Pilot Debrief

PIPER PA28R near Churchville, MD — 2023-07-25

Final reportERA23FA313
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Date
2023-07-25
Location
Churchville, MD, USA
Airport
0W3
Aircraft
PIPER PA28R
Registration
N34PT
Category
Airplane
Highest injury
Fatal
Fatalities
1
Phase of flight
Takeoff roll

Probable cause

The pilot’s exceedance of the airplane’s critical angle of attack during initial climb, which resulted in an aerodynamic stall/spin and loss of control that the pilot did not recover from.

NTSB narrative

The pilot told a mechanic that he was planning to remain in the airport traffic pattern to make sure the airplane was ready for a long cross-country flight the next morning. An earwitness reported hearing the airplane begin its takeoff roll and continued to hear engine noises for a total of about 45 seconds until the airplane impacted the ground. The one eyewitness described the airplane as being in a steep left turn with the wings perpendicular to the ground just before it impacted the terrain. The accident occurred on the first flight after having a new interior and propeller installed, and after the completion of an annual inspection. Postaccident examination of the airplane and engine revealed no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation. The ground impact scars at the accident site, compact distribution of wreckage, and the eyewitness statement were consistent with the airplane entering an aerodynamic stall and left rotating spin in the left crosswind segment of the traffic pattern. At impact, the landing gear were selected to the down position and the flaps were set to the full position, which was not consistent with the with the configurations in the airframe manufacturer’s operating manual for either normal or short-field takeoff procedures. It is possible that this configuration, particularly the fully extended flaps, degraded the airplane’s climb performance and contributed to the aerodynamic stall.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot could have chosen to perform an engine run-up before takeoff.

NTSB coding

Evidence available

  • 14 docket documents
View NTSB final reportView NTSB docket

Docket documents14

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