# NTSB ERA19LA041: Piper PA28R, N52737, Lake City, FL, November 11, 2018 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: November 11, 2018, 13:14 local (18:14 UTC) - Place: Lake City, FL - Coordinates: 30.150554, -82.665 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.1506&lon=-82.6650&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Serious injuries - Injuries: 3 serious, 1 minor - Status: Completed, report April 13, 2020 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA - NTSB case key (mKey): 98626 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA041 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98626/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98626 - Page: https://openairdocs.org/ntsb/ERA19LA041 ## Probable cause The pilot's failure to attain adequate airspeed before attempting the takeoff with a tailwind, which resulted in the airplane being unable to sustain flight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28R-201, 3 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7102816), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28R-201, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102816), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Wind: tailwind](https://openairdocs.org/ntsb-findings/03034015): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Piper PA-28R-201, 1 case](https://openairdocs.org/ntsb-findings/03034015/cases.md?model=7102816), [All aircraft, 594 cases](https://openairdocs.org/ntsb-findings/03034015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28R-201, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102816), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Initial climb: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-28R-201, 1 case](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102816), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28R-201, 8 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102816), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot was attempting to depart from a 2,600-ft-long turf runway with a right quartering tailwind with three passengers onboard. A witness estimated that the tailwind was about 8 knots. The pilot reported that the only thing he could recall about the flight was that he had "difficulty getting the airplane into the air." Another witness reported that, immediately after becoming airborne, the airplane entered a series of pitch oscillations; during each oscillation, the airplane appeared to be near the stall speed and lose altitude. After several oscillations, the airplane neared the left side of the runway and impacted treetops before impacting the ground and cartwheeling. One of the witnesses stated that the engine sound did not change during takeoff and that the engine appeared to be running well the entire time. Given the evidence, it is likely that the pilot's failure to attain adequate airspeed before attempting the takeoff with a tailwind, which led to the airplane being unable to sustain flight. ## Factual narrative On November 11, 2018, about 1314 eastern standard time, a Piper PA-28R-201, N52737, was substantially damaged when it impacted the ground during the initial climb after takeoff from Cannon Creek Airpark (15FL), Lake City, Florida. The private pilot and two passengers were seriously injured, and one passenger sustained minor injuries. Visual meteorological conditions prevailed, and no flight plan was filed for the local flight. The personal flight was conducted under the provisions of Title 14 Code of Federal Regulations Part 91.The right front seat passenger stated that as soon as they took off, he knew something was wrong because the airplane was not climbing very fast. He thought the airplane was going to touch back down on the runway when he noticed the airplane's nose going "up and down." The airplane made several nose-up and nose-down oscillations before going to the left side of the runway and contacting tree tops. The airplane then impacted the ground and cartwheeled. The pilot stated that he remembered the takeoff roll. He stated he was "having difficulty getting the airplane in the air." The next thing he remembered was waking up in the hospital several days later. A witness, who was parked on the side of the runway to watch the airplane taking off, stated he observed the pilot perform a preflight engine run-up and the airplane begin the departure on runway 27, a 2,600 ft-long turf runway. The wind was a right quartering tailwind at an estimated velocity about 8 to 10 mph. He thought the pilot "forced" the airplane off the ground and it immediately began "oscillations." When the airplane appeared to be near stall speed, the nose lowered and would then raise again, which repeated until the airplane contacted some tree tops. He further stated that each time the airplane oscillated, it resulted in a lower altitude. Another witness, who was also a pilot, watched the airplane during the takeoff. He stated that it appeared as if the accident pilot had "pulled" the airplane off the ground too early, and he watched as the airplane "porpoised" 3 to 4 times down the runway, while flying at or near stall speed. The witness further described that there was no change in the engine's sounded throughout the takeoff, and that it appeared to be running well the entire time. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that the airplane's wings sustained buckling and tears. The left main landing gear collapsed. The fuselage had buckling along its length aft to the elevator. The rudder was undamaged. The four seat, low-wing, tricycle gear airplane was manufactured in 1989. It was powered by a Lycoming IO-360 series, 200-horsepower engine, equipped with a two-bladed McCauley propeller. The pilot held a private pilot certificate, with ratings for airplane single-engine land and instrument airplane. His FAA third class medical certificate was issued on August 20, 2015. He reported 3,583 total hours of flightexperience at that time. ## Aircraft - Registration: [N52737](https://openairdocs.org/deregistered/N52737-2019-06-25), registration cancelled 2019-06-25, S/N 28-37021, built 1989 (OpenAirDocs) - Reported make and model: Piper PA28R (201) - Registry model: [Piper PA-28R-201](https://openairdocs.org/model/piper-pa-28r-201) (registry code 7102816) (OpenAirDocs) - Registry engine: [Lycoming I0360 SER A&C](https://openairdocs.org/engine/lycoming-i0360-ser-a-c) (registry code 41511, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-37021 - Year built: 1989 - Engines: Lycoming IO-360 200 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Departed: 15FL, Lake City, FL - Destination: 15FL, Lake City, FL - Airport: 15FL, Cannon Creek Airpark, runway 27, 2,600 × 50 ft, grass/turf - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 75; injuries: serious; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: 3-point; flight hours: 3,583 total ## Weather - Conditions: Visual (VMC), Day - Wind: 60° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: 2,700 ft broken - Temperature: 77 °F, dew point 63 °F - Altimeter: 30.19 inHg - Observed at: KGNV, 34 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 20181111021699A](https://openairdocs.org/incident/20181111021699A), Nov 11, 2018: Piper PA-28R-201, Lake City, FL, Destroyed. Ptrs-20190418 Technical factors Operational factors Weather briefing source Pilot training Pilot information Each of these has been marked no or incomplete,… ## Docket (5 files) The files NTSB released with the investigation on November 26, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98626. 830 KB in all. - Memorandum for Record – Telephone Interview, Pilot (item 1, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478404&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Pilot-Master.PDF - Memorandum for Record – Telephone Interview, Passenger 1 (item 2, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478405&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Passenger%201-Master.PDF - Memorandum for Record – Telephone Interview, Passenger 2 (item 3, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478406&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20%E2%80%93%20Telephone%20Interview,%20Passenger%202-Master.PDF - Witness Statements (item 4, .PDF, 89 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478407&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Investigative Photos (item 5, .PDF, 4 photos, 585 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40478408&FileExtension=.PDF&FileName=Investigative%20Photos-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.