SEA96LA199

NTSB accident investigation · Piper PA-38-112 · Sisters, OR · August 22, 1996

Accident · Serious injuriesLimited investigationFinal report
Date
August 22, 1996, 12:41 local (19:41 UTC)
Place
Sisters, OR
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N2465KPiper PA-38-112
Weather
Visual (VMC) · Day
Status
Completed · report May 23, 1997
Report
Approved by Office Director
FAA report
19960822023509A
Case key
42452

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

inadequate preflight planning/preparation by the flight instructor (CFI), and his failure to obtain and/or maintain adequate airspeed, which resulted in an inadvertent stall. Excessive gross weight, high density altitude, and improper use of flaps were related factors.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightTakeoff - initial climb
Preflight planning/preparation - inadequatePilot in command(cfi)Cause
Aircraft weight and balance - exceededPilot in command(cfi)Factor
Weather condition - high density altitudeFactor
Flaps - improper use ofPilot in command(cfi)Factor
Airspeed - not obtained/maintainedPilot in command(cfi)Cause
Stall - inadvertentPilot in command(cfi)Cause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - mountainous/hilly

Analysis

The student pilot reported that he made an uneventful full flap landing at the airstrip for the completion of the first leg of the instructional cross-country flight. Also, he stated that he did not feel comfortable with the takeoff because he was aware that the airplane was heavy and the density altitude was high. During takeoff, the student followed along as the instructor (CFI) operated the controls until rotation. At that point, the CFI had full control of the airplane. The student stated that he noticed the airspeed was decreasing below 70 knots during the climb, and called out the airspeed when it dropped to 55 knots. At about this time, the student lightly pushed forward on the control yoke, but the CFI continued to pull back. The airplane entered a stall, and the nose and right wing dropped. The airplane then collided with hilly terrain about a half mile north of the airstrip. Weight and balance calculations showed the airplane was about 100 lbs over the maximum certificated gross weight. The density altitude was calculated at 5,252 feet. During an examination, the flaps were found fully extended and the elevator trim was in a nearly full nose up position. No evidence of a mechanical failure or malfunction was found during an engine examination.

Factual narrative

On August 22, 1996, at 1241 Pacific daylight time, a Piper PA-38-112, N2465K, registered to and operated by Jack's Aircraft as a 14 CFR Part 91 instructional flight, collided with the terrain shortly after takeoff from the Sisters Airport, Sisters Oregon. Visual meteorological conditions prevailed at the time and a visual flight rules flight plan was filed. The airplane was substantially damaged and the flight instructor and student pilot were seriously injured.

In a written statement, the flight instructor reported that he does not recall any of the events of the accident due to serious head injuries, however, he does recall that the flight to Sisters was uneventful. After landing, the flight instructor recalls opening the door to the airplane and feeling that the temperature was cool. The instructor felt that the conditions may not produce the density altitude affect and aircraft performance that he wanted for the lesson. The instructor stated that he did not remember anything else after this point.

During a telephone interview and subsequent written statement, the student pilot reported that they had departed from Lebanon earlier in the day for a round trip cross country flight to Sisters. The student reported that the flight from Lebanon was uneventful except that the stall warning horn continuously sounded. After a full flap landing was made at Sisters on runway 2, the student stated that they closed the flight plan and walked around before departing back to Lebanon. The student reported that he does not recall if the flaps were retracted prior to beginning the takeoff roll, and that he was uncomfortable about taking off. The student stated that he was aware that the airplane was heavy, and that he and his flight instructor talked about density altitude effects prior to departing from Lebanon. The student opted to follow on the controls with the flight instructor for the ground roll and rotation. At this point, the student stated that the flight instructor took full control of the airplane. During the climb-out, the student noticed that the airplane was in a nose high attitude and the airspeed was decreasing below 70 knots. The student stated that he called out the airspeed as the airspeed decreased to 55 knots. The student stated that at this time he lightly pushed forward on the control yoke, however, the instructor pulled back and the airspeed decreased to 40 knots and the airplane entered a stall. The student stated that the nose dropped and the airplane did an "immediate 70 degree left bank and immediate 70 degree right bank." The airplane then nosed down and collided with the terrain with the right wing low.

The student pilot reported that there were no mechanical failures or malfunctions with the airplane at the time of the accident.

The wreckage was located approximately one-quarter mile off the end of runway 2, and one-quarter mile north on hilly terrain. The Northwest Airport/Facility Directory for the Sisters Eagle Air airport states "Rising terrain off departure end of Rwy 02. Check density altitude/acft performance prior to takeoff." At the time of the accident, the temperature was approximately 85 degrees. Density altitude was calculated at 5,252 feet.

The weight and balance was calculated for this leg of the flight from data provided from both pilots, and weight and balance calculations from the Tomahawk Pilot's Operating Handbook. The calculations indicate that the gross weight of the airplane was exceeded by approximately 100 pounds.

During the post crash inspection of the airframe, the wing flaps were found in the fully extended position. The elevator trim tab was found in the nearly full nose up position. Both fuel cells were ruptured and only a small amount of fuel was present at the time of the inspection. The engine was examined and no evidence of a mechanical failure or malfunction was found.

Aircraft

Registration
N2465K
Reported as
Piper PA-38-112
Category
Airplane
Serial number
38-79A0650
Airframe hours
2,664
Engine
Lycoming O-235-L2C, 112 horsepower, reciprocating
Damage
Substantial damage
Flight
Instructional · Part 91
Operator
Jack'S Aircraft
Registered owner
Jack Healy
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 4, 1995 · 65 hours before
Destination
S30 · Lebanon, OR
Flight plan
VFR
Airport
6K5 · Sisters Eagle Air, runway 2, 3,550 × 50 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
30
Certificates
Commercial, Flight instructor
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Right
Flight hours
1,136 total · 22 in this make and model · 899 as pilot in command · 251 in the last 90 days · 89 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
330° at 8 knots
Visibility
20 statute miles
Lowest ceiling
None
Temperature
84 °F, dew point 36 °F
Altimeter
30.00 inHg

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.