# NTSB SEA08LA085: Piper PA-28-161, N8400A, Chandler, AZ, March 3, 2008 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 3, 2008, 08:40 local (15:40 UTC) - Place: Chandler, AZ - Coordinates: 33.269165, -111.811111 - Nearby events: https://openairdocs.org/map.md?lat=33.2692&lon=-111.8111&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report May 28, 2008 - Report: Approved by Office Director - Parties: Federal Aviation Administration - NTSB case key (mKey): 67608 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA08LA085 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67608/pdf - Page: https://openairdocs.org/ntsb/SEA08LA085 ## Probable cause The student pilot's delay in initiating the go-around, and the flight instructor's inadequate supervision of the flight and delayed remedial action. Contributing to the accident were the momentary failure of the engine to respond, the failure of both the student and the instructor to adhere to the operator's procedures, and the rough/uneven terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Terrain: rough terrain](https://openairdocs.org/ntsb-findings/03021015): Environmental issues › Physical environment · Not specified (probable cause); cases with it: [Piper PA-28-161, 2 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md?model=7102803), [All aircraft, 442 cases](https://openairdocs.org/ntsb-findings/03021015/cases.md) - [Terrain: sloped/uneven terrain](https://openairdocs.org/ntsb-findings/03021017): Environmental issues › Physical environment · Not specified (probable cause); cases with it: [Piper PA-28-161, 5 cases](https://openairdocs.org/ntsb-findings/03021017/cases.md?model=7102803), [All aircraft, 270 cases](https://openairdocs.org/ntsb-findings/03021017/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Student/instructed pilot (probable cause); cases with it: [Piper PA-28-161, 10 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7102803), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Power plant](https://openairdocs.org/ntsb-findings/01057100): Aircraft › Aircraft power plant · Not specified (probable cause); cases with it: [Piper PA-28-161, 1 case](https://openairdocs.org/ntsb-findings/01057100/cases.md?model=7102803), [All aircraft, 198 cases](https://openairdocs.org/ntsb-findings/01057100/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-161, 10 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7102803), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Attention/monitoring: monitoring other person](https://openairdocs.org/ntsb-findings/02021535): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28-161, 2 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md?model=7102803), [All aircraft, 200 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Instructor/check pilot (probable cause); cases with it: [Piper PA-28-161, 2 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7102803), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR go-around: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) (defining event); cases with it: [Piper PA-28-161, 58 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102803), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The dual student was practicing a simulated engine-out landing, with the intention of executing a go-around during the last part of the final approach. Although the operator's procedures called for the initiation of a go-around no lower than 300 feet above ground level (agl), the flight instructor did not call for the go-around until the airplane was about 100 feet agl. To initiate the go-around, the student pushed the throttle to the full-forward position, whereupon the engine momentarily coughed, and the airplane continued to sink. Just as the engine accelerated to full power, the airplane struck the ground on rough/uneven terrain. The accident sequence resulted in both external and internal damage to both wings. After the accident, the engine was started and run at various power settings, and no anomalies were found that would have kept it from correctly responding to a full-throttle power application. ## Factual narrative On March 3, 2008, about 0840 mountain standard time, a Piper PA-28-161, N8400A, impacted the terrain during a go-around from a simulated engine-out landing about 11 miles south of Chandler Municipal Airport, Chandler, Arizona. The certified flight instructor and his student were not injured, but the airplane, which is owned and operated by Chandler Air Service, sustained substantial damage. The local 14 CFR Part 91 instructional flight, which departed Chandler Municipal Airport about 50 minutes prior to the accident, was being operated in visual meteorological conditions. No flight plan had been filed. According to the flight instructor, his student was practicing a simulated engine-out landing, with the intention of executing a go-around during the last part of the final approach. According to telephone conversations with both the instructor and the student, the go-around was initiated when the airplane was about 100 feet above ground level (agl). To initiate the go-around, the student pushed the throttle to the full-forward position, whereupon the engine momentarily coughed/chocked, and the airplane continued to sink. Just as the engine accelerated to full power, the airplane struck the ground on rough/uneven terrain. The accident sequence resulted in both external and internal damage to both wings. After the accident, the engine was started and run at various power settings, and no anomalies were found that would have kept it from correctly responding to a full-throttle power application. During the investigation it was determined that the operator's procedure for all simulated engine-out activity is for the flight instructor pilot to call for the initiation of a go-around no lower than 300 feet agl. ## Aircraft - Registration: [N8400A](https://openairdocs.org/deregistered/N8400A-2013-08-21), registration cancelled 2013-08-21, S/N 28-8116249, built 1981 (OpenAirDocs) - Reported make and model: Piper PA-28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8116249 - Airframe hours: 15293 - Engines: Lycoming O-320-D3 160 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Registered owner: Chandler Air Service - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, January 1, 2008 - Departed: KCHD, Chandler, AZ - Destination: KCHD - Airport: KCHD, Chandler Municipal ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 27; injuries: none; flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review July 1, 2007; seat: right; flight hours: 687 total, 280 in this make and model, 581 as pilot in command, 218 in the last 90 days, 59 in the last 30 days, 3 in the last 24 hours - Student pilot; age 18; injuries: none; student; medical: class 3, without waivers/limitations; seat: left; flight hours: 57 total, 57 in this make and model, 34 in the last 90 days, 22 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 10 knots, gusting 15 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 55 °F ## 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 20080303012009A](https://openairdocs.org/incident/20080303012009A), Mar 3, 2008: Piper PA28161, Sacaton, AZ, Substantial damage. (-23) On site visual inspection by sdl FSDO inspector conducted. Pictures were taken and original statements collected from both on board flight instructor and… 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.