# NTSB GAA16CA243: Piper PA-28, N991A, Crystal River, FL, May 13, 2016 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: May 13, 2016, 13:50 local (17:50 UTC) - Place: Crystal River, FL - Coordinates: 28.867776, -82.570274 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.8678&lon=-82.5703&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report July 25, 2016 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 93201 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16CA243 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93201/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93201 - Page: https://openairdocs.org/ntsb/GAA16CA243 ## Probable cause The student pilot's failure to maintain directional control during the takeoff, which resulted in runway excursion and collision with a ditch. Contributing to the accident was the improper flap retraction procedure employed by the pilot during takeoff. ## 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-28-181, 53 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102807), [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-28-181, 37 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7102807), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) - [Flight control system: tE flap control system](https://openairdocs.org/ntsb-findings/01022750): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-181, 2 cases](https://openairdocs.org/ntsb-findings/01022750/cases.md?model=7102807), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022750/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-28-181, 10 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7102807), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Wind: gusts](https://openairdocs.org/ntsb-findings/03034045): Environmental issues › Conditions/weather/phenomena · Effect on equipment; cases with it: [Piper PA-28-181, 8 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md?model=7102807), [All aircraft, 1,199 cases](https://openairdocs.org/ntsb-findings/03034045/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Abrupt maneuver](https://openairdocs.org/ntsb-events/270); cases with it: [Piper PA-28-181, 2 cases](https://openairdocs.org/ntsb-events/270/sequence.md?model=7102807), [All aircraft, 346 cases](https://openairdocs.org/ntsb-events/270/sequence.md) - [Takeoff: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Piper PA-28-181, 5 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=7102807), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Takeoff: Loss of lift](https://openairdocs.org/ntsb-events/500); cases with it: [Piper PA-28-181, 2 cases](https://openairdocs.org/ntsb-events/500/sequence.md?model=7102807), [All aircraft, 252 cases](https://openairdocs.org/ntsb-events/500/sequence.md) - [Takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-28-181, 33 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7102807), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-28-181, 9 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7102807), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300); cases with it: [Piper PA-28-181, 35 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102807), [All aircraft, 3,643 cases](https://openairdocs.org/ntsb-events/300/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-181, 70 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102807), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The student pilot reported that shortly after the airplane rotated during the takeoff, he noticed that the flaps were extended. He further reported that about 20 feet above the ground he retracted the flaps from 25 degrees to zero degrees, and simultaneously encountered wind that pushed the airplane towards the ground and left of centerline. Once the airplane settled on the ground, he attempted to correct back to the center of the runway, but reported that the airplane veered off the runway to the left and impacted a ditch. A postaccident examination revealed substantial damage to the engine mount. According to the student pilot there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. A review of recorded data from the automated weather observation station located on the airport, revealed that, about 5 minutes after the accident the wind was 280 degrees true at 6 knots, wind gust 14 knots, visibility 10 statute miles, and sky clear. The airplane landed on runway 27. The Federal Aviation Administration has published the Airplane Flying Handbook FAA-H-8083-3A (2004). This handbook discusses retraction of the flaps and states in part: Depending on the airplane's altitude and airspeed, it may be wise to retract the flaps intermittently in small increments to allow time for the airplane to accelerate progressively as they are being raised. A sudden and complete retraction of the flaps could cause a loss of lift resulting in the airplane settling into the ground. ## Factual narrative The student pilot reported that shortly after the airplane rotated during the takeoff, he noticed that the flaps were extended. He further reported that about 20 feet above the ground he retracted the flaps from 25 degrees to zero degrees, and simultaneously encountered wind that pushed the airplane towards the ground and left of centerline. Once the airplane settled on the ground, he attempted to correct back to the center of the runway, but reported that the airplane veered off the runway to the left and impacted a ditch. A postaccident examination revealed substantial damage to the engine mount. According to the student pilot there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. A review of recorded data from the automated weather observation station located on the airport, revealed that, about 5 minutes after the accident the wind was 280 degrees true at 6 knots, wind gust 14 knots, visibility 10 statute miles, and sky clear. The airplane landed on runway 27. The Federal Aviation Administration has published the Airplane Flying Handbook FAA-H-8083-3A (2004). This handbook discusses retraction of the flaps and states in part: Depending on the airplane's altitude and airspeed, it may be wise to retract the flaps intermittently in small increments to allow time for the airplane to accelerate progressively as they are being raised. A sudden and complete retraction of the flaps could cause a loss of lift resulting in the airplane settling into the ground. ## Aircraft - Registration: [N991A](https://openairdocs.org/aircraft/N991A), registered now, S/N 2843807, built 2015 (OpenAirDocs) - Reported make and model: PIPER PA-28 (181) - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O-360-A4M](https://openairdocs.org/engine/lycoming-o-360-a4m) (registry code 42276, 4 cycle) (OpenAirDocs) - Category: Airplane - Serial number: 2843807 - Year built: 2015 - Airframe hours: 475.6 - Engines: Lycoming O-360-A4M 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Atp USA, Inc. - Registered owner: Archer Aero LLC. - Airworthiness certificate: Standard, Normal; Standard, Utility - Last inspection: 100 hour, April 15, 2016 - Departed: CGC, Crystal River, FL - Destination: CGC, Crystal River, FL - Airport: CGC, Crystal River-Captain Tom Davi, runway 27, 4,557 × 75 ft, asphalt - Equipment: Stall warning system, Electronic multifunction display, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 22; injuries: none; student; medical: class 1, without waivers/limitations; seat: left; restraint: 3-point; flight hours: 71.3 total, 71.3 in this make and model, 5.3 as pilot in command, 64.8 in the last 90 days, 24.8 in the last 30 days, 6.3 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 280° at 6 knots, gusting 14 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 64 °F - Altimeter: 30.03 inHg - Observed at: KCGC ## 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 20160513008809A](https://openairdocs.org/incident/20160513008809A), May 13, 2016: Piper PA-28-181, Crystal River, FL, Substantial damage. On may 13, 2016 a Piper PA-28-181 departed Crystal River, FL airport (kcgc) on runway 28 to complete the second leg of a student solo cross country flight.… ## Docket (4 files) The files NTSB released with the investigation on July 20, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93201. 2.6 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442476&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Email (Student Pilot) (item 2, .PDF, 111 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442477&FileExtension=.PDF&FileName=Record%20of%20Email%20(Student%20Pilot)-Master.PDF - Damage Statement - Damage Director of Maintenance (item 3, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442478&FileExtension=.PDF&FileName=Damage%20Statement%20-%20Damage%20Director%20of%20Maintenance-Master.PDF - Accident Photo (Courtesy of FAA) (item 4, .PDF, 1 photo, 211 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442479&FileExtension=.PDF&FileName=Accident%20Photo%20(Courtesy%20of%20FAA)-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.