# NTSB GAA19CA511: Piper PA28, N8619W, Cottonwood, AZ, August 25, 2019 - Type: NTSB accident investigation - Classification: Accident · No injuries · Data collection · Final report - Date: August 25, 2019, 11:20 local (18:20 UTC) - Place: Cottonwood, AZ - Coordinates: 34.729999, -112.035278 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=34.7300&lon=-112.0353&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report February 11, 2020 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA - NTSB case key (mKey): 100141 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA19CA511 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100141/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100141 - Page: https://openairdocs.org/ntsb/GAA19CA511 ## Probable cause The student pilot's improper pitch and lateral control during a soft-field takeoff, which resulted in impact with terrain. Contributing to the accident was the student pilot's failure to relinquish control of the airplane to the instructor. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Incorrect use/operation (probable cause); cases with it: [Piper PA-28-235, 1 case](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=7102810), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/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-28-235, 28 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102810), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-235, 1 case](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=7102810), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) - [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · Student/instructed pilot (probable cause); cases with it: [Piper PA-28-235, 5 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=7102810), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/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-28-235, 1 case](https://openairdocs.org/ntsb-findings/03023020/cases.md?model=7102810), [All aircraft, 264 cases](https://openairdocs.org/ntsb-findings/03023020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Piper PA-28-235, 1 case](https://openairdocs.org/ntsb-events/400/sequence.md?model=7102810), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28-235, 11 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102810), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Takeoff: Attempted remediation/recovery](https://openairdocs.org/ntsb-events/060); cases with it: [Piper PA-28-235, 1 case](https://openairdocs.org/ntsb-events/060/sequence.md?model=7102810), [All aircraft, 1,422 cases](https://openairdocs.org/ntsb-events/060/sequence.md) - [Takeoff: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-235, 35 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102810), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The flight instructor reported that, during a soft-field takeoff with the student pilot at the flight controls, the airplane was in ground effect and yawed left with a high angle of attack. He added that, as the student was correcting, a wind gust from the right caused the airplane to drift left and put the airplane into a "cross controlled situation." The instructor attempted to assume control of the airplane, but the student did not relinquish control of the airplane. The instructor reported that he was unable to overpower the student and became concerned that the airplane was not producing enough lift and would aerodynamically stall or spin. The instructor pushed forward hard on the yoke to prevent a stall, and the airplane impacted terrain off the side of the runway about midfield. The airplane sustained substantial damage to the fuselage and the left and right wings. The instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The student did not submit a written statement as requested. An automated weather observation station located 14 miles northeast of the accident site reported that, about the time of the accident, the wind was from 210° at 8 knots and variable between 180° and 240°. The airplane was departing from runway 14. The Federal Aviation Administration's Airplane Flying Handbook, FAA-H-8083-3B, contained a subsection titled, "Soft/Rough-Field Takeoff and Climb," which stated, in part, the following: An attempt to climb prematurely or too steeply may cause the airplane to settle back to the surface as a result of the loss of ground effect. During the transition out of the ground effect area, the pilot should not attempt to climb out of ground effect before reaching the sufficient climb airspeed, as this may result in the airplane being unable to climb further, even with full power applied. Therefore, it is essential that the airplane remain in ground effect until at least VX is reached. ## Factual narrative The flight instructor reported that, during a soft field takeoff with the student pilot at the flight controls, the airplane was in ground effect and yawed to the left with a high angle of attack. As the student was correcting, a wind gust from the right caused the airplane to drift left and put the airplane into a "cross controlled situation." The instructor attempted to assume control of the airplane, but the student pilot only heard his name and continued to fly the airplane. The instructor reported he was unable to overpower the student and became concerned that the airplane was not producing enough lift and would aerodynamically stall or spin. The instructor pushed forward hard on the yoke to prevent the stall, and the airplane impacted terrain 50 yards off the side of the runway about midfield. The airplane sustained substantial damage to the fuselage, left and right wings. The flight instructor reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. The student pilot did not submit a written statement as requested. An airport's automated weather observation station, located 14 miles to the north east, reported that, about the time of the accident, the wind was from 210° at 8 knots and variable from 180° to 240°. The airplane was departing from runway 14. The Federal Aviation Administration's Airplane Flying Handbook, FAA-H-8083-3B, provides information and guidance in a section titled "Soft/Rough-Field Takeoff and Climb" which stated in part: The pilot must be aware that the correct takeoff procedure for soft fields is quite different from the takeoff procedures used for short fields with firm, smooth surfaces. To minimize the hazards associated with takeoffs from soft or rough fields, the pilot should transfer the support of the airplane's weight as rapidly as possible from the wheels to the wings as the takeoff roll proceeds by establishing and maintaining a relatively high AOA or nose-high pitch attitude as early as possible. The pilot should lower the wing flaps prior to starting the takeoff (if recommended by the manufacturer) to provide additional lift and to transfer the airplane's weight from the wheels to the wings as early as possible. After the airplane becomes airborne, the pilot should gently lower the nose with the wheels clear of the surface to allow the airplane to accelerate to VY, or VX if obstacles must be cleared. Immediately after the airplane becomes airborne and while it accelerates, the pilot should be aware that, while transitioning out of the ground effect area, the airplane will have a tendency to settle back onto the surface. An attempt to climb prematurely or too steeply may cause the airplane to settle back to the surface as a result of the loss of ground effect. During the transition out of the ground effect area, the pilot should not attempt to climb out of ground effect before reaching the sufficient climb airspeed, as thismay result in the airplane being unable to climb further, even with full power applied. Therefore, it is essential that the airplane remain in ground effect until at least VX is reached. ## Aircraft - Registration: [N8619W](https://openairdocs.org/deregistered/N8619W-2020-05-29), registration cancelled 2020-05-29, S/N 28-10133, built 1963 (OpenAirDocs) - Reported make and model: PIPER PA28 (235) - Registry model: [Piper PA-28-235](https://openairdocs.org/model/piper-pa-28-235) (registry code 7102810) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-10133 - Year built: 1963 - Airframe hours: 1723.8 - Engines: Lycoming O-540 235 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: N8619W Llc - Registered owner: N8619W Llc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 15, 2019 - Departed: HII, Lake Havasu, AZ - Destination: PRC, Prescott, AZ - Flight plan: VFR - Airport: P52, Cottonwood, runway 14, 4,252 × 75 ft, asphalt - Equipment: None ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 42; injuries: none; student; medical: class 1, with waivers/limitations; seat: left; restraint: 4-point; flight hours: 124 total, 19.3 in this make and model, 17 as pilot in command, 17 in the last 90 days, 17 in the last 30 days, 17 in the last 24 hours - Flight instructor; age 41; injuries: none; flight instructor, commercial, airline transport; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review May 23, 2019; seat: right; restraint: 4-point; flight hours: 7,110 total, 113 in this make and model, 6,625 as pilot in command, 362 in the last 90 days, 104 in the last 30 days, 3.2 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 55 °F - Altimeter: 30.19 inHg - Observed at: KSEZ, 14 nm away ## Other investigations on N8619W (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 OAK72FVG57](https://openairdocs.org/ntsb/OAK72FVG57), May 15, 1972: Piper PA-28 (N8619W), Montague, CA, substantial damage ## Docket (2 files) The files NTSB released with the investigation on October 24, 2019, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100141. 4.5 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=40477074&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photo (item 2, .PDF, 1 photo, 385 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40477075&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.