# NTSB GAA19CA350: Piper PA28, N7227F, Nowdoinham, ME, June 7, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: June 7, 2019, 10:30 local (14:30 UTC) - Place: Nowdoinham, ME - Coordinates: 44.694465, -69.382247 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.6945&lon=-69.3822&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff-rejected takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report November 6, 2019 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 99647 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA350 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99647/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99647 - Page: https://openairdocs.org/ntsb/GAA19CA350 ## Probable cause The flight instructor's delayed decision to abort the takeoff from a wet, grass runway with insufficient runway remaining, which resulted in a runway overrun and the airplane going down an embankment. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-140, 17 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7102802), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [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: soft surface](https://openairdocs.org/ntsb-findings/03023020): Environmental issues › Physical environment · Effect on operation; cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/03023020/cases.md?model=7102802), [All aircraft, 264 cases](https://openairdocs.org/ntsb-findings/03023020/cases.md) - [Runway/land/takeoff/taxi surface: wet surface](https://openairdocs.org/ntsb-findings/03023010): Environmental issues › Physical environment · Effect on operation; 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) - [Object/animal/substance: hidden/submerged object](https://openairdocs.org/ntsb-findings/03022052): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-28-140, 1 case](https://openairdocs.org/ntsb-findings/03022052/cases.md?model=7102802), [All aircraft, 36 cases](https://openairdocs.org/ntsb-findings/03022052/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff-rejected 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-rejected takeoff: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-28-140, 38 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7102802), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) - [Takeoff-rejected takeoff: Runway excursion](https://openairdocs.org/ntsb-events/300); 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-rejected 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 flight instructor reported that, while demonstrating a soft-field takeoff for a student pilot, he maintained full back pressure with the control yoke; lowered the flaps to 10°; lined up on the wet, grass, 1,900-ft-long runway; and added full power. He further noted that the airplane was not accelerating as anticipated due to the runway condition. The airplane lifted off about two-thirds of the way down the runway, and he decided that the airspeed of 65 mph was "not adequate." Additionally, he saw tall trees at the end of the runway, so he decided to abort the takeoff and land on the remaining runway. He added that he reduced power, that the airplane touched down, and that he applied the brakes but that, "due to the slick conditions," the airplane overran the runway and went down an embankment, and the right landing gear struck a rock hidden by the tall grass. The airplane continued across a gravel road and came to rest in a yard. The airplane sustained substantial damage to the left wing and the fuselage. The instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Factual narrative The flight instructor reported that, while demonstrating a soft field takeoff for a student pilot, he maintained full back pressure with the control yoke, put in 10° of flaps, lined up on the wet, grass, 1,900 ft runway, and added full power. He further noted that the airplane was not accelerating as anticipated due to the runway conditions. The airplane lifted off about two-thirds of the way down the runway and he decided that the airspeed of 65 mph was "not adequate." Additionally, he saw tall trees at the end of the runway, so he decided to abort the takeoff and land on the remaining runway. He reduced power, the airplane touched down, and he applied the brakes. The airplane overran the runway, went down an embankment, and the right landing gear struck a rock hidden by the tall grass. The airplane continued across a gravel road and came to rest in a yard. The airplane sustained substantial damage to the left wing and fuselage. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N7227F](https://openairdocs.org/aircraft/N7227F), registered now, S/N 28-25139, built 1968 (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: 28-25139 - Year built: 1968 - Airframe hours: 5297.85 - Engines: Lycoming O-320-D3G 160 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, March 25, 2019 - Departed: BXM, Brunswick, ME - Destination: 08B, Nowdoinham, ME - Airport: 08B, Merrymeeting Field, runway 14, 1,935 × 100 ft, grass/turf - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 59; injuries: none; flight instructor, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review March 16, 2019; seat: right; restraint: lap only; flight hours: 623.2 total, 306.2 in this make and model, 556.7 as pilot in command, 71.5 in the last 90 days, 54.7 in the last 30 days - Student pilot; age 55; injuries: none; student; medical: class 3, with waivers/limitations; seat: left; restraint: lap only; flight hours: 25 total, 25 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 220° at 4 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 41 °F - Altimeter: 29.95 inHg - Observed at: KIWI, 8 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 20190607006049A](https://openairdocs.org/incident/20190607006049A), Jun 7, 2019: Piper PA-28-140, Bowdoinham, ME, Substantial damage. On June 7, 2019 N7227F was on a training flight with an instructor and a student. The instructor demonstrated a soft field approach and landing into… ## Other investigations on N7227F (1) 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. - [NTSB NYC75DNC39](https://openairdocs.org/ntsb/NYC75DNC39), Jun 25, 1975: Piper PA-28 (N7227F), Keene, NH, substantial damage ## Docket (2 files) The files NTSB released with the investigation on August 15, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99647. 5.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 3.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475141&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photos (item 2, .PDF, 2 photos, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40475142&FileExtension=.PDF&FileName=Accident%20Photos-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.