Pilot Debrief

PIPER PA 28 near Elko, NV — 2015-09-23

Final reportWPR15LA266
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Date
2015-09-23
Location
Elko, NV, USA
Airport
EKO
Aircraft
PIPER PA 28
Registration
N56897
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Takeoff roll

Probable cause

The pilot's failure to sufficiently lean the engine’s fuel-to-air mixture for the given density altitude, which resulted in reduced engine power output and the airplane’s inability to climb.

NTSB narrative

The private pilot stated that, shortly after takeoff, the airplane would not maintain a positive rate of climb. The pilot reported that he had previously experienced this on hot days, so he continued to make small control corrections in anticipation of the airplane gaining altitude; however, once it reached about 200 ft above ground level, the airplane began to sink. The pilot then decided to retard the throttle and perform a forced landing into a field. The airplane landed hard, resulting in substantial damage. The airplane was operating in a high density altitude environment and at the upper limit of its takeoff performance envelope at the time of the accident. Additionally, the pilot did not lean the engine's fuel mixture control before takeoff as recommended by the engine and airframe manufacturers' operating instructions; therefore, the engine was likely not producing full power, which resulted in the airplane's inability to climb. Further, the engine's spark plugs exhibited carbon fouling signatures consistent with an overly rich fuel-to-air mixture. Postaccident examination revealed no mechanical anomalies that would have precluded normal operation.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have filled fuel tanks to capacity before takeoff.

NTSB coding

Evidence available

  • 9 docket documents
View NTSB final reportView NTSB docket

Docket documents9

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