# NTSB GAA18CA193: Piper PA28, N297PA, Phoenix, AZ, April 1, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: April 1, 2018, 13:53 local (20:53 UTC) - Place: Phoenix, AZ - Coordinates: 33.688888, -112.081947 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=33.6889&lon=-112.0819&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report July 5, 2018 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 96965 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA18CA193 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/96965/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=96965 - Page: https://openairdocs.org/ntsb/GAA18CA193 ## Probable cause The student pilot’s improper selection of the flap setting during a go-around, and the flight instructor’s delayed remedial action, which resulted in an aerodynamic stall. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: configuration](https://openairdocs.org/ntsb-findings/01062017): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/01062017/cases.md?model=7102807), [All aircraft, 80 cases](https://openairdocs.org/ntsb-findings/01062017/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Student/instructed 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) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-181, 11 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7102807), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-181, 7 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7102807), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Object/animal/substance: sign/marker](https://openairdocs.org/ntsb-findings/03022015): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-181, 8 cases](https://openairdocs.org/ntsb-findings/03022015/cases.md?model=7102807), [All aircraft, 214 cases](https://openairdocs.org/ntsb-findings/03022015/cases.md) - [Wind: crosswind](https://openairdocs.org/ntsb-findings/03034040): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Piper PA-28-181, 6 cases](https://openairdocs.org/ntsb-findings/03034040/cases.md?model=7102807), [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. - [Approach-VFR go-around: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28-181, 18 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102807), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Approach-VFR go-around: 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 flight instructor reported that he was conducting a lesson in takeoffs and landings and go-around procedures with the student pilot at the controls. During one particular go-around, the student retracted the flaps too far and the instructor stressed the importance of using the proper flap settings. On the subsequent downwind, the tower advised a crosswind from the south gusting to 18 knots. During the approach, the airplane drifted left of the runway centerline, so he called for the student to execute a go-around. The student pilot applied full power and reduced flaps from 40° to 10° (25º is prescribed in the go-around procedure). When the flight instructor noticed that the airplane was not climbing and the student was not correcting the course, the flight instructor took the flight controls. The flight instructor attempted to recover, but the airplane was in a nose-high attitude and struck the ground. The airplane then lifted off the ground and flew slowly toward a sign; the instructor "pulled up to avoid the sign," but the airplane struck the sign, aerodynamically stalled, and impacted the ground to the right of the runway. The airplane sustained substantial damage to the left wing. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The automated weather observation station located on the accident airport reported that, at the time of the accident, the wind was from 110° at 8 knots. The airplane was landing on runway 7L. The Federal Aviation Administration's Airplane Flying Handbook, FAA-H-8083-3B, contains a section titled "Go-Arounds (Rejected Landings)" which states: After establishing the proper climb attitude and power settings, be concerned first with flaps and secondly with the landing gear (if retractable). When the decision is made to perform a go-around, takeoff power is applied immediately and the pitch attitude changed so as to slow or stop the descent. After the descent has been stopped, the landing flaps are partially retracted or placed in the takeoff position as recommended by the manufacturer. Caution must be used in retracting the flaps. Depending on the airplane's altitude and airspeed, it is 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 flight instructor reported that he was conducting a lesson in takeoffs and landings, and go-around procedures with the student pilot at the controls. During one particular go-around, the student retracted the flaps too far and the instructor stressed the importance of using the proper flap settings. On the subsequent downwind, the tower advised a crosswind from the south gusting to 18 knots. During the approach, the airplane drifted left of the runway centerline, so he called for the student to execute a go around. The student pilot applied full power and reduced flaps from 40° to 10° (25º prescribed in the go-around procedure). When the flight instructor noticed that the airplane was not climbing, and the student was not correcting the course, the flight instructor took the flight controls. The flight instructor attempted to recover, but the airplane was in a nose-high attitude and struck the ground. The airplane then lifted off the ground, flying slowly toward a sign, the instructor "pulled up to avoid the sign'" but the airplane struck the sign, aerodynamically stalled, and impacted the ground to the right of the runway. The airplane sustained substantial damage to the left wing. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The automated weather observation station located on the accident airport reported that, at the time of the accident, the wind was from 110° at 8 knots. The airplane was landing on runway 7L. Federal Aviation Administration's Airplane Flying Handbook, FAA-H-8083-3B, contains a section titled "Go-Arounds (Rejected Landings)" which states: After establishing the proper climb attitude and power settings, be concerned first with flaps and secondly with the landing gear (if retractable). When the decision is made to perform a go-around, takeoff power is applied immediately and the pitch attitude changed so as to slow or stop the descent. After the descent has been stopped, the landing flaps are partially retracted or placed in the takeoff position as recommended by the manufacturer. Caution must be used in retracting the flaps. Depending on the airplane's altitude and airspeed, it is 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: [N297PA](https://openairdocs.org/deregistered/N297PA-2019-05-04), registration cancelled 2019-05-04, S/N 2843506, built 2002 (OpenAirDocs) - Reported make and model: PIPER PA28 (181) - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O-360 series](https://openairdocs.org/engine/lycoming-o-360-series) (registry code 41575, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2843506 - Year built: 2002 - Airframe hours: 18692 - Engines: LYCOMING O-360 SERIES 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: AeroGuard Flight Training Center - Registered owner: Bird Acquisition LLC - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, March 20, 2018 - Departed: E25, WICKENBURG, AZ - Destination: DVT, Phoenix, AZ - Airport: DVT, Phoenix Deer Valley, runway 07L, 4,500 × 75 ft, asphalt - Equipment: ADS-B, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 32; injuries: none; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review January 22, 2018; seat: right; restraint: 3-point; flight hours: 336.3 total, 73 in this make and model, 219.3 as pilot in command - Student pilot; age 24; injuries: none; student; medical: class 3, without waivers/limitations; seat: left ## Weather - Conditions: Visual (VMC), Day - Wind: 110° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 19 °F - Altimeter: 29.80 inHg - Observed at: KDVT ## 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 20180401003239A](https://openairdocs.org/incident/20180401003239A), Apr 1, 2018: Piper PA-28-181, Phoenix, AZ, Substantial damage. The aircraft was on final to 7L at kdvt with the student at the controls. The instructor reported the winds were from the south at 12 knots gusting to 18… ## Docket (3 files) The files NTSB released with the investigation on May 23, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=96965. 4.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463436&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Record of Conversation - Flight Instructor (item 2, .PDF, 68 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463437&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Flight%20Instructor-Master.PDF - Accident Photo (item 3, .PDF, 1 photo, 268 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40463438&FileExtension=.PDF&FileName=Accident%20Photo-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.