ERA20LA121

NTSB accident investigation · Piper PA28 · Mount Pleasant, TN · February 28, 2020

Accident · No injuriesClass 3 · LimitedFinal report
Date
February 28, 2020, 15:30 local (21:30 UTC)
Place
Mount Pleasant, TN
Injuries
2 uninjured
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N79HAPiper PA28
Defining event
Takeoff: Fuel related
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
FAA/FSDO
FAA report
20200228000399A
Case key
101042

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

A partial loss of engine power during initial climb due to carburetor icing that formed while idling on the ground for an extended amount of time. Contributing was the flight instructor's failure to perform the recommended ground checks before takeoff.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Temp/humidity/pressure: conducive to carburetor icingEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomePiper PA-28-140: 10 casesAll aircraft: 435 casesProbable cause
Use of equip/info: use of checklistPersonnel issues › Task performance · PilotPiper PA-28-140: 2 casesAll aircraft: 336 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

After engine startup, the flight instructor and pilot receiving instruction discussed the soft field takeoff maneuver on the ramp for 12 to 15 minutes before taxiing to the turf runway. They did not perform an engine runup or apply carburetor heat before departing. About 900 ft down the turf runway, the airplane became airborne in ground effect. The pilot attempted twice to climb, but on both attempts the airplane settled back into ground effect. The instructor reported that the airplane did not seem to be producing sufficient power to climb. The pilot assessed the airplane's ability to clear the power lines at the edge of the airport property, made the decision to stay on the airport property, and initiated a left turn. The airplane descended and impacted the ground in a nose-low attitude. Postaccident examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The atmospheric conditions at the time of the accident were conducive to the formation of serious carburetor icing at low engine power settings. It is likely that during the extended ground delay, when the engine was operating at low power, carburetor ice formed, which resulted in a partial loss of engine power during the initial climb. It is also likely that the carburetor ice would have been detected or prevented prior to takeoff had the recommended pre-takeoff ground checks been completed according to the pilot's operating handbook.

Factual narrative

On February 28, 2020, about 1530 central standard time, a Piper PA-28-140, N79HA, was substantially damaged when it was involved in an accident near Pleasant, Tennessee. The flight instructor and pilot receiving instruction were not injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. According to the pilot receiving instruction, after engine startup, they discussed the soft-field takeoff procedure on the ramp for about 12 to 15 minutes. They then taxied to runway 35 and took off without performing an engine run-up. He stated that he did not note the engine rpm during the takeoff roll because his eyes were focused outside. About 900 ft down the turf runway, the airplane lifted off and he moved the yoke forward to maintain level flight while accelerating in ground effect. He attempted twice to climb, but during both attempts, the airplane settled back into ground effect. He told the instructor, "It's still not climbing," and assessed the airplane's ability to clear the power lines at the edge of the airport property, which were at his eye-level. He made the decision to stay on the airport property, initiated a left turn, and the airplane descended to the ground. According to the flight instructor, the airplane settled back into ground effect twice after the pilot attempted to raise the nose to climb. He instructed the pilot to make a left turn to avoid the power lines about 1,000 ft beyond the departure end of runway 35 and stated that the pilot banked more steeply than anticipated. He joined the pilot on the controls; however, the airplane descended and impacted the ground in a nose-low attitude. Examination of the wreckage by a Federal Aviation Administration aviation safety inspector revealed the airplane came to rest in an upright position, 650 ft and 313° from the departure end of runway 35. The airplane remained intact; however, the nose gear was separated, the left wing displayed buckling from the leading to the trailing edge, and the aileron was bent. Both propeller blades exhibited aft bending and chordwise scratching. The inspector noted fuel in both wing tanks. Examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. The 1535 weather included temperature 8°C and dew point -2°C. The calculated relative humidity at this temperature and dewpoint was about 49.3%. According to an FAA Icing Probability Chart, the atmospheric conditions at the time of the accident were "conducive to serious icing at glide [idle] power." According to FAA Advisory Circular 20-113 , "To prevent accident due to induction system icing, the pilot should regularly use [carburetor] heat under conditions known to be conducive to atmospheric icing and be alert at all times for indications of icing in the fuel system." The circular recommended that when operating in conditions where the relative humidity is greater than 50%,"…apply carburetor heat briefly immediately before takeoff, particularly with float type carburetors, to remove any ice which may have been accumulated during taxi and runup." It also stated, "Remain alert for indications of induction system icing during takeoff and climb-out, especially when the relative humidity is above 50 percent, or when visible moisture is present in the atmosphere." The examination of the engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. According to the ground check procedures section of the airplane's Pilot's Operating Handbook (POH): Carburetor heat should be checked prior to takeoff to be sure that the control is operating properly and to clear any ice which may have formed during taxiing.

Aircraft

Registration
N79HA
Reported as
Piper PA28 (140)
Category
Airplane
Serial number
28-7425135
Built
1973
Airframe hours
3,424.41
Engine
Lycoming O-320-E2A, 140 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Airworthiness certificate
Standard, Utility; Standard, Normal
Last inspection
Annual · October 31, 2019 · 60 hours before
Departed
MRC · Mount Pleasant, TN
Destination
MRC · Mount Pleasant, TN
Airport
MRC · Maury County, runway 35, 1,811 × 150 ft, grass/turf
Equipment
ADS-B, Stall warning system

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
26
Injuries
None
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
January 20, 2019
Seat
Right
Restraint
Lap only
Flight hours
950 total · 80 in this make and model · 850 as pilot in command · 120 in the last 90 days · 57 in the last 30 days · 3 in the last 24 hours
Role
Pilot
Age
42
Injuries
None
Certificates
Military, Commercial
Instrument ratings
Helicopter
Medical
Without waivers/limitations
Seat
Left
Restraint
Lap only
Flight hours
2,500 total · 2.5 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 6 knots, gusting 11
Visibility
10 statute miles
Lowest ceiling
None
Temperature
46 °F, dew point 28 °F
Altimeter
30.10 inHg
Observed at
MRC

Docket · 8

The files NTSB released with the investigation on March 16, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 42.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.