. HVN is equipped with two asphalt runways; runway 2/20 is 5600 ft long, and runway 14/32 is 3,626 ft long. On July 16, 2016, about 1845 eastern daylight time, a Piper PA-28R-201, N2241Q, collided with terrain after takeoff from Hogan Airport (NY05), Esperance, New York. The private pilot was seriously injured, the three passengers were fatally injured, and the airplane was destroyed. No flight plan was filed for the personal flight conducted under the provisions of 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed for the flight that originated at NY05 and was destined for Tweed-New Haven Airport (HVN), New Haven, Connecticut. According to a fixed base operator at HVN, on the day of the accident, the airplane was fueled with 14 gallons of 100LL aviation fuel, which brought the fuel level to "just above the tabs." The pilot then flew the airplane with the three passengers onboard from HVN to NY05. According to witnesses, the pilot and passengers attended a party at NY05. A witness reported that the accident airplane was the last of a group of airplanes to depart from NY05 and that another pilot had suggested to the accident pilot that he depart on runway 12L. A review of surveillance video revealed that the airplane took off on runway 30R, which was 3,000 ft long; the first 600 ft and the final 400 ft of runway 30R were turf, and middle 2,000 ft was asphalt. The surveillance video showed that the pilot began the takeoff roll where the paved section of the runway began (with 2,400 ft ofavailable runway). During the takeoff roll, the nosewheel of the airplane lifted off and then settled back onto the runway. The nosewheel lifted again, and the airplane became airborne with about 900 ft of runway remaining. Several witnesses observed the airplane's takeoff from runway 30R. They consistently described the airplane's takeoff as "slow" and "sluggish" and reported that it entered a "gentle" left turn immediately after takeoff. One witness stated that the airplane attempted to rotate earlier than the other airplanes that were departing that day. When the airplane became airborne, "the nose was pitched so high that the wings wallowed;" the witness then reached for his phone to dial 911. The airplane overflew a hangar located left of the departure end of the runway at a low altitude as it continued its left turn before descending into trees. Another witness stated that "the airplane was under full power the entire time. The engine did not fail." Due to his injuries, the pilot was not interviewed. In a written statement, the pilot reported that he had "no personal recollection of the subject flight." Radar track data obtained from the Federal Aviation Administration (FAA) depicted the airplane in a left turn after takeoff. The airplane climbed to about 100 ft above ground level, and its groundspeed ranged between 58 and 67 knots from takeoff to the final radar target. The radar track ended about 100 ft beyond the departure end of the runway and about 1,000 ft left of the runway centerline. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of samples from the pilot, which were negative for ethanol and drugs of abuse. At 1851, the weather reported at Albany International Airport (ALB), Albany, New York, located about 23 nautical miles east of the accident site, included wind from 030° at 3 knots, visibility 10 statute miles; few clouds at 5,000 ft, scattered clouds at 11,000 ft, broken clouds at 22,000 ft, overcast at 25,000 ft; temperature 27°C; dew point 16°C; and altimeter 30.04 inches of mercury. The calculated density altitude at NY05 was about 3,000 ft. The density altitude at HVN when the airplane departed at 1845 was 1,971 ft. The pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. He was issued a third-class medical certificate on May 1, 2015. The pilot reported about 561 total hours of flight experience. The pilot's logbooks were not recovered and no determination could be made of his flight experience in the accident airplane make and model. The airplane came to rest in swampy, wooded terrain and was destroyed by impact and postcrash fire. All major components of the airplane were accounted for at the scene. The wreckage path was oriented on a 180° magnetic heading and was 60 ft in length. The main wreckage was oriented on a magnetic heading of 350° and rested upright about 1,400 ft beyond the departure end ofthe runway and about 700 ft left of the runway's centerline. The right stabilator and a portion of the right wing were separated and found in trees along the debris path. All flight controls surfaces were accounted for at the accident site, and flight control continuity was confirmed from the cockpit to each control surface. The left wing was separated at the wing root and had thermal damage on the inboard portion. The right wing was still attached to the fuselage and sustained substantial thermal damage. The flap control handle indicated a flap position of 10°. The cockpit and fuselage were destroyed by fire. Both propeller blades exhibited aft bending and leading-edge polishing. The landing gear was retracted. The engine was rotated by hand at the propeller, and continuity of the drive train, valve train, and accessory section were established. The sparkplugs showed signs of normal wear. The magnetos were destroyed by fire. Thumb compression was confirmed on all cylinders. Examination of the engine and disassembly of its accessories revealed no evidence of any preimpact mechanical anomalies.

## Aircraft

- Registration: [N2241Q](https://openairdocs.org/deregistered/N2241Q-2018-08-31), registration cancelled 2018-08-31, S/N 28R-7737029 (OpenAirDocs)
- Reported make and model: PIPER PA 28R-201 (201)
- Registry model: [Piper PA-28R-201](https://openairdocs.org/model/piper-pa-28r-201) (registry code 7102816) (OpenAirDocs)
- Category: Airplane
- Serial number: 28R-7737029
- Year built: 1977
- Airframe hours: 6573.6
- Engines: Lycoming IO-360-C1C6 200 horsepower reciprocating
- Damage: Destroyed
- Fire: On-Ground
- Flight: Personal, Part 91
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, March 1, 2016
- Departed: NY05, Esperance, NY
- Destination: HVN, NEW HAVEN, CT
- Airport: NY05, Hogan, runway 30R, 3,000 × 27 ft, grass/turf
- Equipment: Unknown

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 38; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 561.2 as pilot in command

## Weather

- Conditions: Visual (VMC), Day
- Wind: 30° at 3 knots
- Visibility: 10 statute miles
- Lowest ceiling: 22,000 ft broken
- Temperature: 81 °F, dew point 61 °F
- Altimeter: 30.04 inHg
- Observed at: KALB, 23 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 20160716011109A](https://openairdocs.org/incident/20160716011109A), Jul 16, 2016: Piper PA-28R-201, Esperance, NY, Destroyed, 3 fatal. 07/16/2016 The albany flight standards district office (FSDO)investigated an accident with aircraft N2241Q Piper pa 28R-201 serial number 28R-7737029. At…

## Other investigations on N2241Q (1)

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 MKC78FCJ04](https://openairdocs.org/ntsb/MKC78FCJ04), Nov 18, 1977: Piper PA-28R (N2241Q), Omaha, NE, substantial damage

## Docket (14 files)

The files NTSB released with the investigation on November 22, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93610. 8.0 MB in all.

- Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 577 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458306&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF
- Witness Statements (item 2, .PDF, 398 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458318&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF
- Photo Array (item 3, .PDF, 475 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458319&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF
- Radar Plot (item 4, .PDF, 508 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458320&FileExtension=.PDF&FileName=Radar%20Plot-Master.PDF
- Radar Data (item 5, .CSV, 6 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458321&FileExtension=.csv&FileName=Radar%20Data-Master.csv
- Surveillance Video - Takeoff (item 6, MP4, 4.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458322&FileExtension=mp4&FileName=Surveillance%20Video%20-%20Takeoff-Master
- Surveillance Video - Climb (item 7, MP4, 864 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458323&FileExtension=mp4&FileName=Surveillance%20Video%20-%20Climb-Master
- Estimated Weight and Balance (item 8, .PDF, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458324&FileExtension=.PDF&FileName=Estimated%20Weight%20and%20Balance-Master.PDF
- Memorandum for Record – Robinson Aviation (item 9, .PDF, 43 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458325&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Robinson%20Aviation-Master.PDF
- Fuel Receipt (item 10, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458326&FileExtension=.PDF&FileName=Fuel%20Receipt%20-Master.PDF
- Memorandum for Record – Investigator Stevens (item 11, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458327&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Investigator%20Stevens-Master.PDF
- Piper Arrow Arrow III POH excerpts (item 12, .PDF, 206 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458328&FileExtension=.PDF&FileName=Piper%20Arrow%20Arrow%20III%20POH%20excerpts-Master.PDF
- Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 76 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458329&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF
- Toxicological Report (item 14, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458330&FileExtension=.PDF&FileName=Toxicological%20Report-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.