# NTSB NYC06LA197: Piper PA-46-350P, N9227U, Bellefonte, PA, August 6, 2006 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: August 6, 2006, 11:30 local (15:30 UTC) - Place: Bellefonte, PA - Coordinates: 40.885555, -77.81639 - Nearby events: https://openairdocs.org/map.md?lat=40.8856&lon=-77.8164&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: No injuries - Injuries: 6 uninjured - Status: Completed, report August 30, 2007 - Report: Approved by Office Director - Parties: Piper Aircraft, FAA/FSDO, Lycoming Engines - NTSB case key (mKey): 64277 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC06LA197 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/64277/pdf - Page: https://openairdocs.org/ntsb/NYC06LA197 ## Probable cause Improper maintenance of the throttle linkage, which resulted in a lack of engine power during takeoff. Factors were the pilot's premature retraction of the flaps, an improper elevator trim setting, a high gross takeoff weight, and a high density altitude; which resulted in settling during the initial climb and a subsequent emergency landing after takeoff. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Miscellaneous/other, takeoff - initial climb - maintenance - improper, company maintenance personnel (cause) - throttle/power lever,linkage - incorrect - miscellaneous,engine - other - Overrun, emergency landing after takeoff - weather condition - high density altitude (contributing factor) - raising of flaps - premature, pilot in command (contributing factor) - aircraft weight and balance - high (contributing factor) - trim setting - improper, pilot in command (contributing factor) - In flight collision with terrain/water, emergency landing after takeoff - terrain condition - ground ## Analysis The airport elevation was 1,071 feet msl, and the density altitude at the time of the accident was approximately 2,487 feet msl. During a high gross weight normal takeoff procedure, from a 3,640-foot-long asphalt runway, at 79 degrees F., the airplane became airborne at 80 knots indicated airspeed (KIAS). The nose rose higher than needed, most likely due to elevator trim setting, which required the pilot to push forward on the yoke. The airplane accelerated to 90 knots, but did not initially climb out of ground effect, and then began a very slow climb. During the slow climb, the pilot elected to "clean up" the airplane by retracting the landing gear and the 10 degrees of flap extension. The airplane subsequently sank at the end of the runway, and the pilot decided to abort the takeoff. A test run of the engine revealed that it was producing about 4.5 percent less than the maximum Brake Horsepower (BHP). Examination of the engine revealed that the throttle adjustment was not correct, per a manufacturer service instruction. During a recent annual inspection, the throttle was adjusted, but there was no record of the manufacturer service instruction being utilized. Although the make and model airplane flight manual (AFM) checklist did not specify climb performance with regards to flap retraction during a normal takeoff, the FAA Airplane Flying Handbook suggested that the flaps should be retracted once a positive rate of climb is established. For short field takeoffs, the Airplane Flying Handbook stated that the flaps and landing gear should remain the takeoff position until clear of obstacles and Vy has been established. When the Vy has stabilized, the gear and then the flaps should be retracted. It advised to raise the flaps in increments to avoid sudden loss of lift and settling of the airplane. The Vy for the accident airplane was 110 knots. ## Factual narrative On August 6, 2006, about 1130 eastern daylight time, a Piper PA-46-350P (Malibu Mirage), N9227U, was substantially damaged during takeoff from Bellefonte Airport, Bellefonte, Pennsylvania. The certificated private pilot and five passengers were not injured. Visual meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the planned flight to Erie International Airport, Erie, Pennsylvania. The personal flight was conducted under 14 CFR Part 91. According to the pilot's written statement, the airplane's annual inspection was completed 3 days prior to the accident. On the day of the accident, the pilot completed a previous flight to check all of the airplane's systems after the inspection. No discrepancies were noted, except for a pressurization leak that he was already aware of. Prior to the accident flight, the pilot's weight and balance calculations revealed that the airplane was 50 pounds below the maximum gross takeoff weight, and within the center-of-gravity limits. The pilot added that review of takeoff performance data revealed that for the given weight and density altitude, the airplane needed 1,800 feet to 2,000 feet of runway, depending on the wind. The pilot started the engine, taxied, and performed a run-up with no discrepancies noted. The flaps were extended 10 degrees, in preparation for a normal takeoff on runway 25; a 3,640-foot-long, 40-foot-wide, asphalt runway. The pilot taxied the airplane to an area about 50 to 100 feet prior to the runway, which provided additional takeoff roll distance. He then applied brakes, applied engine power, and noted that all gauges were "green." The manifold pressure climbed above 30 inches of barometric pressure, indicating that the turbocharger was functioning, and the manifold pressure indicator stopped below redline as the pilot released the brakes. During the takeoff roll, at 45 knots indicated airspeed (KIAS), the pilot again noted that all gauges were "green." He then voiced that the airspeed was alive, and crosschecked his instruments with the copilot side. At 80 KIAS, the nose rose a bit higher than needed, possibly due to a trim setting. The pilot pushed forward and the airplane flew in ground effect. The pilot further stated that the airplane accelerated to 90 knots, but did not climb out of ground effect. He continued to hold forward pressure on the yoke, and the airplane began a "very slow" climb. The pilot decided to continue the takeoff as the airplane was nearing the end of the runway. During the slow climb, the pilot elected to "clean up" the airplane by retracting the landing gear and the 10 degrees of flap extension. The airplane subsequently sank at the end of the runway, and the pilot decided to abort the takeoff rather than risk a stall. He believed that the tailskid struck a light at the end of the runway. The airplane overran the runway, came to rest in a field, and a postcrash fire ensued. All occupants egressed safely before the fire consumed the airplane. Examination of the wreckage by representatives from the airframe and engine manufacturers, under the supervision of a Federal Aviation Administration (FAA) inspector, revealed that the elevator trim drum displayed 12 exposed threads. A representative from the airframe manufacturer stated that 12 exposed threads was consistent with a nose-up elevator trim setting; with 14 to 15 exposed threads equating to a full nose-up elevator trim setting, and 7 to 8 exposed threads equivalent to a neutral elevator trim setting. The engine was subsequently test run at the manufacturer's facility on September 14, 2006, under the supervision of an FAA inspector. During the test run, a full throttle manifold pressure of 39.58 inches of barometric pressure was achieved, at 2,417 rpm. Further examination revealed that when the throttle lever was placed to the full power position, there was approximately 1/4 inch of travel yet to be obtained by the variable absolute pressure controller (VAPC). The engine was test run again with a dynamometer on October 10, 2006, under the supervision of a Safety Board investigator. The test run revealed that at a full throttle setting, the engine produced 334.2 Brake Horsepower (BHP); however, the engine was type certificated for 350 BHP. The VAPC was then set up per the specifications listed in Lycoming Service Instruction 1431 Supplement No. 2. After which, the engine produced 347.1 BHP at the full throttle setting. Review of a maintenance invoice and aircraft logbooks revealed that during the airplane's most recent annual inspection, "...Injector throttle arm spliner not lined up; removed & replaced in proper position; adjusted throttle arm spline so they meet..." There was no mention of compliance with Lycoming Service Instruction 1431 Supplement No. 2 with regards to the throttle adjustment. Review of a PA-46-350P (Malibu Mirage) airplane flight manual (AFM) revealed the following procedure for a normal takeoff: "...Flaps - 0 to 10; Trim - Set; Power - SET TO MAXIMUM; Liftoff - 80-85 KIAS; Climb Speed - 90-95 KIAS; Landing Gear (when straight ahead landing on runway not possible) - UP; Flaps - RETRACT..." Although the AFM did not specifically mention climb performance with regards to flap retraction during a normal takeoff, review of FAA-H-8083-3, Airplane Flying Handbook revealed: "...The airplane will pick up speed rapidly after it becomes airborne. Once a positive rate of climb is established, the flaps and landing gear can be retracted (if equipped)..." Although the pilot was not performing a short field takeoff, further review of the respective section in the Airplane Flying Handbook revealed: "...On short-field takeoffs, the flaps and landing gear should remain in the takeoff position until clear of obstacles (or as recommended by the manufacturer) and Vy has been established. It is generally unwise for the pilot to be looking in the cockpit or reaching for flap and landing gear controls until obstacle clearance is assured. When the Vy has stabilized, the gear (if equipped) and then the flaps should be retracted. It is usually advisable to raise the flaps in increments to avoid sudden loss of lift and settling of the airplane..." Review of the AFM revealed Vy was 110 knots. The reported weather at an airport approximately 3 miles southwest of the accident site, at 1143, was: wind from 250 degrees at 3 knots; visibility 10 miles; sky clear; temperature 79 degrees F; dew point 61 degrees F; altimeter 30.23 inches Hg. The airport elevation was 1,071 feet msl, and the density altitude at the time of the accident was approximately 2,487 feet msl. ## Aircraft - Registration: [N9227U](https://openairdocs.org/deregistered/N9227U-2009-02-06), registration cancelled 2009-02-06, S/N 4622101, built 1990 (OpenAirDocs) - Reported make and model: Piper PA-46-350P - Registry model: [Piper PA 46-350P](https://openairdocs.org/model/piper-pa-46-350p) (registry code 7104620) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 4622101 - Airframe hours: 1785 - Engines: Lycoming TIO-540 350 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Scott M Buchart - Registered owner: C.M. Air, Llc. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 1, 2006, 1 hours before - Departed: N96, Bellefonte, PA - Destination: ERI, Erie, PA - Flight plan: IFR - Airport: N96, Belefonte Airport, runway 25, 3,640 × 40 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 41; injuries: none; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, without waivers/limitations; last flight review September 1, 2005; seat: left; flight hours: 1,136 total, 93 in this make and model, 1,016 as pilot in command, 15 in the last 90 days, 1 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 79 °F, dew point 61 °F - Altimeter: 30.22 inHg - Observed at: UNV, 3 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 20060806017649A](https://openairdocs.org/incident/20060806017649A), Aug 6, 2006: Piper PA46350P, Bellefonte, PA, Destroyed. (-23) During takeoff, runway 25 @ N96, aircraft rotated and flew in ground effect over runway surface. Pilot stated that normal engine indications were present… 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.