Pilot Debrief

PIPER PA-28-161 near Danville, VA — 2013-08-29

Final reportERA13FA385
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Date
2013-08-29
Location
Danville, VA, USA
Airport
DAN
Aircraft
PIPER PA-28-161
Registration
N9089N
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Approach

Probable cause

The student pilot's failure to maintain control and climb the airplane during a go-around maneuver. Contributing to the accident was the flight instructor's failure to provide adequate oversight of the student pilot by ensuring that the cockpit was free of distractions.

Contributing factors

Contributing to the accident was the flight instructor's failure to provide adequate oversight of the student pilot by ensuring that the cockpit was free of distractions.

NTSB narrative

Several eyewitnesses reported observing the airplane performing several takeoffs and landings. One witness stated that, during one landing attempt, the airplane was low, that a go-around maneuver was initiated, and that the airplane banked sharply left and right during the maneuver. The witness reported that the second landing attempt was successful and that the airplane was then taxied back to the beginning of the runway for another takeoff. During the accident approach, the airplane was observed flaring too high and banking left. One witness stated that the pilot added power and categorized the subsequent climbout as very shallow just before the airplane impacted an antenna and terrain. A postimpact fire ensued. Examination of the wreckage revealed no abnormalities or malfunctions that would have precluded normal operation. Review of flight school records revealed that the student pilot's first solo flight was 4 days before the accident and that the flight was 0.8 hour long. It could not be determined if the first solo flight was considered the student pilot's supervised solo or if the accident flight was considered the supervised solo. The flight school's standard operating procedure was to "completely go through all requirements twice"; therefore, although the accident flight was the student pilot's second solo flight, it should still have been supervised by the flight instructor. The flight instructor reported that the student pilot was scheduled to fly about an hour earlier than when the accident flight initiated; however, due to work requirements, the student pilot had to delay the flight. The flight instructor stated that the student was "upset" about the delay. He said that they conducted three takeoffs and landings together, which took about 30 minutes, and that he then exited the airplane for the student pilot's solo flight. The flight instructor reported that, when the student pilot departed on the solo flight, he witnessed a "beautiful" landing and then went inside to check on another student. He subsequently observed the student pilot conduct more landings, which he categorized as "good." A cell phone was located inside a thermally damaged case. The cell phone was found off; however, when activated, it indicated that a missed call occurred around the time of the accident. According to the manufacturer, the cell phone may overheat and shut down when exposed to high temperatures and will not register a call when powered off. Therefore, it is likely that the cell phone was on and that the pilot was aware of the incoming call when it was received. Although the investigation could not determine if the student pilot had become distracted by a cell phone call, the flight instructor further stated that the student was very focused on learning but that he was distracted when his cell phone rang. However, the flight instructor did not require the pilot to turn the cell phone off during flight. The flight instructor was in a position of authority and operational control and should have taken steps to ensure that the student was not distracted by the cell phone while flying.

Analysis

Primary failure mode
Human factors
First missed decision gate
CFI should have terminated solo flight due to pilot's emotional state.

NTSB coding

Evidence available

  • Photos
  • 26 docket documents
View NTSB final reportView NTSB docket

Docket documents26

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