# NTSB WPR12LA076: Piper PA28, N4175V, Phoenix, AZ, January 6, 2012 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: January 6, 2012, 15:48 local (22:48 UTC) - Place: Phoenix, AZ - Coordinates: 33.688331, -112.082496 - Nearby events: https://openairdocs.org/map.md?lat=33.6883&lon=-112.0825&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Defining event: [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) - Highest injury: No injuries - Injuries: 1 uninjured - Status: Completed, report July 30, 2014 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: FAA FSDO - NTSB case key (mKey): 82645 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12LA076 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82645/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82645 - Page: https://openairdocs.org/ntsb/WPR12LA076 ## Probable cause The pilot’s inability to maintain directional control during the landing roll for reasons that could not be determined because impact damage precluded determination of the preaccident functionality of the braking and steering systems. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Piper PA-28-181, 8 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=7102807), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Landing gear system: nose/tail landing gear](https://openairdocs.org/ntsb-findings/01023220): Aircraft › Aircraft systems · Not specified; cases with it: [Piper PA-28-181, 1 case](https://openairdocs.org/ntsb-findings/01023220/cases.md?model=7102807), [All aircraft, 185 cases](https://openairdocs.org/ntsb-findings/01023220/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-181, 53 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102807), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: directional control](https://openairdocs.org/ntsb-findings/01062020): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-181, 37 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md?model=7102807), [All aircraft, 3,958 cases](https://openairdocs.org/ntsb-findings/01062020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Loss of control on ground](https://openairdocs.org/ntsb-events/230) (defining event); cases with it: [Piper PA-28-181, 33 cases](https://openairdocs.org/ntsb-events/230/sequence.md?model=7102807), [All aircraft, 4,585 cases](https://openairdocs.org/ntsb-events/230/sequence.md) ## Analysis The student pilot planned to conduct a solo cross-country flight with intermediate stops at two other airports before returning to the flight school base airport. The taxi, takeoff, flight, and touchdown of the first leg were normal. However, during the landing roll, the airplane pulled right, but the pilot was able to keep the airplane on the runway. The pilot stopped the airplane but did not shut down the engine or exit the airplane. Instead, he leaned out the door of the low-wing airplane to check for anomalies. He did not report seeing anything unusual; however, the wing would have blocked his view of the landing gear. He then taxied the airplane, departed, and did not experience any anomalies or difficulties with the airplane during that departure and flight. However, the student was concerned about the event at the first destination, so he opted not to land at the second planned destination, and, instead, he circled a few times and then headed toward the base airport. Although the flight school encouraged students to solicit assistance in the event of off-site problems and the pilot could have contacted the school via radio, he did not do so nor did he explain why he did not do so. The landing at the base airport was normal until the nose gear touched down, and the airplane subsequently veered right and departed the runway. The airplane struck a runway distance sign and a berm, which substantially damaged the nose and right main landing gear. Postaccident examination of the airplane did not reveal any preexisting mechanical malfunctions or failures with the landing gear that would have precluded normal operation, but impact damage to the landing gear precluded a determination of the braking and steering systems' preaccident condition and functionality. Review of maintenance records indicated that the airplane had operated normally in the several months since its most recent landing gear and steering system maintenance. Subsequent to the accident, the flight school provided students with mobile phones to improve their ability to contact the flight school in the event of off-site problems or difficulties. ## Factual narrative Maintenance Information Review of the maintenance records revealed the following: - The airplane was on a progressive inspection program - The most recent phase inspection was completed on December 17, 2011 - The airplane accumulated about 49 hours between the phase inspection and the accident - Since May 2010, there were eight maintenance events regarding the brakes; these were primarily replacement of worn brake pads - The most recent replacement of the brake pad linings was completed in November 2011 - Since May 2010, there was one event involving the steering, to correct a loose jam nut on the steering horn. That action was completed in September 2010. Pilot's Decision-Making and Communication at E63 There were no public telephones available at E63. It was not determined whether the pilot had a mobile phone with him at the time of the event. The pilot reported that he did not shut down the airplane or exit it after landing at E63. He indicated that once he landed at E63, he exited the runway, stopped the airplane in an area where he could set the parking brake, and opened the door to visually check for problems. However, the low wing configuration, right-side door, and idling engine significantly limited the pilot's ability to observe much of the airplane exterior, and completely prevented him from observing the landing gear. The student reported that since he did not observe any abnormalities by looking out the door, he decided that it was an appropriate course of action to continue the flight, without either further examining the airplane, or contacting the flight school. Flight School Procedures The flight school was equipped with a "dispatch" section which primarily served as the communication and coordination link between the students and the flight school regarding operational matters, primarily the scheduling, fueling, release, and return of the school's airplanes. It did not comply with, nor was it required to, the FAA requirements for "dispatch" functions, responsibilities or qualifications under 14CFR 121. According to the school flight safety manager, each airplane was equipped with a "tin" that he described as "an aluminum container that holds aircraft Hobbs time records, squawk information, VOR check records, and contact information for TransPac and is dispatched with the crew. The manager reported that crews "are advised that they can use any means available to expeditiously communicate with company Dispatch." He further reported that the school dispatch operates a "radio base station" that allows for verbal radio communications to and from airplanes within approximately 50 miles of DVT. The school flight safety manager noted that "TransPac has a standard policy in place that addresses communication requirements with regard to [off site] abnormalities encountered in flight or taxi. [Flight instructors] participate in a three week standardization course which includes this subject. Students are introduced to these areas in theirground training." Finally, the manager reported that as of "January 18, 2012, students will be issued a company cell phone to better facilitate the communication process. As part of the Duty CFI or Flight Director position, (this position is there specifically to dispatch, monitor, and provide assistance to all solo missions), the position will be responsible for assignment of company cell phones." The provision of those phones is intended to improve the ability of the school to communicate with its crews (and vice versa) when they are on trips away from DVT. According to FAA information, the low-wing airplane was manufactured in 1998. It was equipped with a Lycoming O-360 series engine and a fixed pitch metal propeller. The tricycle style landing gear was not retractable. The airplane was equipped with only one cabin entry/exit door, which was located on the right (passenger) side of the airplane. Review of the airplane flight log revealed that the day prior to the accident, the airplane was flown 8 times, by 12 different pilots or instructors. On the day of the accident, the airplane was flown once prior to the accident pilot's flight. The 9 previous flights put a total of 13 hours on the airplane, and no directional control problems were reported by any of the other individuals. At the time of the accident, the airplane had accumulated a total time in service of about 10,389 hours total time in service. FAA information indicated that E63 runway 4 measured 5,200 feet long by 75 feet wide, with an elevation of 789 feet above mean sea level (msl). DVT runway 25L measured 8,197 feet long by 100 feet wide, with an elevation of 1,478 feet msl. On January 6, 2012, about 1548 mountain standard time, a Piper PA-28-181, N4175V, was substantially damaged when it veered off runway 25L at Phoenix Deer Valley Airport (DVT), Phoenix, Arizona, during the landing rollout. The student pilot was not injured. The instructional flight was operated under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed, and a visual flight rules (VFR) flight plan was filed and activated for the flight. The airplane was operated by TransPac Aviation Academy, and was based at DVT. According to the pilot, the flight was a solo cross-country flight, which was to go from DVT to Gila Bend Municipal Airport (E63), then to Wickenburg Municipal Airport (E25), and then back to DVT. The pilot stated that during the landing rollout on runway 4 at E63, the airplane pulled to the right, but the pilot did not experience a runway excursion. After slowing, the pilot exited the runway, and the airplane taxied normally. The pilot stopped the airplane and leaned out the door to check the airplane, but he did not see anything unusual. He did not shut down the engine or exit the airplane at E63. He then departed E63, and did not experience any unusual control behaviors or difficulties with the airplane during the departure or flight. The pilotmade a low approach to E25, but proceeded to go around without landing, since he still had concerns due to his landing experience at E63. He circled the airport a few times, and then departed for DVT, without another approach or landing attempt at E63. The pilot said that his landing at DVT was normal, but that once the nose gear touched down, the airplane veered right, and departed the runway. The airplane struck a runway distance sign, and then a berm. The nose landing gear, right main landing gear, and the right wing sustained significant damage. Recorded wind information at an airport about 5 miles south-southwest of E63 (the site of the initial landing irregularity) indicated that the wind speed gradually decreased from 7 to 2 mph between the period from 1300 to 1500; at all those times the wind direction was "variable." The DVT 1553 automated weather observation included calm winds, visibility 10 miles, clear skies, temperature 21 degrees C, dew point -3 degrees C, and an altimeter setting of 29.97 inches of mercury. The pilot held a student pilot/medical certificate. He had a total flight experience of about 66 hours, all of which was in the accident airplane make and model. He had about 8 hours of solo flight time. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued in October 2011. The accident flight was not the pilot's first solo cross-country flight, but it was his first flight of the day. The airplane exited the north side of runway 25L, struck a runway distance sign, and continued to slide on the unpaved surface. It came to rest upright in the retention area between taxiway Bravo and runway 25L. The nose and right main landing gear had collapsed or were partially separated from the airplane. The right wing incurred substantial damage from the collision with the sign. The propeller and cowl were damaged from ground contact after the gear collapse. There was no fire. The airplane was recovered to a secure location. An FAA inspector examined the airplane 6 days after the accident. The inspector reported that he "found nothing irregular" with the airplane. He did not provide a detailed account of his examination. The insurance company determined that the airplane was damaged beyond economical repair. ## Aircraft - Registration: [N4175V](https://openairdocs.org/deregistered/N4175V-2021-07-03), registration cancelled 2021-07-03, S/N 2843126 (OpenAirDocs) - Reported make and model: PIPER PA28 (181) - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2843126 - Airframe hours: 10389 - Engines: LYCOMING O360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Instructional, Part 91 - Operator: TransPac Aviation Academy - Registered owner: Bird Acquisition - Airworthiness certificate: Standard, Normal - Last inspection: AAIP, December 17, 2011, 49 hours before - Departed: E63, Gila Bend, AZ - Destination: DVT, Phoenix, AZ - Flight plan: VFR - Airport: DVT, Phoenix Deer Valley, runway 25L, 8,197 × 100 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Student pilot; age 22; injuries: none; student; medical: class 3, without waivers/limitations; seat: left; flight hours: 66 total, 66 in this make and model, 8 as pilot in command, 66 in the last 90 days, 28 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 0 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 70 °F, dew point 27 °F - Altimeter: 29.96 inHg - Observed at: DVT ## 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 20120106000709A](https://openairdocs.org/incident/20120106000709A), Jan 6, 2012: Piper PA-28-181, Phoenix, AZ, Substantial damage. Student airman stated that after nose wheel touched runway, aircraft began to drift to the right. Airman applied left rudder with no effect. Aircraft departed… ## Docket (10 files) The files NTSB released with the investigation on June 20, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82645. 8.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413504&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Record of Conversation Pilot (item 2, .PDF, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413505&FileExtension=.PDF&FileName=Record%20of%20Conversation%20Pilot-Master.PDF - Pilot Statement (item 3, .PDF, 450 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413506&FileExtension=.PDF&FileName=Pilot%20Statement-Redacted.PDF - Record of Conversation Director of Safety (item 4, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413507&FileExtension=.PDF&FileName=Record%20of%20Conversation%20Director%20of%20Safety-Master.PDF - Record of Communication Transpac Academy (item 5, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413508&FileExtension=.PDF&FileName=Record%20of%20Communication%20Transpac%20Academy-Master.PDF - NTSB Transpac FAA Email (item 6, .PDF, 49 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413509&FileExtension=.PDF&FileName=NTSB%20Transpac%20FAA%20Email-Redacted.PDF - Airplane and Accident Information (item 7, .PDF, 6.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413510&FileExtension=.PDF&FileName=Airplane%20and%20Accident%20Information-Redacted.PDF - Maintenance Event Summary (item 8, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413511&FileExtension=.PDF&FileName=Maintenance%20Event%20Summary-Master.PDF - Gila Bend METARs (item 9, .PDF, 39 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413512&FileExtension=.PDF&FileName=Gila%20Bend%20METARs-Master.PDF - Deer Valley METARs (item 10, .PDF, 146 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40413513&FileExtension=.PDF&FileName=Deer%20Valley%20METARs-Master.PDF 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.