ERA23LA165

NTSB accident investigation · Piper PA-28-151 · St. Augustine, FL · March 26, 2023

Accident · Minor injuriesClass 4 · LimitedFinal report
Date
March 26, 2023, 11:30 local (15:30 UTC)
Place
St. Augustine, FL
Injuries
1 minor, 1 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N541SPPiper PA-28-151
Defining event
Landing-landing roll: Loss of control on ground
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Eastern Region Aviation
Parties
FAA/ FSDO
FAA report
20230326007599A
Case key
106962

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

The pilot’s failure to maintain directional control during the landing roll in gusting crosswind conditions, which resulted in a runway excursion and an impact with a ditch.

Findings · 3

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-28-151: 10 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: directional controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28-151: 9 casesAll aircraft: 3,958 casesProbable cause
Wind: crosswindEnvironmental issues › Conditions/weather/phenomena · Response/compensationPiper PA-28-151: 3 casesAll aircraft: 1,008 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

The pilot reported that following a local flight, the approach to landing and touchdown were normal, however, as he applied wheel brakes, the airplane veered to the right. He attempted to correct with left rudder and brake application but was unable to stop the right veer. Subsequently, the airplane exited the runway to the right and impacted a drainage ditch about 175 ft from the runway’s edge, which resulted in substantial damage to the fuselage and engine mounts. The pilot reported that this was the first landing of the flight, and no anomalies were noted with the brakes or flight controls prior to the landing. He recalled that during the runway excursion, shortly before impacting the ditch, the airplane straightened out and stopped the right turn. Shortly after the accident, the wings were removed for recovery which prevented the investigation from determining whether air was present in the brake lines. Photographs of the main landing gear wheels, brakes, and brake lines revealed no evidence of catastrophic mechanical failures or evidence that brake lines had become disconnected. Review of maintenance records found no evidence of recent brake work, and the endorsements showed that the brake fluid reservoir was serviced routinely. The operator and pilot both submitted a National Transportation Safety Board Aircraft Accident Incident Report (6120.1) and neither party reported that there were mechanical malfunctions or failures with the airplane. About the time of the accident, the automated weather observing system reported wind 220° at 9 knots, gusting to 15 knots, which was a direct crosswind for the landing runway 13. It is likely that the airplane encountered a crosswind gust during the landing roll, which resulted in the airplane veering right toward the direction of the crosswind. This conclusion is further supported by the pilot’s report that the airplane straightened out, once the crosswind became a headwind, shortly before its collision with the ditch.

Aircraft

Registration
N541SP
Reported as
Piper PA-28-151 (NO SERIES)
Category
Airplane
Serial number
28-7415570
Airframe hours
9,579
Engine
Lycoming O-320-E3D, 160 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Florida Aviation Career Training Inc.
Registered owner
Red Baron Rentals LLC
Airworthiness certificate
Standard, Normal
Last inspection
Annual · February 18, 2023
Airport
SGJ · Northeast Florida Regional Airport, runway 13, 8,001 × 150 ft, asphalt
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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
83
Injuries
None
Certificate
Private
Airplane ratings
Single-engine land
Medical
BasicMed, Waiver time limited special
Seat
Left
Restraint
3-point
Flight hours
288 total

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 9 knots, gusting 15
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 70 °F
Altimeter
30.09 inHg
Observed at
SGJ
METAR
KSGJ 261543Z 22009G15KT 10SM 27/21 A3009 RMK AO2 $

Docket · 5

The files NTSB released with the investigation on July 7, 2023, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.4 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.