# NTSB ERA18FA200: Piper PA24, N6427P, Palatka, FL, July 27, 2018 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 26, 2018, 20:07 local (Jul 27, 2018, 00:07 UTC) - Place: Palatka, FL - Coordinates: 29.656389, -81.688613 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.6564&lon=-81.6886&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report July 8, 2019 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA, Piper Aircraft, Lycoming Engines - NTSB case key (mKey): 97896 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA18FA200 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/97896/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=97896 - Page: https://openairdocs.org/ntsb/ERA18FA200 ## Probable cause The pilot's exceedance of the airplane's critical angle of attack during the initial climb after takeoff, which resulted in an aerodynamic stall and a loss of control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-24-250, 34 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102404), [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-24-250, 9 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7102404), [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. - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Piper PA-24-250, 12 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7102404), [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-24-250, 55 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102404), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The accident flight was the private pilot's second solo flight in the accident airplane, which he had purchased and had first flown 13 days before the accident. A witness standing near the departure end of the runway stated that the pilot held the airplane's brakes while advancing the engine to full power, and he believed that the pilot was going to perform a short-field takeoff. As the airplane accelerated down the runway, the nosewheel lifted off then touched down again before the airplane rotated off the runway and began to climb. The witness further stated that he thought that the pilot had rotated the airplane "early," as the airplane appeared slow. The airplane's angle of climb continued to increase until, about 150 ft above ground level, the airplane entered an aerodynamic stall and spiraled to the ground. Examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or abnormalities that would have precluded normal operation. Between the time of purchase and the accident flight, the pilot logged about 15 hours of flight instruction in the airplane; logbook remarks indicated that, during those flights, the pilot had received instruction in normal and crosswind takeoffs and landings. Autopsy and toxicology testing of the pilot identified no evidence of physiological impairment or incapacitation. The lack of mechanical anomalies, the witness statement, and the surveillance video footage are consistent with the pilot's exceedance of the airplane's critical angle of attack during the initial climb after takeoff, which resulted in an aerodynamic stall and a subsequent loss of control. ## Factual narrative HISTORY OF FLIGHT On July 26, 2018, about 2007 eastern daylight time, a Piper PA-24-250, N6427P, was destroyed when it impacted the ground during the initial climb after takeoff from Palatka Municipal Airport (28J), Palatka, Florida. The private pilot and passenger were fatally injured. The airplane was owned by the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight. A witness was standing in his hangar about 200 yards from the end of runway 17 when he heard the accident airplane beginning its takeoff. He noticed that the airplane's brakes were engaged while the engine was at full throttle and he believed that the pilot was going to perform a short-field takeoff. As the airplane rolled down the runway, it's nosewheel lifted off the ground then touched down again before the airplane became airborne. The witness thought that the pilot rotated the airplane "early," as the airplane appeared slow. He added that the airplane kept climbing "steeper and steeper" and that the pilot did not lower the nose to gain airspeed. When the airplane was about 150 ft above ground level, it entered a stall and the left wing dropped; the airplane spiraled to the ground. The witness further stated that the engine was operating at full power during the entire flight. An airport security video at 28J showed the airplane immediately after takeoff as it climbed to about 150 ft; the airplane's left wing dropped and the airplane spiraled to the ground, consistent with the witness' account. PERSONNEL INFORMATION The pilot held a private pilot certificate with ratings for airplane single-engine land and instrument airplane. He was operating under the provisions of the BasicMed; his most recent physical exam was completed on July 14, 2018. According to the pilot's logbook, he had a total of 704.4 hours of flight experience. The accident flight was the pilot's second solo flight in the airplane. The pilot purchased the airplane 13 days before the accident; since purchase, the pilot had logged 15.1 hours of flight instruction in the airplane. Logbook remarks indicated that, during those flights, the pilot had received instruction in normal and crosswind takeoffs and landings, approach and departure stalls, and simulated engine failures. AIRCRAFT INFORMATION The four seat, low-wing, tricycle gear airplane was manufactured in 1959. It was powered by a Lycoming O-540-A1C5, 250-horsepower engine equipped with a three-bladed McCauley propeller. The most recent annual inspection was completed on July 12, 2018. At the time of the accident, the airframe total time was 3,435.73 hours (13.73 hours since the annual inspection) and the engine had accrued 1,268 hours since major overhaul. METEOROLOGICAL INFORMATION At 2015, the recorded weather at 28J included wind from 180° at 5 knots, 10 statute miles visibility, temperature 27°C, dew point 26°C, and analtimeter setting of 29.98 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was located about 60 ft to the left of and about halfway down the length of runway 17, which measured 3,510 ft long. The wreckage came to rest on a magnetic heading of 270°. The propeller was fractured from the engine and buried about 2 ft into the ground. The engine was displaced into the instrument panel and cockpit. The landing gear was extended, and the wing flaps were retracted. Both wings exhibited accordion-like crushing on the leading edges. Flight control cable continuity was established from the cockpit to all flight controls. The stabilator trim control was fragmented and the trim position could not be verified. Both pitch and trim servos rotated freely, and the clutch was not engaged. The fuselage was crushed, and the empennage was bent over top of the cabin. The vertical stabilizer, rudder, and elevator were not damaged. The engine was removed from the airframe for further examination. The top spark plugs were removed, and a lighted borescope was used to look inside the cylinders. All valves and pistons showed normal wear. Thumb compression was confirmed on all cylinders. Drive train continuity was established through the engine and accessory case by rotating the propeller flange and observing the movement of the gears. Both magnetos were removed and turned by hand. All leads sparked to ground. MEDICAL AND PATHOLOGICAL INFORMAITON An autopsy was performed on the pilot by the Office of the Medical Examiner, St. Augustine, Florida. The report listed the cause of death as multiple blunt force trauma. Toxicology testing performed at the FAA Forensic Sciences Laboratory was negative for drugs and alcohol. ## Aircraft - Registration: [N6427P](https://openairdocs.org/deregistered/N6427P-2019-06-26), registration cancelled 2019-06-26, S/N 24-1537, built 1959 (OpenAirDocs) - Reported make and model: Piper PA24 (250) - Registry model: [Piper PA-24-250](https://openairdocs.org/model/piper-pa-24-250) (registry code 7102404) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 24-1537 - Year built: 1959 - Airframe hours: 3422 - Engines: Lycoming O-540 SERIES 250 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 12, 2018, 14 hours before - Departed: 28J, Palatka, FL - Destination: 28J, Palatka, FL - Airport: 28J, Palatka Muni - Lt Kay Larkin F, runway 17, 3,510 × 75 ft, asphalt - Equipment: Stall warning system, Auto-pilot, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: basicmed; last flight review July 16, 2018; seat: left; toxicology performed; flight hours: 704.4 total, 15.1 in this make and model, 660.5 as pilot in command, 38 in the last 90 days, 15.1 in the last 30 days ## Weather - Conditions: Visual (VMC), Dusk - Wind: 180° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 79 °F - Altimeter: 29.97 inHg - Observed at: 28J ## 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 20180726018049A](https://openairdocs.org/incident/20180726018049A), Jul 26, 2018: Piper PA-24-250, Palatka, FL, Destroyed, 2 fatal. On July 26, 2018 about 2007 eastern daylight time, a Piper PA-24-250, N6427P, was destroyed while taking off from Palatka municipal airport-lt. kay Larkin… ## Other investigations on N6427P (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 UNK64X2845](https://openairdocs.org/ntsb/UNK64X2845), Jul 15, 1964: Piper PA24 (N6427P), Vernon, UT, substantial damage ## Docket (10 files) The files NTSB released with the investigation on May 15, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=97896. 15.0 MB in all. - Witness Statement (item 1, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472933&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Fuel Receipt (item 2, .PDF, 18 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472934&FileExtension=.PDF&FileName=Fuel%20Receipt-Master.PDF - Pilot Logbook Excerpts (item 3, .PDF, 7.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472935&FileExtension=.PDF&FileName=Pilot%20Logbook%20Excerpts-Master.PDF - Maintenance Records (item 4, .PDF, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472936&FileExtension=.PDF&FileName=Maintenance%20Records-Master.PDF - Weather Reports and Records (item 5, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472937&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Master.PDF - Investigative Photos (item 6, .PDF, 5 photos, 994 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472938&FileExtension=.PDF&FileName=Investigative%20Photos-Master.PDF - Toxicological Report (item 7, .PDF, 306 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472939&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Video File (item 8, .PDF, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472940&FileExtension=.PDF&FileName=Video%20File-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 9, .PDF, 556 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472941&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472942&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.