WPR20LA024

NTSB accident investigation · Piper PA28R · Ogden, UT · November 17, 2019

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
November 17, 2019, 15:52 local (22:52 UTC)
Place
Ogden, UT
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N3206RPiper PA28R
Defining event
Takeoff: Landing gear not configured
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Piper Aircraft, Federal Aviation Administration, Lycoming Engines
FAA report
20191117021299A
Case key
100577

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 NTSB’s determination of the probable cause, and any contributing factors.

The flight instructor’s failure to raise the landing gear using the alternate system, which resulted in a reduced climb rate and impact with an obstacle. Contributing to the accident was the flight instructor’s lack of understanding of the backup landing gear extender system.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

The flight instructor and the pilot receiving instruction attempted to depart the airport for a training flight. A vehicle video captured the airplane striking a billboard about 2,200 ft off the departure end of the runway before impacting the ground. Neither pilot recalled the accident. The airplane was equipped with a backup landing gear extender system designed to automatically extend the landing gear, even if the position selector is up, depending on airspeed and engine power. The system will also prevent the landing gear from retracting until the airplane has accelerated to approximately 85 mph with full power, regardless of the landing gear selector switch position. Manual override of the system is possible by using an emergency gear lever located between the front seats. During postaccident examination of the wreckage the landing gear selector switch was found in the gear-up position, the emergency gear lever was found in the down position, the flaps were down 25 °, and the landing gear was found down. There were no mechanical malfunctions with the airplane that would have precluded normal operation. The airplane was within center-of-gravity limits, was not over its maximum gross weight, and should have established a climb rate of about 650 ft per minute with the landing gear retracted. The airplane likely did not attain the airspeed necessary for the landing gear to retract, and the flight instructor did not attempt to raise the gear using the emergency gear retract lever. As a result, the airplane’s rate of climb was reduced after takeoff, and it did not clear the billboard. The airplane owner’s handbook included a detailed description of the backup gear extender system and how to manually override it to aid in clearing an obstacle and for operations at high altitude airports. Additionally, a service bulletin applicable to the airplane advised pilots to review and understand all information pertaining to the backup gear extender system. The flight instructor had limited experience in the airplane. Prior to instructing in it, he had flown it twice with instructors but did not review the backup gear extender system in detail with them. His lack of understanding of the backup gear extender system was evident on his first flight with the pilot receiving instruction, when he could not identify a component of the backup gear extender system. When the gear would not retract after takeoff during the same flight, the flight instructor failed to use the emergency gear up lever to raise the gear. Thus, his lack of understanding of the backup landing gear extender system contributed to this accident.

Factual narrative

The factual narrative1,476 words

On November 17, 2019, about 1552 mountain standard time, a Piper PA28R-180, N3206R, was substantially damaged when it was involved in an accident near Ogden, Utah. The flight instructor and pilot receiving instruction were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. Neither the flight instructor nor the pilot receiving instruction had a clear recollection of the events leading to the accident but recalled they were practicing touch-and-go landings when the accident occurred. No witnesses came forward; however, a video recorded from a vehicle on a nearby freeway, captured the airplane as it struck the top of a 40-ft-tall billboard and descended to the ground about 2,200 ft southwest from the departure end of runway 17 and adjacent to the freeway. All major components of the airplane were in the small debris field around the wreckage. The wings and fuselage were substantially damaged. The airplane was equipped with a backup landing gear extender system. The system is designed to automatically extend the landing gear even if the position selector is up, depending on airspeed and engine power. The system will also prevent the landing gear from retracting until the airplane has accelerated to approximately 85 mph with full power, regardless of the landing gear selector switch position. Manual override of the system is possibly by using an emergency gear lever located between the front seats to the left of the flap handle (see figure). Postaccident examination of the wreckage revealed the landing gear was extended, the landing gear selector switch was in the up position, the emergency gear lever was near the normal (non-override) position, and the flaps were in the 25°, second notch position. The flap torque tube position, along with the chain length over the torque tube sprocket were also consistent with flaps set to 25°. Flight control continuity was established for the aileron, rudder, and elevators, from the cockpit controls to the respective control surfaces. There were no mechanical malfunctions or failures with the airframe or engine that would have precluded normal operation. The operation of the backup gear extender system is detailed in the airplane owner’s handbook; however, when questioned about his knowledge of the system, the flight instructor replied that he did not study the airplane’s systems very much. Figure. Photo of the emergency gear lever on the accident airplane. According to a mechanic employed by the operator, the backup gear extender system tested and operated normally when it was inspected during the annual inspection on January 7, 2018. Density altitude was calculated to be 4,472 ft. Runway 17 was an asphalt runway that measured 5,197 ft by 100 ft. The calculated weight of the airplane at takeoff was about 2,197.5 pounds. According to the operator’s handbook, takeoffs are normally made with the flaps up. However, the handbook stated for short fieldtakeoffs, or takeoffs under difficult conditions, such as deep grass or soft surface, distances can be reduced appreciably by setting the flaps to 25°. The airplane owner’s handbook stated that with the airplane at maximum gross weight of 2,500 pounds, the required takeoff distance would be 2,000 ft with flaps at 0°, and 1,700 ft with flaps at 25°. The distance to clear a 50 ft obstacle with flaps at 25° was 3,200 feet, and about 3,800 ft to clear a 50 ft obstacle with flaps at 0° ft. The calculated rate of climb at the observed environmental conditions would have been about 650 ft per minute with the flaps and landing gear retracted. The owner’s handbook did not contain a chart to calculate the climb rate with the landing gear extended. The calculated backup gear extender system retraction speed for 4,000 ft was about 92 mph indicated airspeed (IAS). Postaccident interviews with the flight instructor and the pilot receiving instruction were conducted but neither were confident in the accuracy of their memories of the accident. In an email sent shortly after the accident while he was still under the effects of medication, the flight instructor conjectured that he was not sure that this is what happened on the flight, but if he was flying toward a billboard without power to climb and he couldn’t go around or under it, he could see himself trying to use full flaps in a desperate attempt to rise the airplane over the obstacle. He also conjectured that they would not have been performing a soft-field takeoff, and if he were halfway down the runway, and it was safe, but because of density altitude, he probably would have added 10° flaps to aid the airplane’s climb. The flight instructor and the pilot receiving instruction were able to give details of preaccident events including their first flight in the airplane, which occurred 4 days before the accident. During the preflight, the pilot receiving instruction recalled that he had asked why the airplane appeared to have two pitot-static tubes, one underneath the left wing, and one above the left wing, which the flight instructor could not explain. The pilot receiving instruction later discovered on his own that the apparent second pitot-tube was the mast for static and high-pressure air source for the backup gear extender system. According to the flight instructor, on the flight prior to the accident, the gear in transition light did not extinguish and the airplane felt sluggish. He stated that he cycled the landing gear and got better performance but the gear in transition light remained illuminated for the rest of the flight. According to the pilot receiving instruction, on the flight prior to the accident, the flight instructor was demonstrating a touch and go maneuver, and after the takeoff, the landing gear would not retract. He recalled that the gear came up eventually, after the flight instructor lowered the nose slightly to gain airspeed. Prior to instructing in the airplane, the flightinstructor accrued about 5 hours of experience in the airplane. Two fellow flight instructors, employed by the accident operator, each flew one training flight with the accident flight instructor, in the accident airplane. One fellow instructor reported that the flight was uneventful with no problems with the landing gear. He stated that on the flight, there was not much discussion about the airplane’s systems, but he did mention to the accident pilot that if the gear didn’t come up, use the [emergency gear up] lever. The second fellow instructor flew with the accident flight instructor on his second flight in the airplane. He stated that the flight was fine, and they had no problems with the airplane. He recalled that he did discuss the backup gear extender system with the accident flight instructor but did not recall what they specifically talked about. The airplane owner’s handbook states in part: After takeoff, the pilot should retract the landing gear with the gear selector switch located on the instrument panel. If the airplane is equipped with the backup gear extender and the gear selector switch is placed in the gear up position before reaching the airspeed* at which the system no longer commands the gear down, the gear will not retract. This simply indicates that the system is functioning. Normally the airplane should be allowed to accelerate to this airspeed* before placing the selector switch in the gear up position. For obstacle clearance on takeoff and for takeoff from high altitude airports, on aircraft equipped with the backup gear extender, the landing gear can be retracted at the pilot’s discretion by placing the gear selector switch in the up position and then holding the emergency gear lever in the override position. It is necessary to hold the lever in the override position until the airspeed* required for retraction by the system has been attained. * Approximate airspeed of 85 mph IAS at sea level to 100 mph IAS at 10,000 ft, with straight line variation between. In March 1988, Piper Aircraft issued Service Bulletin (SB) 866A, which superseded SB 866 and indicated mandatory compliance. SB866A reiterated the required removal of the backup gear extender due to a concern that pilots, not familiar with all aspect of the system’s operation, might inadvertently encounter situations that would adversely affect safe flight. The SB provided an alternative means of compliance for affected owner/operators who chose to continue operation of their aircraft with the backup gear extender system installed and functioning. A component of SB 866A advised that pilots do the following: Review and understand all information contained in the applicable Airplane Flight Manual/Pilot’s Operating Handbook, Operations, Limitations and Systems section, pertaining to the normal and emergency operation of the Back Up Landing Gear Extender System for the affected aircraft model. SB 866A stated, in part: Failure to comply with this Service Bulletin couldresult in an inability to attain/maintain safe airspeeds including, but not limited to reduced rate of climb due to delayed landing gear retraction.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft

Registration
N3206R
Reported as
Piper PA28R (180)
Category
Airplane
Serial number
28R-31128
Built
1969
Airframe hours
5,288.2
Engine
Lycoming IO-360-B1E, 180 hp, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Instructional · Part 91
Operator
Axiom Aviation
Registered owner
Whitesands Financial Inc
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 14, 2019
Departed
OGD · Ogden, UT
Destination
SGU · St. George, UT
Airport
OGD · Ogden-Hinkley Airport, runway 17, 5,195 × 100 ft, asphalt
Equipment
None

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
34
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
July 16, 2019
Seat
Right
Restraint
3-point
Flight hours
423 total · 10.2 in this make and model · 324.5 as pilot in command · 112.8 in the last 90 days · 54.8 in the last 30 days · 4.7 in the last 24 hours
Role
Pilot
Age
22
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
November 12, 2019
Seat
Left
Restraint
3-point
Flight hours
131 total · 4.7 in this make and model · 66.2 as pilot in command · 56.6 in the last 90 days · 15.1 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
210° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
52 °F, dew point 25 °F
Altimeter
30.28 inHg
Observed at
KOGD, 1 nm away

Docket · 9

The files NTSB released with the investigation on May 26, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 21.9 MB in all.

FAA reports on this event · 1

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