NYC08FA237

NTSB accident investigation · Piper PA-28-161 · Middletown, RI · July 3, 2008

Accident · FatalField investigationFinal report
Date
July 3, 2008, 19:31 local (23:31 UTC)
Place
Middletown, RI
Injuries
2 fatal, 1 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N9888KPiper PA-28-161
Defining event
Initial climb: Collision during takeoff/land
Weather
Visual (VMC) · Day
Status
Completed · report May 12, 2009
Report
Approved by Office Director
Parties
Lycoming Engines, FAA/FSDO, Piper Aircraft
FAA report
20080703854519A
Case key
68362

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

On this page

Probable cause

The flight instructor's failure to initiate a go-around during a high approach, and his inadequate remedial action during an attempted touch-and-go.

Findings · 4

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Action: lack of actionPersonnel issues › Action/decision · Instructor/check pilotPiper PA-28-161: 8 casesAll aircraft: 792 casesProbable cause
Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomePiper PA-28-161: 9 casesAll aircraft: 933 cases
Performance/control parameters: climb rateAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28-161: 2 casesAll aircraft: 265 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

A flight instructor and student pilot, with the student pilot's wife in the rear passenger seat, were performing touch-and-go landings on runway 22. Runway 22 was 2,999 feet long, 75 feet wide, and consisted of asphalt. During the approach prior to the accident, the airplane approached high, touched down long, and completed a touch-and-go. During the next approach, the airplane touched down further, about 2,000 feet from the runway threshold. The airplane then rotated and began a slow laborious climb, with the wings rocking. The airplane flew a shallow left turn, never rising above the trees, until it impacted trees. Throughout the accident sequence, witnesses heard constant engine noise and then a lack of engine noise, immediately followed by the sound of impact. Examination of the wreckage did not reveal any preimpact mechanical malfunctions. The reported wind at the airport, about the time of the accident, was variable at 4 knots. The flight instructor was experienced, operating out of his home airport, and familiar with the accident airplane. The flight instructor had a painful arthritic condition, primarily resulting in hand and wrist pain and stiffness. He was taking two different medications for arthritis, with the possibility of significant side effects, and for one of which the dose had been increased just two weeks previously. It is possible that toxicity from either drug, or from both in combination, may have resulted in impairment; however, the investigation could not determine if the pilot was impaired. The instructor pilot had not noted his diagnosis or treatment on his most recent application for airman medical certificate.

Factual narrative

History of flight

On July 3, 2008, at 1931 eastern daylight time, a Piper PA 28-161, N9888K, sustained substantial damage when it impacted trees, during the initial climb from Newport State Airport (UUU), Middletown, Rhode Island. The certificated flight instructor and a passenger were killed. The third occupant, a student pilot, was seriously injured and succumbed to his injuries on September 15, 2008. Visual meteorological conditions prevailed and no flight plan was filed for the local instructional flight conducted under the provisions of 14 Code of Federal Regulations Part 91.

According to the airplane owner and fueling records, the airplane was "topped-off" with 25.1 gallons of 100 low-lead aviation fuel, and departed on runway 22, a 2,999-foot-long, 75-foot-wide, asphalt runway. Several witnesses, who lived near the airport, reported hearing the engine noise cease, immediately followed by the sound of an impact. One of the witnesses approached the wreckage from the right side, and was able to extricate the student pilot before the airplane was consumed by fire.

Another witness was a professional pilot, who held an airline transport pilot certificate and reported 12,670 total hours of flight experience. The witness stated that he was approaching UUU in a Socata TBM 700, with the intent to land and drop-off a passenger. During the approach, the witness was behind a "PA 28 aircraft" in the traffic pattern (but could not positively identify it as the accident airplane). A pilot in the PA 28 reported that he was on a downwind leg for runway 22, with the intention to touch-and-go. The witness thought it was odd that the PA 28 was "quite high" on final approach, landed about mid-field, and the performed a touch-and-go.

The professional pilot witness then landed, dropped-off his passenger, and prepared to depart about 10 minutes later. During engine start-up, the witness noticed that the accident airplane (but could not positively identify it as the previous PA 28) landed about 2,000 feet beyond the approach end of runway 22. It was slow, but the witness thought that the accident airplane might not be able to stop on the remaining runway. The witness was then "shocked" that the pilot attempted to perform a touch-and-go as the airplane rotated and began a "slow laborious climb." The witness further stated:

"The nose was too high to permit any gain in airspeed and it mushed along with the wings occasionally rocking. It was basically in a slow left turn never rising above the tree line until it impacted the trees more or less wings level."

Radar data was obtained from the Federal Aviation Administration (FAA). Review of the radar plot revealed targets with a 1200-transponder code, oriented along a path consistent with a left-hand traffic pattern for runway 22 at UUU. The last target was recorded at 1931:04, near the threshold of runway 22, indicating an altitude of 100 feet above mean sea level. No subsequent corresponding radar targets were recorded near the departure end of runway 22.

Personnel information

The pilots' logbooks were not recovered. The flight instructor, age 63, held a commercial pilot certificate, with ratings for airplane single-engine land, airplane multiengine land, and instrument airplane. He also held a flight instructor certificate, with ratings for airplane single-engine and instrument airplane. The flight instructor's most recent third-class medical certificate was issued on January 14, 2008. At that time, he reported a total flight experience of 2,650 hours. According to the airplane owner, UUU was the flight instructor's home airport, and he frequently instructed in the accident airplane. The flight instructor was seated in the left front seat at the time of the accident.

The student pilot, age 38, obtained his most recent third-class medical certificate on December 4, 2007. At that time, he reported a total flight experience of 12 hours. According to the airport manager at UUU, the student pilot completed his first solo flight during June 2008. The student pilot was seated in the right front seat, and his wife was seated in a rear passenger seat.

Aircraft information

The four-seat, low-wing, fixed-gear airplane, serial number 28-7816207, was manufactured in 1977. It was powered by a Lycoming O-320, 160-horsepower engine and equipped with a Sensenich propeller.

Review of the airplane's logbooks revealed that a 100-hour inspection was completed on June 23, 2008, at a total airframe time of 4,405.1 hours. At the time of the inspection, the engine had accumulated 1,081.8 hours of operation since major overhaul.

Meteorological information

The reported weather at UUU, at 1953, was: wind variable at 4 knots; visibility 5 miles in haze; broken ceiling at 8,000 feet, overcast ceiling at 9,000 feet; temperature 22 degrees Celsius (C); dew point 18 degrees C; altimeter 29.97 inches of mercury.

Wreckage and impact information

The airplane came to rest in trees on a residential property, about 1,000 feet beyond the departure end of runway 22. An approximate 30-foot debris path was observed, which consisted of damaged trees. The debris path was oriented along a magnetic course of approximately 180 degrees. The wreckage was also oriented on a heading about 180 degrees. The aft portion of the wreckage remained upright, while the engine was inverted. The cockpit and cabin area were consumed by fire; however, all major portions of the airplane were accounted for at the scene.

The wreckage was examined at the accident site on July 4 and 5, 2008. The right wing separated near the wing root and about mid-span. The middle section of the right wing, including the right flap and inboard right aileron, was consumed by fire. Crush damage was noted on the leading edge of the right wing, and approximately two-thirds of the aileron remained attached to the right wing. The inboard section of the left wing, including the left flap, had also been consumed by fire. two-thirds (outboard) of the left wing remained intact, with the left aileron attached. The empennage also remained intact. Stabilator and rudder control continuity were confirmed from the control surfaces to the control column in the cockpit. Aileron control continuity was confirmed from their respective bellcranks to the control column in the cockpit. The stabilator trim jackscrew was measured, revealing four visible threads, which equated to an approximate neutral position. The left aileron bellcrank remained attached to the airframe, and the right aileron bellcrank had separated from the right wing, consistent with impact forces. Both aileron cables were intact and traced from their respective bellcranks, to the sprocket and chain assembly at the cockpit control column. The aileron balance cable had separated and exhibited features consistent with tensile overload.

The remnants of the throttle and mixture cable were found in the aft position, and the remnant of the carburetor heat control was found in the midrange position. The flap handle was in the 10-degree flap extended position, and the fuel selector was destroyed. Only two readable cockpit instruments were recovered. The vertical speed indicator displayed an approximate 500-foot-per-minute descent, and the attitude indicator was tumbled.

The propeller remained attached to the engine, and exhibited little damage. The engine exhibited fire damage to the accessory section and carburetor. The engine was removed from the airframe, and the propeller was rotated by hand. Crankshaft, camshaft, and valve train continuity were confirmed, and thumb compression was attained on all four cylinders. The magnetos sustained fire damage and could not be tested; however, when the No. 1 cylinder was placed to top-dead-center, internal timing of the engine was verified via rocker arm oscillation on the No 2. cylinder. When the oil filter was opened, no metallic contamination was observed

Aircraft

Registration
N9888K
Reported as
Piper PA-28-161
Category
Airplane
Serial number
28-7816207
Airframe hours
4,405
Engine
Lycoming O-320, 160 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Hallal Charles
Registered owner
Hallal Charles
Airworthiness certificate
Standard, Normal
Last inspection
100 hour · June 23, 2008
Departed
UUU · Middletown, RI
Destination
UUU · Middletown, RI
Airport
UUU · Newport State Airport, runway 22, 2,999 × 75 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Flight instructor
Age
63
Injuries
Fatal
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
2,650 total
Role
Student pilot
Age
38
Injuries
Serious
Certificate
Student
Medical
Class 3
Seat
Right
Flight hours
12 total

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 4 knots
Visibility
5 statute miles
Lowest ceiling
8,000 ft broken
Temperature
72 °F, dew point 64 °F
Altimeter
29.96 inHg
Observed at
UUU, 1 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.