# NTSB ERA17LA311: Piper PA32R, N544DG, Merritt Island, FL, September 3, 2017 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: September 3, 2017, 09:20 local (13:20 UTC) - Place: Merritt Island, FL - Coordinates: 28.341667, -80.685554 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.3417&lon=-80.6856&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed, report April 8, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 95951 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA17LA311 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/95951/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=95951 - Page: https://openairdocs.org/ntsb/ERA17LA311 ## Probable cause The pilot's inadequate preflight planning and improper takeoff technique, which resulted in an exceedance of the airplane's critical angle of attack and an aerodynamic stall. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: weight/balance calculations](https://openairdocs.org/ntsb-findings/02061015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-32R-300, 3 cases](https://openairdocs.org/ntsb-findings/02061015/cases.md?model=7103213), [All aircraft, 110 cases](https://openairdocs.org/ntsb-findings/02061015/cases.md) - [Planning/preparation: performance calculations](https://openairdocs.org/ntsb-findings/02061010): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-32R-300, 2 cases](https://openairdocs.org/ntsb-findings/02061010/cases.md?model=7103213), [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-32R-300, 14 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103213), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-32R-300, 4 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7103213), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/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: Preflight or dispatch event](https://openairdocs.org/ntsb-events/030); cases with it: [Piper PA-32R-300, 6 cases](https://openairdocs.org/ntsb-events/030/sequence.md?model=7103213), [All aircraft, 355 cases](https://openairdocs.org/ntsb-events/030/sequence.md) - [Takeoff: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Piper PA-32R-300, 4 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7103213), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-32R-300, 32 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103213), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot attempted to take off for the personal flight with three passengers from a 3,601-ft-long asphalt runway. Video footage and a witness confirmed that the airplane did not rotate and become airborne until it was near the end of the runway. The nose initially pitched up about 5°, and the airplane climbed about 20 to 30 ft above ground level. As the airplane approached trees, the nose pitched up about 15° and the left wing dropped, consistent with a stall. Examination of the wreckage did not reveal any evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. Pilot estimates regarding occupant/baggage weights and the available fuel on board suggest that the airplane was slightly below its maximum allowable takeoff weight. However, although the exact baggage weight and fuel load during takeoff could not be determined, witness estimates of baggage weight and the airplane's total capacity for usable fuel suggest that the airplane was likely at or above its maximum gross weight. The pilot reported that he rotated the airplane at 80 knots. He also initially reported that he attempted the takeoff with "two notches" of flap extension but subsequently stated that the takeoff was with the flaps retracted. Although performance data indicate that the takeoff could be accomplished in about 2,900 ft at maximum gross weight with flaps retracted, the pilot likely did not fly the airplane at the optimal airspeeds recommended in the pilot's operating handbook for the airplane make and model, which were 64 knots at rotation and 69 knots at an altitude of 50 ft. ## Factual narrative On September 3, 2017, about 0920 eastern daylight time, a Piper PA-32R-300, N544DG, was substantially damaged when it collided with water during takeoff at Merritt Island Airport (KCOF), Merritt Island, Florida. The private pilot and three passengers were not injured. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed and a visual flight rules flight plan was filed for the planned flight to Marsh Harbour International Airport (MYAM), Marsh Harbour, Bahamas.The pilot reported that prior to the flight, he fueled the airplane to a total of 80 gallons of 100-low-lead aviation gasoline. He then completed a preflight inspection of the airplane and subsequent engine run-up prior to takeoff, with no anomalies noted. The pilot added that although the automated surface observation system reported the wind from 350° at 5 knots, the wind was light and variable at the time of the accident. Additionally, an airplane was in the airport traffic pattern and using runway 11, so the pilot elected to depart in that direction. The pilot initially stated that he extended the flaps "two notches" and rotated the airplane at 80 knots, about two-thirds down the 3,601-foot asphalt runway. He later stated that the flaps were retracted during the takeoff attempt. A witness, who was a flight instructor at a fixed-based-operator, was standing near a hangar and observed the accident takeoff. The witness stated that his attention was drawn to the accident airplane as it used more of a ground roll during the takeoff attempt than what he was accustomed to seeing. Specifically, the airplane did not rotate until about 2,300 feet down the runway. The nose initially pitched up about 5° and the airplane climbed about 20 to 30 feet above ground level. Then, as the airplane approached trees, the nose pitched up about 15° and the left wing dropped, consistent with a stall. The witness added that the pilot initially reported the engine "quit," but the witness heard engine noise throughout the takeoff, until the airplane impacted the water. Review of airport surveillance video revealed that the airplane had not lifted off as it traveled off the right side of camera view, about 600 feet prior to the departure end of the runway. Examination of the wreckage by a Federal Aviation Administration inspector did not reveal any preimpact mechanical malfunctions. The inspector rotated the propeller and confirmed crankshaft, camshaft, and valve train continuity to the rear accessory section of the engine. During rotation, the inspector noted saltwater emitting from the exhaust. The inspector did not attempt a test-run of the engine as saltwater remained in the engine and had corroded one of the magnetos. The pilot provided weights of the occupants and baggage, and estimated 75 gallons of fuel onboard at takeoff. Based on information provided by the pilot, the airplane was about 117 lbs. below its maximumtakeoff weight of 3,600 lbs. The witness estimated 12 bags on board and their combined weight more than double the 100 lbs. that the pilot reported; however, the bags were wet after the accident and could not be accurately weighed. Additionally, the airplane held a total of 94 gallons of useable fuel and the exact fuel load during the takeoff attempt could not be determined. The recorded weather at an airport located about 8 miles southeast of the accident site, at 0853, was: wind from 330° at 6 knots; visibility 10 miles; few clouds at 6,500 ft; temperature 26° C; dew point 24° C; altimeter 30.09 inches of mercury. Review of a pilot's operating handbook for the make and model airplane revealed that at 80° F, with flaps retracted, at 3,600 lbs., with a 3-knot tailwind, at sea level, the airplane required about 2,900 feet to clear a 50-foot barrier. The data assumed a liftoff speed of 64 knots and a barrier speed of 69 knots. ## Aircraft - Registration: [N544DG](https://openairdocs.org/deregistered/N544DG-2018-06-08), registration cancelled 2018-06-08, S/N 32R-7780440, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA32R (300) - Registry model: [Piper PA-32R-300](https://openairdocs.org/model/piper-pa-32r-300) (registry code 7103213) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7780440 - Year built: 1977 - Airframe hours: 1897 - Engines: Lycoming IO-540 300 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 1, 2016, 113 hours before - Departed: KCOI, Merritt Island, FL - Destination: MYAM, Marsh Harbour - Flight plan: VFR - Airport: KCOI, Merritt Island Airport, runway 11, 3,601 × 75 ft, asphalt - Equipment: Handheld GPS, Onboard weather, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 43; injuries: none; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3; last flight review February 18, 2016; seat: left; restraint: 3-point; flight hours: 627 total, 65 in this make and model, 627 as pilot in command, 10 in the last 90 days, 0 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 75 °F - Altimeter: 30.09 inHg - Observed at: KCOF, 8 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 20170903017589A](https://openairdocs.org/incident/20170903017589A), Sep 3, 2017: Piper PA-32R-300, Merritt Island, FL, Substantial damage. Pilot used almost entire length of runway before rotation, post rotation the aircraft settled and contacted water. ## Docket (9 files) The files NTSB released with the investigation on November 28, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=95951. 40.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 897 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468603&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Correspondence from Pilot (item 2, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468604&FileExtension=.PDF&FileName=Correspondence%20from%20Pilot-Master.PDF - Interview Summaries (item 3, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468605&FileExtension=.PDF&FileName=Interview%20Summaries-Master.PDF - Airport Surveillance Video (17 sec, 37MB, MP4) (item 4, MP4, 38.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468606&FileExtension=mp4&FileName=Airport%20Surveillance%20Video%20(17%20sec,%2037MB,%20MP4)-Master - Excerpts From Pilot Operating Handbook (item 5, .PDF, 372 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468607&FileExtension=.PDF&FileName=Excerpts%20From%20Pilot%20Operating%20Handbook-Master.PDF - Airplane Basic Empty Weight (item 6, .PDF, 104 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468608&FileExtension=.PDF&FileName=Airplane%20Basic%20Empty%20Weight-Master.PDF - Estimated Takeoff Weight (Based on Information Provided by Pilot) (item 7, .PDF, 8 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468609&FileExtension=.PDF&FileName=Estimated%20Takeoff%20Weight%20(Based%20on%20Information%20Provided%20by%20Pilot)-Master.PDF - Photo Array (item 8, .PDF, 2 photos, 686 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468610&FileExtension=.PDF&FileName=Photo%20Array-Master.PDF - Weather Report (item 9, .PDF, 60 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40468611&FileExtension=.PDF&FileName=Weather%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.