# NTSB NYC94LA180: Piper PA-28R-200, N2815T, Oakland, MD, September 20, 1994 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 20, 1994, 19:00 local (23:00 UTC) - Place: Oakland, MD - Coordinates: 39.409038, -79.410438 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.4090&lon=-79.4104&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 3 minor - Status: Completed, report October 13, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 38833 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC94LA180 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/38833/pdf - Page: https://openairdocs.org/ntsb/NYC94LA180 ## Probable cause the pilot's inadequate preflight planning and preparation in which the pilot attempted a high density altitude takeoff, up-slope, with the airplane over the maximum allowable gross weight, utilizing a rolling takeoff technique with an improper flap setting. This resulted in an inadvertent mush into trees during the initial climb. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - terrain condition - uphill - weather condition - high density altitude - aircraft weight and balance - exceeded, pilot in command - procedures/directives - not followed, pilot in command - preflight planning/preparation - inadequate, pilot in command (cause) - airspeed - not attained, pilot in command (cause) - stall/mush - inadvertent, pilot in command - In flight collision with object, descent - uncontrolled - object - tree(s) ## Analysis THE PILOT/OWNER OF THE AIRPLANE AND THREE OTHER PILOTS WERE PLANNING TO FLY TO AN AVIATION SAFETY MEETING. A PREFLIGHT WAS COMPLETED AND FUEL SAMPLES WERE TAKEN. AFTER THE RUN-UP, FLAPS WERE SET TO 10 DEGREES AND FULL POWER WAS APPLIED DURING THE TAKEOFF ROLL. THE AIRPLANE ROTATED NEAR THE END OF THE 3,000 FOOT RUNWAY, CLIMBED ABOUT 40 FEET AND SETTLED DOWN INTO THE TREES. THE PILOT STATED THAT NO DEFICIENCIES WERE NOTED WITH THE ENGINE AND AIRPLANE DURING THE TAKEOFF. EXAMINATION REVEALED THAT THE AIRPLANE WAS ABOUT 175 POUNDS OVER THE MAXIMUM GROSS WEIGHT AT TAKEOFF, THE AIRPORT DENSITY ALTITUDE WAS 4,500 FEET, AND THE TAKEOFF RUNWAY HAD A 0.5% UP-SLOPE GRADE. THE PILOT'S OPERATING MANUAL SPECIFIES A 25 DEGREE FLAP SETTING, WITH FULL POWER APPLIED BEFORE BRAKE RELEASE, FOR AN OBSTACLE CLEARANCE TAKEOFF. ## Factual narrative On September 20, 1994, about 1850 eastern daylight time, a Piper PA-28R-200, N2815T, owned and pilot by Lawrence R. Rosage, was destroyed when it struck trees during initial climb after takeoff from the Garrett County Airport, Oakland, Maryland. The pilot and two passengers received minor injuries, while a third passenger was seriously injured. Visual meteorological conditions prevailed and no flight plan had been filed for the flight operating under 14 CFR 91. All four occupants of the airplane were rated pilots and were planning to attend an aviation safety meeting in Morgantown, West Virginia. In the NTSB 6120.1/2, the pilot stated that after he conducted a preflight, he took fuel samples and found no contaminates. He further stated: "...Engine start up was normal and both magnetos were running smoothly. The wind indicator showed a westerly direction so a departure on runway 26 was made. The plane climbed normally to a height of approximately 40 to 50 feet and slowly stopped climbing. It slowly sank. Full power was still in and the engine was running smoothly. The plane settled into a stand of tall pine trees directly in line with the runway. At no time did a stall or even an approach to a stall occur...I flew the airplane to the ground with the power I had available...." A Federal Aviation Administration (FAA) Inspector interviewed the pilot and passengers and summarized their statements. In the pilot's summarized statements, Mr. Rosage stated that he rotated at 80 knots with 10 degrees of flaps set, and retracted the landing gear. The engine was developing good power, but after the airplane climbed to 30 to 40 feet, it hesitated and started to descend into the trees. He stated that the winds were calm, the fuel tanks were full, and he had checked the weight and balance before the flight. In the summarized statement of one passenger, Mr. John Burnside, he stated the engine did not reach full RPM before the takeoff roll was initiated. He felt at one point the airplane was moving slow, and the pilot might abort the takeoff; however, the takeoff was continued and the airplane lift-off occurred near the end of the runway. He further stated that it did not feel like the airplane was climbing properly when it settled into the trees. In a telephone conversation with the FAA Inspector, he stated that during his on scene investigation he determined that the airplane takeoff roll used about 2800 feet of the runway. He also stated that during the airplane's descent through the trees the propeller cut several 6 inch diameter pine trees. The Garrett County Airport Field elevation is 2,933 feet. Runway 26 is 3,000 feet long, asphalt surfaced, with a 0.5% up slope to the west. The computed density altitude for the takeoff conditions was approximately 4,500 feet. The maximum takeoff gross weight for N2815T was 2,650 pounds (lbs). The airplane weight computed as follows: Airplane empty weight plus oil 1,652 lbs. Fuel (48 gallons useable minus run-up) 276 Baggage 40 Rosage (Pilot) 203 Vitez (Passenger) 257 Burnside (Passenger) 180 Yommer (Passenger) 220 ===== Total takeoff gross weight 2,828 lbs. According to the Piper Pilot's Operating Manual (POM), there are four flap position settings; up, 10, 25, and 40 degrees. The takeoff performance charts in the POM provide takeoff distances over 50 foot obstacles based on full power before brake release, a maximum gross weight of 2,650 lbs., zero wind, a density altitude, and flaps set to 25 degrees. ## Aircraft - Registration: [N2815T](https://openairdocs.org/deregistered/N2815T-1995-05-11), registration cancelled 1995-05-11, S/N 28R7235138 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7235138 - Airframe hours: 3153 - Engines: LYCOMING IO-360-C1C 200 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Lawrence R. Rosage - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 13, 1993, 60 hours before - Departed: 2G4 - Destination: MGW, MORGANTOWN, WV - Airport: 2G4, Garrett County, runway 26, 3,000 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 494 total, 465 in this make and model, 494 as pilot in command, 19 in the last 90 days, 6 in the last 30 days ## Weather - Conditions: Visual (VMC), Dawn - Wind: calm - Visibility: 20 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 52 °F - Altimeter: 30.00 inHg - Observed at: MRB, 64 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 19940920029139A](https://openairdocs.org/incident/19940920029139A), Sep 20, 1994: Piper PA28R200, Oakland, MD, Destroyed. Aircraft crashed on takeoff. (.4)the pilot/owner of the airplane and three other pilots were planning to fly to an aviation safety meeting. A preflight was… 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.