ERA17LA277

NTSB accident investigation · Piper PA28 · Canton, GA · August 15, 2017

Accident · Minor injuriesLimited investigationFinal report
Date
August 15, 2017, 16:35 local (20:35 UTC)
Place
Canton, GA
Injuries
2 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2804TPiper PA28
Defining event
Initial climb: Powerplant sys/comp malf/fail
Weather
Visual (VMC) · Day
Status
Completed · report July 8, 2019
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Power Flow Systems Inc, FAA/FSO
FAA report
20170815017979A
Case key
95826

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

Maintenance personnel's failure to ensure the proper throttle linkage travel clearance after the installation of an exhaust system.

Findings · 2

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.

Maintenance: installationPersonnel issues › Task performance · Maintenance personnelPiper PA-28-140: 4 casesAll aircraft: 371 casesProbable cause
Engine controls: power leverAircraft › Aircraft power plant · Not inspectedPiper PA-28-140: 2 casesAll aircraft: 95 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

According to the flight instructor, during the takeoff roll, he noted that the airplane felt "sluggish." After checking all systems, he and the student pilot continued the takeoff. The flight instructor noted that, after climbing to 200 ft, the airspeed began to decrease while the engine continued to produce power. The flight instructor performed an emergency landing in a wooded area, which resulted in substantial damage to the wings and fuselage. An examination of the airplane revealed that the carburetor throttle linkage was striking against the exhaust shield, which prevented the carburetor throttle linkage from its full movement at full throttle. A review of the maintenance logbooks revealed that a new exhaust system was recently installed on the engine. It is likely that maintenance personnel failed to ensure that the throttle linkage was properly adjusted, which prevented the throttle from opening fully and resulted in the engine being unable to produce full static power.

Factual narrative

On August 15, 2017, about 1635 eastern daylight time, a Piper PA-28-140, N2804T, was substantially damaged during a forced landing after takeoff from the Cherokee County Airport (CNI), Canton, Georgia. The flight instructor and student pilot sustained minor injuries. The instructional flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and no flight plan was filed for the local flight.According to the flight instructor, after an uneventful engine run-up, they taxied to the active runway for takeoff. As the takeoff roll commenced, he noted that the airplane felt "sluggish." He asked the student pilot if he had his foot on the brakes, and the student pilot replied "no." The flight instructor checked the throttle and airspeed and noted that the throttle was full forward and the airspeed was increasing slowly. Once the airplane reached 75 knots, the airplane lifted off the runway and began to climb. The climb appeared normal for approximately the first 200 ft. Then, the flight instructor noticed that the airspeed was decreasing but the engine never stopped. He took over the flight controls and elected to perform an emergency landing in a wooded area. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that both wings separated from the fuselage and the fuselage of the airplane was buckled. A post-crash fire ensued within the engine cowling and spread to the cockpit. An examination of the engine revealed that the carburetor throttle linkage was striking against the exhaust heat shield. This prevented the carburetor throttle linkage from its full movement at full throttle. A review of the maintenance logbooks revealed that on July 28, 2017, a Power Flow exhaust system was installed on the engine. The airplane accumulated about 6 hours of flight time prior to the accident event.

Aircraft

Registration
N2804T
Reported as
Piper PA28 (140)
Category
Airplane
Serial number
28-7225235
Built
1972
Airframe hours
7,976.09
Engine
Lycoming O-320-E3D, 150 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 12, 2017 · 76 hours before
Departed
CNI · Canton, GA
Destination
CNI · Canton, GA
Airport
CNI · Cherokee County, runway 5, 5,001 × 75 ft, asphalt
Equipment
Stall warning system

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
63
Injuries
Minor
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
December 8, 2016
Seat
Right
Restraint
3-point
Flight hours
3,623 total · 987 in this make and model · 3,518 as pilot in command · 16 in the last 90 days · 10 in the last 30 days
Role
Student pilot
Age
50
Injuries
Minor
Certificate
Student
Seat
Left
Restraint
3-point
Flight hours
12 total · 12 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
280° at 4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
86 °F, dew point 75 °F
Altimeter
29.97 inHg
Observed at
CNI

Docket · 7

The files NTSB released with the investigation on April 8, 2019, on NTSB’s docket system: statements, records, photos and specialists’ reports. 6.7 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.