# NTSB GAA18CA546: Piper PA28, N7595R, De Pere, WI, September 7, 2018 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: September 7, 2018, 08:00 local (13:00 UTC) - Place: De Pere, WI - Coordinates: 44.367778, -88.158607 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.3678&lon=-88.1586&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report September 26, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 98278 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA18CA546 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/98278/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=98278 - Page: https://openairdocs.org/ntsb/GAA18CA546 ## Probable cause The pilot's improper decision not to abort the takeoff after the airplane encountered standing water on the runway, which decreased its speed and led to its subsequent inability to climb and resulted in a runway overrun. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-140, 43 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102802), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-140, 103 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102802), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Runway/land/takeoff/taxi surface: wet surface](https://openairdocs.org/ntsb-findings/03023010): Environmental issues › Physical environment · Effect on operation (probable cause); cases with it: [Piper PA-28-140, 4 cases](https://openairdocs.org/ntsb-findings/03023010/cases.md?model=7102802), [All aircraft, 141 cases](https://openairdocs.org/ntsb-findings/03023010/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-140, 15 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7102802), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Performance/control parameters: climb rate](https://openairdocs.org/ntsb-findings/01062035): Aircraft › Aircraft oper/perf/capability · Attain/maintain not possible (probable cause); cases with it: [Piper PA-28-140, 9 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md?model=7102802), [All aircraft, 265 cases](https://openairdocs.org/ntsb-findings/01062035/cases.md) - [Object/animal/substance](https://openairdocs.org/ntsb-findings/03022000): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-140, 4 cases](https://openairdocs.org/ntsb-findings/03022000/cases.md?model=7102802), [All aircraft, 224 cases](https://openairdocs.org/ntsb-findings/03022000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-28-140, 14 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102802), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Takeoff: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-28-140, 19 cases](https://openairdocs.org/ntsb-events/060/sequence.md?model=7102802), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300) (defining event); cases with it: [Piper PA-28-140, 47 cases](https://openairdocs.org/ntsb-events/300/sequence.md?model=7102802), [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-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that he initiated a takeoff roll on the 2,200-ft-long wet, turf runway, and that, about 1,650 ft down the runway, the airplane encountered standing water, and the speed decreased. He reported that he "still felt I had plenty of room to regain airspeed and take off safely." The airplane encountered standing water again on another section of the runway, and the speed decreased further. The pilot retracted two notches of flaps and attempted to climb the airplane, but it exited the departure end of the runway and entered a cornfield. The airplane sustained substantial damage to the engine mounts. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Factual narrative The pilot reported that he initiated a takeoff roll on the 2,200-foot wet turf runway, and about 1,650-feet down the runway, the airplane encountered standing water and the airplane's airspeed decreased. He reported that he "still felt I had plenty of room to regain airspeed and takeoff safely." The airplane encountered additional standing water on another section of the runway and the airplane's airspeed again decreased. The pilot retracted 2 notches of flaps and attempted to climb, but the airplane exited the departure end of the runway and collided with a cornfield. The airplane sustained substantial damage to the engine mounts. The pilot reported that there were no mechanical malfunctions or failures with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N7595R](https://openairdocs.org/aircraft/N7595R), registered now, S/N 28-22163 (OpenAirDocs) - Reported make and model: Piper PA28 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-22163 - Airframe hours: 3938.73 - Engines: Lycoming O-320-EZA 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 9, 2018 - Departed: 9WS2, De Pere, WI - Destination: IMT, Iron Mountain, MI - Airport: 9WS2, Antique Aerodrome, runway 18, 2,200 × 65 ft, grass/turf - Equipment: Stall warning system, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: none; private; airplane ratings: single-engine land; medical: class 3; last flight review April 18, 2018; seat: left; restraint: lap only; flight hours: 1,359.3 total, 1,359.3 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 10° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 55 °F - Altimeter: 30.34 inHg - Observed at: KGRB, 7 nm away ## 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 20180907013259A](https://openairdocs.org/incident/20180907013259A), Sep 7, 2018: Piper PA-28-140, De Pere, WI, Substantial damage. Pilot attempted a southern departure from a water saturated 2000 ft. grass runway. During departure roll out, pilot had difficulties gaining airspeed while the… ## Docket (2 files) The files NTSB released with the investigation on April 30, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=98278. 4.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472309&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Photo (item 2, .PDF, 1 photo, 199 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40472310&FileExtension=.PDF&FileName=Photo-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.