Pilot Debrief

PIPER PA28 near Osage Beach, MO — 2023-07-13

Final reportCEN23FA304
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Date
2023-07-13
Location
Osage Beach, MO, USA
Aircraft
PIPER PA28
Registration
N8225N
Category
Airplane
Highest injury
Fatal
Fatalities
2
Phase of flight
Takeoff roll

Probable cause

The pilot’s failure to properly set the stabilator trim before takeoff, which resulted in an exceedance of the airplane’s critical angle of attack and an aerodynamic stall during takeoff.

NTSB narrative

The surviving passenger reported that the airplane did not seem to be climbing as well as it should have during the takeoff for the local sightseeing flight. The passenger believed the pilot was perhaps fighting the flight controls for an unknown reason. Shortly after takeoff, the airplane made a “violent turn” to the right, and it seemed like the airplane went straight down. The turn to the right and the airplane going straight down seemed to happen at the same time. The airplane came to rest nose down near multiple large trees. The accident site was about 0.55 mile from the departure end of the runway. The airplane sustained substantial damage to the fuselage, both wings, and the empennage. Two witnesses reported observing the airplane during the takeoff with its nose “pitched up in the air” and “the tail was lower than the nose.” A review of local area surveillance video recordings showed the airplane in flight with a nose-up attitude. Examination of the wreckage did not reveal any preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. During the examination, the stabilator trim was found in the full nose-up position. The takeoff checklist for the airplane included instructions to properly set the stabilator trim before takeoff. The passenger did not recall if the pilot used the checklist or adjusted the stabilator trim once before takeoff. It is likely that the stabilator trim position resulted in the airplane's extreme nose-up attitude, which led to an exceedance of the airplane's critical angle of attack and an aerodynamic stall during the takeoff. It is also likely the stabilator trim was left at the setting from when the airplane landed at the airport the day before. It was undetermined why the pilot did not set the stabilator trim before takeoff.

Analysis

Primary failure mode
Human factors
First missed decision gate
Pilot did not conduct a safety briefing or use a checklist before takeoff.

NTSB coding

Evidence available

  • Video
  • Photos
  • 25 docket documents
View NTSB final reportView NTSB docket

Docket documents25

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