# NTSB WPR20LA278: Piper PA28, N317LB, Harlowton, MT, August 14, 2020 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: August 14, 2020, 12:35 local (18:35 UTC) - Place: Harlowton, MT - Coordinates: 46.448612, -109.85277 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.4486&lon=-109.8528&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) - Highest injury: Minor injuries - Injuries: 4 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: FAA - NTSB case key (mKey): 101825 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR20LA278 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101825/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101825 - Page: https://openairdocs.org/ntsb/WPR20LA278 ## Probable cause The pilot’s failure to follow the appropriate takeoff procedures, which resulted in a collision with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-140, 3 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7102802), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Terrain](https://openairdocs.org/ntsb-findings/03021000): Environmental issues › Physical environment · Effect on equipment; cases with it: [Piper PA-28-140, 4 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md?model=7102802), [All aircraft, 267 cases](https://openairdocs.org/ntsb-findings/03021000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Miscellaneous/other](https://openairdocs.org/ntsb-events/900) (defining event); cases with it: [Piper PA-28-140, 14 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102802), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## Analysis The pilot conducted a short-field takeoff in high density altitude conditions, with the airplane close to, or slightly above its maximum gross weight. During the initial climb, the airplane accelerated to best rate-of-climb speed, but it descended back to the ground, collided with a fence, and nosed over. In the days leading up to the flight, the pilot had expressed concern that the engine was not producing maximum power, so he had it examined by an airframe and powerplant mechanic. The mechanic stated that both the engine and tachometer were operating appropriately. The pilot told investigators that it was his habit to take his hand off the throttle during takeoffs and place both hands on the yoke. Postaccident examination revealed that the, throttle was found slightly aft of the full-forward position, the carburetor heat control was partially backed out, and the flaps were extended. It is likely the throttle backed out during takeoff and engine performance was further reduced by the carburetor heat control being partially backed out. Additionally, the airplane procedures for a short field-takeoff called for the slow retraction of the flaps after takeoff. The circumstances of the accident are consistent with a loss of climb performance occurring after a heavyweight, high density altitude takeoff due the pilot’s failure to properly set and monitor the engine controls and retract the flaps as required. ## Factual narrative On August 14, 2020, at 1235 mountain daylight time, a Piper, PA-28-140, N317LB, was substantially damaged when it was involved in an accident near Harlowton, Montana. The private pilot and the three passengers sustained minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot reported that while operating the airplane during the summer months, the engine was not performing like it had during the winter. The airplane’s engine and tachometer were inspected by an airframe and powerplant mechanic (A&P). The A&P determined that the engine and tachometer were operational and met the manufacturer specifications. Two days later, the pilot and one passenger boarded the airplane, took off, and remained in the airport traffic pattern completing three takeoffs and landings. The pilot confirmed that the airplane’s engine oil temperature, oil pressure, and rpm remained in the green, ascertaining that the engine was operating normally. Subsequently, they departed the traffic pattern on a 75 nm, visual flight rules cross-country flight to Harlowton, Montana. After landing at Harlowton, the pilot onboarded two additional passengers. The pilot selected runway 27 (length 4,200 ft) for the departure with what he ascertained was into a direct headwind. He chose to perform a short-field takeoff with two notches of flaps (25°). During the takeoff roll, the pilot kept the airplane on the ground until the indicated speed reached 77 mph. The airplane departed and began to climb before reaching the end of the runway. The airplane had reached about 100 ft above ground level (agl), but seconds later, it would no longer climb. The pilot decreased the airplane’s pitch attitude and the airplane descended. The airplane continued to descend and about one mile west of the airport, the airplane touched down on the soft grass surface of a livestock grazing pasture, collided with a barbed wire fence, and nosed over. The pilot reported that while no component of the airplane’s engine malfunctioned during takeoff, it was not producing the power that he had expected. He affirmed that three combined factors caused the accident: airplane gross weight, atmospheric conditions, and the engine power. The airplane’s maximum gross weight was 2,150 pounds. The pilot reported that at the time of the accident, the airplane’s gross weight was exactly 2,150 pounds. However, review of the airplanes total weight using the pilot-supplied approximate weight of the passengers, baggage, and 31 gallons of fuel, revealed that the airplane weight was about 2,197 lbs at takeoff. The airplane’s owner handbook stated that for short-field takeoffs requiring no obstacle clearance, the pilot will lower the flaps to 25° (second notch), accelerate to 55-60 mph and ease back on the control wheel to rotate. After breaking ground, accelerate to the best rate of climb speed, 85 mph, and slowly retract the flaps while climbing out. The meteorologicalaerodrome report located at the accident airport reported that about the time of the accident, the wind was out of 300° at 13 knots and gusting to 22 knots. The temperature was 73.4° F, the field elevation was 4,312 ft and the altimeter setting was 30.18 inches of mercury. The pressure altitude was 4,073 ft and the density altitude (DA) about the time of takeoff was 6,035 ft. With the airplane loaded to its maximum gross weight, and operating at a density altitude of 6,035 ft, with zero flaps, and no wind, the ground roll would have been 1,600 ft, with 3,300 ft needed to clear a 50 ft obstacle. Under the same conditions, the climb rate would have been 425 ft-per-minute. The manual does not provide a distance or climb rate when the airplane is configured with flaps applied. The mechanic who performed the engine and engine tachometer inspection informed the pilot that the engine produced between 2,200-2,300 rpm. The engine tachometer inspection confirmed normal operation by the mechanic. The pilot reported that the engine was operated 1,268 hours since the last engine overhaul and that the engine had accumulated 159 hours since the last annual inspection. During a conversation between the pilot and Federal Aviation Administration (FAA) aviation safety inspectors, the pilot provided the accident sequence of events by reenacting his actions during the flight. The pilot’s actions indicated that he was in the habit of lining up on the runway, adding full power and immediately moving his right hand from the throttle control to join his left hand on the yoke. When asked, the pilot confirmed that he did not verify that the throttle control remained in the fully open position after realizing that he could no longer maintain the airplane’s airspeed and altitude. He reported that both hands remained on the yoke for the duration of the flight after initiating the takeoff roll and he did not manipulate any engine controls after the accident. A postaccident airplane examination of the airplane’s cockpit configuration revealed a rich mixture control position, the carburetor heat control was partially backed out, and the throttle control was backed out from the full-power position. An FAA inspector stated PA-28 throttle quadrants are “very susceptible” to throttle creep during takeoff and climb-out if the throttle friction is not set properly and the pilot does not keep his hands on the throttle. A photograph of the accident airplane taken shortly after the collision revealed that the wing flaps remained extended. ## Aircraft - Registration: [N317LB](https://openairdocs.org/aircraft/N317LB), registered now, S/N 28-26935, built 1970 (OpenAirDocs) - Reported make and model: PIPER PA28 (140) - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-26935 - Year built: 1970 - Airframe hours: 6788 - Engines: Lycoming O-320 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Trail Of 140 Tears LLC - Registered owner: Trail Of 140 Tears LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 26, 2019 - Departed: HWQ, Harlowton, MT - Destination: 7S6, White Sulfur Sp, MT - Airport: HWQ, Wheatland County At Harlowton, runway 27, 4,200 × 60 ft, asphalt - Equipment: Electronic flight bag or handheld device, Stall warning system, Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 61; injuries: minor; private; airplane ratings: single-engine land; medical: basicmed, with waivers/limitations; last flight review October 24, 2019; seat: left; restraint: lap only; flight hours: 600 total, 600 in this make and model, 522 as pilot in command, 54 in the last 90 days, 21 in the last 30 days, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 300° at 13 knots, gusting 22 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 28 °F - Altimeter: 30.15 inHg - Observed at: K1KM, 2 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 20200814013729A](https://openairdocs.org/incident/20200814013729A), Aug 14, 2020: Piper PA-28-140, Harlowtown, MT, Substantial damage. Pilot departed airport loaded to max gross takeoff weight. Outside temperature was 80 degrees f. on departure roll, the aircraft lifted off the runway and… ## Docket (14 files) The files NTSB released with the investigation on May 5, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101825. 13.6 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 4.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12460702&FileExtension=pdf&FileName=6120_1_Redacted-Rel.pdf - Atmospheric conditions (item 2, PDF, 1 page, 580 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12460712&FileExtension=pdf&FileName=Atmospheric%20Conditions-Rel.pdf - Record of conversation -pilot (item 3, PDF, 2 pages, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13139042&FileExtension=pdf&FileName=Record%20of%20Conversation%20-Pilot-Rel.pdf - Record of conversation -FAA inspector watters (item 4, PDF, 2 pages, 139 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12461467&FileExtension=pdf&FileName=Record%20of%20Conversation%20-FAA%20Inspector-Rel.pdf - Record of conversation -FAA and pilot (item 5, PDF, 1 page, 85 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12461477&FileExtension=pdf&FileName=FAA%20Record%20of%20Conversation%20Harold%20Brown-Rel.pdf - Type certificate data sheet (item 6, PDF, 2 pages, 527 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12461144&FileExtension=pdf&FileName=Type%20Certificate%20Data%20Sheet-Rel.pdf - Additional equipment list, c.g. range & weight and balance data (item 7, PDF, 1 page, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12471756&FileExtension=pdf&FileName=Weight%20and%20Balance%20Sheet%20from%20N317LB_Redacted-Rel.pdf - Accident flight weight and balance (item 8, PDF, 1 page, 435 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12472220&FileExtension=pdf&FileName=Weight%20and%20Balance%20N317LB%20Accident%20Flight%20-Rel.pdf - Hwq airport chart supplement (item 9, PDF, 1 page, 540 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12461358&FileExtension=pdf&FileName=HWQ%20Chart%20Sup-Rel.pdf - Aircraft performance -power vs altitude (item 10, PDF, 1 page, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12461368&FileExtension=pdf&FileName=Power%20Vs%20Altitude%20-Rel.pdf - Aircraft performance -takeoff distance vs density altitude (item 11, PDF, 1 page, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12460828&FileExtension=pdf&FileName=Takeoff%20Distance%20Vs%20Density%20Altitude%20-Rel.pdf - Aircraft performance -rate of climb vs density altitude (item 12, PDF, 1 page, 412 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12460885&FileExtension=pdf&FileName=Rate%20of%20Climb%20Vs%20Density%20Altitude%20-Rel.pdf - Operating instructions -takeoff_ short field (item 13, PDF, 2 pages, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12461154&FileExtension=pdf&FileName=Operating%20Instructions_Takeoff_Short%20Field-Rel.pdf - Photograph of damage to airplane (item 14, PDF, 1 page, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12460639&FileExtension=pdf&FileName=Photo-Rel.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.