ERA17LA227

NTSB accident investigation · Piper PA28 · San Juan, PR · July 4, 2017

Accident · No injuriesLimited investigationFinal report
Date
July 4, 2017, 17:21 local (20:21 UTC)
Place
San Juan, PR
Injuries
4 uninjured
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N9427JPiper PA28
Defining event
Initial climb: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report April 20, 2020
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20170704008859A
Case key
95494

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

A partial loss of engine power during initial climb for reasons that could not be determined and the pilot's subsequent exceedance of the airplane's critical angle of attack, which resulted in an aerodynamic stall.

Findings · 3

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.

Not determinedNot determined › Not determined · Unknown/Not determinedPiper PA-28-180: 18 casesAll aircraft: 2,247 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-28-180: 67 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28-180: 5 casesAll aircraft: 990 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, before the local, personal flight, the airplane was fueled and that he performed a preflight inspection and an engine run-up with no issues noted. The takeoff was normal; however, during the initial climb, about 250 ft above ground level, the engine started to run roughly and lose power. The engine did not respond to throttle inputs. The pilot contacted the air traffic control tower and stated that he intended to return to the departure airport to land. He did not recall the remainder of the accident sequence. A passenger, who was also a certificated pilot, stated that, as the pilot was turning the airplane left back to the airport, he saw that the airspeed was decreasing and that the stall warning light was flashing. Subsequently, the airplane entered an aerodynamic stall and spun into a canal. A review of a video taken by a witness corroborated the passenger's account. Examination of the airframe and engine did not reveal any preaccident mechanical malfunctions or failures that would have precluded normal operation. Sound spectrum analysis of onboard video revealed that the engine rpm decreased by about 300 and then increased by about 300 twice but then remained steady near full power for about 6 seconds before impact. The reason for the rpm changes could not be determined.

Factual narrative

On July 4, 2017, at 1721 Atlantic daylight time, a Piper PA28-180, N9427J, operated by Horizon Aviation, was substantially damaged when it impacted the San Antonio Canal shortly after takeoff from Fernando Luis Ribas Dominicci Airport (SIG), San Juan, Puerto Rico. The private pilot and three passengers were not injured. Visual meteorological conditions prevailed, and no flight plan was filed for the local personal flight, which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.According to the pilot, the purpose of the flight was to fly to a designated practice area, and return. Prior to the flight, the airplane was fueled. The pilot also calculated the weight and balance, performed a preflight inspection of the airplane and an engine run-up, with no issues noted. During the takeoff roll on runway 9, the engine instruments were "in the green" and the engine developed full power. During the initial climb at an altitude of about 250 ft above ground level, the engine started to run rough and lose power. The engine did not respond to throttle inputs. The pilot informed the air traffic control tower that he intended to return and land on runway 27. As the airplane flew toward a marina, the pilot recalled seeing people on the ground and wanted to avoid them. He did not recall the remainder of the accident sequence. One of the passengers was also a certificated pilot. He stated that the takeoff roll was normal, he observed the airspeed indicator at 60 knots, and liftoff was normal. The pilot flying then reported the engine was rough and radioed the control tower to request to return to runway 27. The passenger estimated the altitude to be around 200 to 300 ft at that time and he also noticed the engine roughness and loss of power, accompanied by vibrations. He stated that the pilot tried hard to avoid people on the ground. As the pilot was turning left, the passenger observed that the airplane was losing airspeed, and he saw the stall warning light flashing and he called out to the pilot "airspeed" a few times. He then recalled the airplane in a stall/spin attitude. A witness located at the marina recorded a portion of the flight on a video camera. A review of the recording revealed that about 20 seconds before impact, the airplane was flying relatively level in an easterly direction, for about 5 seconds, before being obscured by a water drop on the camera lens. About 7 seconds later, the airplane was visible again and on a southerly heading, toward the camera, in a left descending turn. The airplane's bank angle increased to about 90° left wing down, before it impacted the canal. The pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. His most recent first-class medical certificate was issued on October 9, 2012. Review of the pilot's logbook revealed that he had accrued a total flight experience of about 142 hours. His previous flight was on April 10, 2017, whichwas a "rental check" in the accident airplane. Review of the airplane's maintenance records revealed that the most recent 100-hour inspection was performed on March 25, 2017, about 90 hours prior to the accident. Additionally, the most recent annual inspection was completed on July 19, 2016, about 193 hours prior to the accident. The engine had accrued a total of 4,233 hours since new, and 937 hours since overhaul. Initial examination of the airplane by a Federal Aviation Administrator (FAA) inspector revealed that left wing was separated from the fuselage at the root, the right wing was partially separated at the root. The empennage was crushed in several locations, the left stabilator was partially separated and bent upward about 90° at its root. The throttle and mixture controls were found in the full-forward position, the carburetor heat control was in the off position. The fuel selector handle was in the right tank position, the electric fuel pump switch was in the "on" position. Both fuel caps were secure with their seals intact. The engine was drained of sea water, oil, and sediment for examination by an FAA inspector. The inspector removed the spark plugs and did not observe any wear or damage. The carburetor was removed from engine and no damage was noted. The inspector was able to rotate the propeller and obtain compression on all cylinders. The examination did not reveal any preimpact anomalies. An on-board video recording and the witness video recording were forwarded to the National Transportation Safety Board Vehicle Recorder Laboratory, Washington, DC. Review of the onboard video revealed that the airplane lifted off about 35.2 seconds elapsed time (all times are elapsed times). At 1:16.3, the airplane rolled slightly right. Between 1:18.7 and 1:19.7, the engine noise decreased. At 1:20.0, the airplane rolled level and the engine noise further decreased between 1:27.2 and 1:30.1. At 1:30.8, the airplane began to bank left. At 1:34.9, the airplane was in a descending left bank turn. Between 1:34.0 and 1:36.6, there was a momentary increase in background noise, consistent with an increase in engine noise. Between 1:36.8 and 1:37.7, the background noise decreased slightly, and remained at the same levels between 1:36.6 and 1:44.3. The sound of impact was recorded at 1:44.6. A sound spectrum study of the onboard video revealed that engine rpm was at 2,265 for about 7 seconds as the airplane was in the right bank. It then decreased to 1,980 rpm and the airplane began to bank left. The rpm momentarily increased to 2,292 about 5 seconds later, followed by a momentary decrease to 1,950, but remained stable between 2,373 to 2,451 rpm for about 6 seconds leading up to impact. The recorded weather at SIG, at 1729, was: wind from 070° at 14 knots; visibility 8 miles; thin scattered clouds at 3,500 ft; scattered clouds at 8,000 ft; temperature 29° C; dew point 25° C; altimeter 30.01 inches of mercury. Review of an FAA Carburetor Icing Chartfor the given temperature and dew point revealed "Icing (glide and cruise power)."

Aircraft

Registration
N9427J
Reported as
Piper PA28 (180)
Category
Airplane
Serial number
28-3538
Built
1966
Airframe hours
4,323
Engine
Lycoming O-360-A3A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Horizon Aviation
Registered owner
Latitude Aviation LLC
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · March 25, 2017 · 90 hours before
Departed
SIG · San Juan, PR
Destination
SIG · San Juan, PR
Airport
SIG · Fernando Luis Ribas Dominicci, runway 09, 5,539 × 100 ft, asphalt
Equipment
Stall warning system, Video recording device

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
26
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Flight hours
142 total · 50 in this make and model · 64 as pilot in command · 1 in the last 90 days · 0 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
70° at 14 knots
Visibility
8 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 77 °F
Altimeter
30.01 inHg
Observed at
TJIG, 1 nm away

Docket · 10

The files NTSB released with the investigation on October 25, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.9 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 N9427J · 1

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