# NTSB ERA19LA227: Piper PA22, N7833D, Hastings, FL, July 14, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Limited · Final report - Date: July 14, 2019, 07:59 local (11:59 UTC) - Place: Hastings, FL - Coordinates: 29.693332, -81.506942 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.6933&lon=-81.5069&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Fuel related](https://openairdocs.org/ntsb-events/190) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 99837 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA19LA227 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99837/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99837 - Page: https://openairdocs.org/ntsb/ERA19LA227 ## Probable cause The pilot’s failure to secure the engine primer control, which resulted in an overly rich fuel/air mixture and degraded engine performance. Contributing to the accident was the pilot’s failure to abort the takeoff in a timely manner. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Landing gear system: landing gear/wheel fairing](https://openairdocs.org/ntsb-findings/01023201): Aircraft › Aircraft systems · Not serviced/maintained; cases with it: [Piper PA-22-150, 1 case](https://openairdocs.org/ntsb-findings/01023201/cases.md?model=7102210), [All aircraft, 9 cases](https://openairdocs.org/ntsb-findings/01023201/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-22-150, 6 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102210), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-22-150, 13 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102210), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Fuel related](https://openairdocs.org/ntsb-events/190) (defining event); cases with it: [Piper PA-22-150, 3 cases](https://openairdocs.org/ntsb-events/190/sequence.md?model=7102210), [All aircraft, 361 cases](https://openairdocs.org/ntsb-events/190/sequence.md) - [Initial climb: Low altitude operation/event](https://openairdocs.org/ntsb-events/220); cases with it: [Piper PA-22-150, 1 case](https://openairdocs.org/ntsb-events/220/sequence.md?model=7102210), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Piper PA-22-150, 4 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7102210), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) ## Analysis The pilot reported that, during takeoff, the airplane did not accelerate to rotation speed within its normal takeoff roll distance, but he continued the takeoff and the airplane lifted off near the end of the runway. Just after liftoff, the landing gear impacted vegetation at the end of the runway. The pilot believed the airplane was stalling and attempted to “get the airspeed up”; however, the airplane impacted a tree and then the ground, resulting in substantial damage. Examination of the wreckage revealed that the engine primer was in the unlocked position, and the spark plugs were black and sooty. The unlocked primer, which fed fuel to all four cylinders, likely resulted in an overly rich fuel mixture. The pilot recalled that, at the time of liftoff, the engine speed was 2,400 rpm. According to the owner’s manual, the maximum engine speed was 2,700 rpm. It is likely that the excessively rich fuel mixture prevented the engine from reaching full power during the takeoff roll and resulted in the increased takeoff distance and poor climb performance. Additionally, the wheel bearings on all three landing gear were found to have excessive side play. This may have resulted in additional drag during the takeoff roll, which if present, would have further decreased the takeoff performance. The extent to which this may have contributed to the accident could not be determined. ## Factual narrative On July 14, 2019, at 0759 eastern daylight time, a Piper PA22-150, N7833D, was substantially damaged when it was involved in an accident in Hastings, Florida. The pilot and passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that, before takeoff, he completed a preflight inspection and engine runup that revealed no anomalies. He applied the brakes, advanced the throttle to full power, and released the brakes to take off. During the takeoff roll, he noticed that the airplane did not lift off in its “normal distance” and he continued the takeoff roll until the airspeed reached 50 to 55 knots, as the airplane neared the end of the runway. The airplane became airborne and the landing gear impacted vegetation at the end of the runway. He believed that the airplane was stalling and attempted to “get the airspeed up”; however, the airplane impacted a tree and then the ground. According to a witness who was mowing the turf runway, the grass was "really high and wet." He was mowing the perimeter of the runway when he noticed the accident airplane performing an engine run-up, so he mowed one 12-ft pass down the center of the runway before the airplane took off. He watched the airplane take off to the north and noticed that it used nearly the entire 2,300-ft-long runway before lifting off. The airplane remained within the recently-mowed section of the runway during the takeoff roll. He stated that after liftoff, the airplane flew through tall cornstalks located in a field adjacent to the runway and continued to gain altitude. The airplane then made a left turn toward a crosswind traffic pattern leg followed by another left turn toward a downwind leg. During the turns, the airplane descended behind a row of trees before he lost sight of it. The pilot stated that the engine “was fine” and that he “just didn’t get enough airspeed.” He recalled that, at the time of rotation, the engine speed was 2,400 rpm. A review of an airplane owner’s manual for the same make and model airplane revealed that the engine’s maximum speed was 2,700 rpm. The engine data plate and tachometer markings found on the airplane both indicated the maximum speed was 2,700 rpm. Examination of the wreckage by a Federal Aviation Administration (FAA) inspector revealed that all major components of the airplane were present at the accident site. The airplane came to rest inverted. Both wings were impact damaged and separated from the fuselage at the wing root. The engine and upper cowling were separated at the firewall. The fuel primer control was unlocked and extended about 1/8 to 1/4 inch from the closed position. The mixture control and throttle were at or near the full forward position. A follow-up examination of the engine revealed that the spark plug electrodes were black in color and sooty. The engine crankshaft was rotated manually using a tool attached to an accessory drive gear, andthumb compression and suction was present on all four cylinders. Continuity of the crankshaft and valvetrain was confirmed. Both magnetos produced spark on all towers when rotated by hand. The engine priming system was of the type that fed fuel to all four cylinders independently. The wheel bearings in all three landing gear were found to have excessive side play. ## Aircraft - Registration: [N7833D](https://openairdocs.org/deregistered/N7833D-2020-05-29), registration cancelled 2020-05-29, S/N 22-5479, built 1957 (OpenAirDocs) - Reported make and model: Piper PA22 (150) - Registry model: [Piper PA-22-150](https://openairdocs.org/model/piper-pa-22-150) (registry code 7102210) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 22-5479 - Year built: 1957 - Engines: Lycoming O-320 -A2B 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 1, 2019 - Destination: Same as departure - Airport: 13FA, Earle Airpark, runway 36, 2,300 × 100 ft, grass/turf - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review August 13, 2017; seat: left; restraint: lap only; flight hours: 227 total, 84.8 in this make and model, 104.3 as pilot in command, 10.3 in the last 90 days, 3.9 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 75 °F - Altimeter: 30.15 inHg - Observed at: SGJ, 18 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 20190714017519A](https://openairdocs.org/incident/20190714017519A), Jul 14, 2019: Piper PA-22-150, Hastings, FL, Destroyed. The aircraft departed on a hot muggy Florida morning. The grass strip was wet and the grass was long. The airport mowed a strip down the centerline to help the… ## Docket (8 files) The files NTSB released with the investigation on March 9, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99837. 11.8 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 8.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12538914&FileExtension=pdf&FileName=01-01%206120%20ERA19LA227_Redacted_print-Rel.pdf - Memorandum for record - conversation with pilot (item 2, PDF, 1 page, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12537809&FileExtension=pdf&FileName=01-02%20Memorandum-Record%20of%20Conversation_LinebachERA17LA227%20(1)-Rel.pdf - Memorandum for record - conversation with FAA inspector (item 3, PDF, 1 page, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12538567&FileExtension=pdf&FileName=01-03%20ERA19LA227_MFR_Kandravi%20(1)-Rel.pdf - Witness statement - airport maintainer (item 4, PDF, 2 pages, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12538362&FileExtension=pdf&FileName=01-04%20Airport%20Maintainer%20Statement_Redacted-Rel.pdf - Excerpts from airplane owner's manual (1960 model year) (item 5, PDF, 9 pages, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12538924&FileExtension=pdf&FileName=03-01%20-%20Airplane%20Owner_s%20Handbook-Excerpts%201960%20Model%20Year-Rel.pdf - Investigative photographs (item 6, PDF, 2 pages, 2 photos, 530 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12539066&FileExtension=pdf&FileName=06-01%20Photo%20Array%20Template-Rel.pdf - Memorandum for record - wreckage examination (item 7, PDF, 4 pages, 3 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12538372&FileExtension=pdf&FileName=06-02%20Memorandum%20for%20Record%20-%20Wreckage%20Examination-Rel.pdf - Statement of party representatives to NTSB investigation (item 8, PDF, 1 page, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12563707&FileExtension=pdf&FileName=09-01%20Statement%20of%20Party%20Representative_Redacted-Rel.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.