# NTSB ERA17LA277: Piper PA28, N2804T, Canton, GA, August 15, 2017 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: August 15, 2017, 16:35 local (20:35 UTC) - Place: Canton, GA - Coordinates: 34.312221, -84.422225 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.3122&lon=-84.4222&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report July 8, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Power Flow Systems Inc, FAA/FSO - NTSB case key (mKey): 95826 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA277 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95826/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95826 - Page: https://openairdocs.org/ntsb/ERA17LA277 ## Probable cause Maintenance personnel's failure to ensure the proper throttle linkage travel clearance after the installation of an exhaust system. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance: installation](https://openairdocs.org/ntsb-findings/02062035): Personnel issues › Task performance · Maintenance personnel (probable cause); cases with it: [Piper PA-28-140, 4 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md?model=7102802), [All aircraft, 371 cases](https://openairdocs.org/ntsb-findings/02062035/cases.md) - [Engine controls: power lever](https://openairdocs.org/ntsb-findings/01057603): Aircraft › Aircraft power plant · Not inspected (probable cause); cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/01057603/cases.md?model=7102802), [All aircraft, 95 cases](https://openairdocs.org/ntsb-findings/01057603/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-28-140, 12 cases](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102802), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Initial climb: Powerplant sys/comp malf/fail](https://openairdocs.org/ntsb-events/340) (defining event); cases with it: [Piper PA-28-140, 4 cases](https://openairdocs.org/ntsb-events/340/sequence.md?model=7102802), [All aircraft, 820 cases](https://openairdocs.org/ntsb-events/340/sequence.md) - [Emergency descent: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-28-140, 56 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7102802), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) - [Emergency descent: 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 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](https://openairdocs.org/deregistered/N2804T-2020-04-03), registration cancelled 2020-04-03, S/N 28-7225235, built 1972 (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: 28-7225235 - Year built: 1972 - Airframe hours: 7976.09 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 63; injuries: minor; 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 - Student pilot; age 50; injuries: minor; 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 ## 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 20170815017979A](https://openairdocs.org/incident/20170815017979A), Aug 15, 2017: Piper PA-28-140, Ball Ground, GA, Destroyed. Reduction in engine power experienced on take off with worsening effects as altitude increased during climb out. Approximately 200'AGL, engine power was not… ## Docket (7 files) The files NTSB released with the investigation on April 8, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95826. 6.7 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471734&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Pilot's Statement (item 2, .PDF, 65 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471735&FileExtension=.PDF&FileName=Pilot%27s%20Statement-Master.PDF - Student Pilot Statement (item 3, .PDF, 624 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471736&FileExtension=.PDF&FileName=Student%20Pilot%20Statement-Master.PDF - FAA Record of Conversation (item 4, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471737&FileExtension=.PDF&FileName=FAA%20Record%20of%20Conversation-Master.PDF - Maintenance Record excerpts (item 5, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471738&FileExtension=.PDF&FileName=Maintenance%20Record%20excerpts-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 530 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471739&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Photo Array (item 7, .PDF, 3 photos, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471740&FileExtension=.PDF&FileName=Photo%20Array-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.