# NTSB ERA23LA165: Piper PA-28-151, N541SP, St. Augustine, FL, March 26, 2023 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 4 · Limited · Final report - Date: March 26, 2023, 11:30 local (15:30 UTC) - Place: St. Augustine, FL - Coordinates: 29.95925, -81.339729 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=29.9593&lon=-81.3397&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - 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 - NTSB case key (mKey): 106962 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA23LA165 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106962/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106962 - Page: https://openairdocs.org/ntsb/ERA23LA165 ## 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 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-28-151, 10 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102805), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-151, 9 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7102805), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Wind: crosswind](https://openairdocs.org/ntsb-findings/03034040): Environmental issues › Conditions/weather/phenomena · Response/compensation (probable cause); cases with it: [Piper PA-28-151, 3 cases](https://openairdocs.org/ntsb-findings/03034040/cases.md?model=7102805), [All aircraft, 1,008 cases](https://openairdocs.org/ntsb-findings/03034040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-28-151, 7 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7102805), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Landing-landing roll: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-28-151, 12 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102805), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) ## 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](https://openairdocs.org/aircraft/N541SP), registered now, S/N 28-7415570 (OpenAirDocs) - Reported make and model: PIPER PA-28-151 (NO SERIES) - Registry model: [Piper PA-28-151](https://openairdocs.org/model/piper-pa-28-151) (registry code 7102805) (OpenAirDocs) - Category: Airplane - Serial number: 28-7415570 - Airframe hours: 9579 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 83; injuries: none; 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 $ ## 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 20230326007599A](https://openairdocs.org/incident/20230326007599A), Mar 26, 2023: Piper PA-28-151, St. Augustine, FL, Substantial damage. A Piper PA-28,[privacy data omitted], was on a personal non-revenue flight returned to Northeast Florida regional airport (ksgj), upon landing on runway 13 and… ## Docket (5 files) The files NTSB released with the investigation on July 7, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106962. 14.4 MB in all. - Pilot submitted - aircraft accident report, NTSB form 6120.1 (item 1, PDF, 8 pages, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15725882&FileExtension=pdf&FileName=NTSB%206120.1_Pilot%20Submission_Redacted-Rel.pdf - Operator submission - aircraft accident report, NTSB form 6120.1 (item 2, PDF, 9 pages, 3.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15725582&FileExtension=pdf&FileName=NTSB%206120.1_Operator%20Submission_Redacted-Rel.pdf - Memo for record (pilot) (item 3, PDF, 2 pages, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15725483&FileExtension=pdf&FileName=Memo%20for%20Record%20(Pilot)-Rel.pdf - Photo array - ERA23LA165 (item 4, PDF, 6 pages, 5 photos, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15724880&FileExtension=pdf&FileName=Photo%20Array%20-%20ERA23LA165-Rel.pdf - Maintenance record excerpts (item 5, PDF, 5 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15724890&FileExtension=pdf&FileName=Maintenance%20Record%20Excerpts%20-%20Redacted-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.