Pilot Debrief

Piper PA32R near West Jordan, UT — 2020-07-25

Final reportWPR20LA238
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Date
2020-07-25
Location
West Jordan, UT, USA
Airport
U42
Aircraft
Piper PA32R
Registration
N7677C
Category
Airplane
Highest injury
Fatal
Fatalities
4
Phase of flight
Takeoff roll

Probable cause

The pilot's failure to maintain the airplane’s speed during takeoff near the airplane’s maximum gross weight in high-density altitude conditions, which resulted in the exceedance of the airplane's critical angle of attack and led to an aerodynamic stall, loss of control, and subsequent impact with structures and terrain.

NTSB narrative

The pilot and five passengers departed on an instrument flight rules cross-country flight. A security camera located about midfield at the airport captured the airplane as it lifted off about 3,700 ft from the beginning of the 5,862-ft runway; the liftoff point was likely due to the effects of a 7- to 10 knot tailwind. The airplane then began a series of shallow climbs and descents that continued until the airplane was no longer visible on the camera video. About 1 minute 15 seconds after takeoff, the video captured the airplane again as it descended at a steep angle into a residential neighborhood about 1.5miles southeast of the airport. The airplane struck a tree and three structures before it came to rest on its left side in a backyard of a private residence. A postaccident fire ensued, which consumed most of the wings, the cabin area of the fuselage, and a residence. GPS data revealed that the airplane did not exceed an altitude of 120 ft above ground level. Recorded engine data revealed consistent operation of the engine throughout the flight until about 15 seconds before the loss of data, when the exhaust gas temperatures and the fuel flow fluctuated likely because the pilot was adjusting the mixture lever. No mechanical malfunctions or failures with the airplane were found that would have precluded normal operations. The density altitude about the time of the accident exceeded 7,200 ft mean sea level, and the airplane was close to its maximum gross weight. The effects of high-density altitude conditions and a heavy airplane weight on takeoff performance include increased takeoff roll distance and reduced rate of climb. Review of performance charts indicated that the airplane should have been able to climb at a rate around 500 ft per minute; however, the video evidence indicated that, after takeoff, the airplane had difficulty establishing climb performance. It is likely that, after losing ground effect and while experiencing degraded climb performance due to the high-density altitude, the pilot responded by repeatedly pitching the nose down to gain airspeed and then pitching the nose up to climb. The engine data showed that the pilot apparently manipulated the mixture lever to gain power; however, soon afterward, the airplane’s critical angle of attack was likely exceeded, which resulted in an aerodynamic stall, a loss of control, and an impact with structures and terrain. A debris path of about 95 ft and minor damage to the spinner and front of the engine cowling suggested that the airplane’s descent was not consistent with a fully developed aerodynamic stall. However, multiple witness accounts were consistent with the onset of an aerodynamic stall, including one witness who reported that the airplane started to bank before it “fell from the sky.”

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot should have recognized high density altitude effects before takeoff.

NTSB coding

Evidence available

  • Video
  • FDR / data
  • ADS-B / radar
  • Photos
  • 21 docket documents
View NTSB final reportView NTSB docket

Docket documents21

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Piper PA32R near West Jordan, UT — 2020-07-25 · Pilot Debrief