Aviation Accident Summaries

Aviation Accident Summary CEN12LA569

Leesburg, OH, USA

Aircraft #1

N1845J

PIPER PA28

Analysis

The pilot was taking off on a 2,100 foot grass runway with a quartering tailwind. The pilot stated that the airplane lifted off and climbed normally until it passed the end of the runway, at which time the engine "coughed" and lost power. A witness stated that the airplane's speed during the takeoff and climb was slow and that the airplane reached an altitude of about 40-50 feet above the runway end. A review of the airplane's takeoff performance data from a hard surface runway showed that the airplane's takeoff distance over a 50-foot obstacle was nearly equal to the runway length for the density altitude at the time of the accident. However, the soft grass runway surface, runway slope, and quartering tailwind present during the accident takeoff would have further lengthened the airplane's takeoff distance. Because of these considerations, the pilot should not have attempted to takeoff on that runway in those conditions. The airplane's most recent annual maintenance inspection was completed about 5 months (about 7.8 flight hours) before the accident. However, the engine had not been overhauled within the manufacturer's recommended overhaul time of 12 years. Postaccident examination of the airplane revealed a leak from the fuel selector and evidence that one of the magnetos had a preexisting grounding anomaly; both conditions should have been discovered during the annual maintenance inspection. Additionally, the grounded magneto should have been evident to the pilot during the engine run-up. However, these anomalous conditions would not have had a significant effect on the airplane's performance. Examination did not reveal any preimpact mechanical malfunctions or anomalies that would have precluded normal operation.

Factual Information

On August 18, 2012, about 1700 eastern daylight time, a Piper PA-28-140, N1845J, impacted trees and terrain during initial climb from Donner Field Airport (OH28), Leesburg, Ohio. The private pilot and a passenger were uninjured. The airplane sustained substantial damage to the fuselage. The airplane was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and a flight plan had not been filed for the local flight that was originating at the time of the accident.A witness, who also had given the pilot a recent biennial flight review in the accident airplane, stated that the airplane's performance was 'anemic'. The witness questioned the pilot prior to the accident takeoff whether he should attempt to depart from the airport given the density altitude, grass runway, and airplane weight. Another witness stated that the airplane seemed "too slow," and its climb was "slow". The airplane attained an altitude of 40-50 feet above the ground, and from his view, it was level with the trees on the side of the runway and slightly above the trees at the end of the runway. The pilot stated that prior to departing, he performed a preflight inspection and engine runup, all of which were "normal." He set 20 degrees of flaps and used a short/soft field takeoff technique with a best angle of climb from runway 09 (2,100 feet by 120 feet, turf). He said that the airplane was climbing "normally" when it 'coughed' over the end of the runway. The airplane "quickly" lost engine speed, and the propeller was turning. He leveled the airplane in time to hit the trees at the departure end of the runway. According to the pilot's logbook, he accumulated a total flight time of 523.5 hours as of the last flight entry, which was dated August 12, 2012. The last flight was in the accident airplane and was 1.0 hours in duration from "REED-OH28-REED". The preceding flight was dated June 7, 2012, which was the pilot's recent biennial flight review. The flight review was conducted in the accident airplane for a flight that was 1.1 hours in duration from "MGY-I74-MGY." The entry for the flight review includes "...short/soft t/os + landings... ." The 1968 Piper PA-28-140, serial number 28-24280, airplane was powered by a Lycoming O-320-D2A engine. The airplane was registered to the pilot on March 14, 2012. A logbook entry dated June 19, 1998, stated that the engine was overhauled and installed on the airplane on November 15, 1998, at a tachometer time of 2,333.3 hours. Lycoming Service Instruction No. 1009AS states, "...all engines that do not accumulate the hourly period of time between overhauls specified in this publication are recommended to be overhauled in the twelfth year. Logbook entries for the last annual inspections of the airplane and engine were dated March 7, 2012, at a total time of 3,230.6 hours. The entry for annual inspection for this dates stated that time since major overhaul was 897 hours and the total time since new was 1,962.3 hours. The tachometer at the accident site indicated 3,238.37 hours. The Piper Cherokee 140 Owner's Handbook provided a Take-off Distance vs. Density Altitude chart for hard surfaced runways for airplane gross weights of 1,950 lbs and 2,150 lbs. At a density altitude of about 2,524 feet and gross weight of 1,950 lbs, the takeoff ground run was about 1,000 feet, and the distance over a 50-foot obstacle was 2,050 feet. At a density altitude of 2,524 feet and gross weight of 2,150 feet, the ground run was about 1,100 feet, and the distance over a 50-foot obstacle was 2,300 feet. According to the airplane weight and balance form, the airplane had an empty weight of 1,301 lbs. The pilot reported that there was 30 gallons of fuel on board at the time at takeoff. The pilot's airman medical certificate indicated his weight was 220 lbs. The weight of the passenger was estimated by a witness as 180 lbs. Another witness estimated the passenger weight as 190-200 lbs. The Wilmington Air Park (ILN), Wilmington, Ohio, automated weather observing system located about 10 miles northwest of OH28 recorded at 1654: wind - 150 degree at 5 knots; temperature - 25 degrees Celsius; dew point - 9 degree Celsius; altimeter - 29.92 inches of mercury. Based upon the field elevation of OH28, which was 990 feet, and the ILN temperature and altimeter, the density altitude was about 2,524 feet. According to a Federal Aviation Administration inspector, the airplane came to rest at the northwest corner of a field located about 700 feet from the departure end of runway 09. The airplane's left wing initially contacted a tree yawing the airplane left into another tree, which impacted the right side of the fuselage just behind the aft seats. Photos show that the cockpit flap control and the flaps were in the 0 degree flap position. The fuel selector was in the off position, the magneto switch was in the off position, and the keys for magneto key switch had been removed and were hanging on the altimeter's post light. The cockpit engine throttle control was in the full forward position, the carburetor heat control was in off position, the master switch in the off position, the electric driven fuel pump switch was in the off position, and the mixture control was in the full aft position. Both wing fuel tank caps were secure, and when they were opened, 100 low lead fuel poured out. The engine firewall fuel sump bowl was unseated from its mount due to impact damage and contained fuel. Fuel was present in the carburetor bowl. The propeller displayed S-shaped bending on one of the two propeller blades. The other propeller blade did not exhibit impact damage. A severed tree limb consistent with a propeller strike was near the airplane. The tree limb was estimated to be several inches in diameter. Examination of the engine confirmed throttle and mixture control continuity. The engine sump contained about 5 quarts of oil. The top spark plugs were removed and none of the spark plugs exhibited fouling. The engine was rotated and compression from all cylinders was confirmed. Engine continuity was also confirmed. The air induction system was unobstructed. The carburetor, both magnetos, and the cockpit fuel selector were tested and examined under the supervision of the National Transportation Safety Board Investigator-In-Charge. The left magneto was a Bendix magneto with a "Teledyne Continental Motors – Orig Mfr" data tag showing model "S4LN-21," part number "10-51360-37," serial number "A192644," and overhaul date "4/98. "Examination and testing of the left magneto revealed that the magneto flange gasket was red in color and had annotations of "PMA" and "L62224." The gasket had two holes at one edge and one hole at the opposite edge. The P-lead and its internal spring, part number 10-20-90, had evidence of arching consistent with a preexisting partial/intermittent grounded/ungrounded condition. The left magneto was placed on a magneto test stand and operated at about 4,500 rpm. A spark of at least 0.25 inch test gap was noted from each lead from the distributor. The impulse coupling also was tested and functioned without any anomalies. The magneto was not able to be grounded using the P-lead during the test. The right magneto was a Bendix magneto with a Teledyne Continental Motors – Orig Mfr" data tag showing model "S4LN-20," part number "10-51360-29, serial number "A194869," and overhaul date "4/98." The P-lead and its internal spring, part number 10-20-90, had no evidence of arching. The right magneto was placed on a magneto test stand and operated at about 4,500 rpm. A spark of at least 0.25 inch test gap was noted from each lead from the distributor. The impulse coupling also was tested and functioned without any anomalies that would have precluded normal operation. The magneto was able to be grounded using the P-lead during the test. The carburetor was a Facet Aerospace Products model "4SPA," part number "10-5135," serial number "CK 4 8686," and original manufacture "MF V A1 92." Examination of the carburetor revealed that the heat box to carburetor gasket had a smaller inside diameter than that of the carburetor inlet and the incorrect gasket. The gasket was similar in size to the carburetor manifold gasket. The correct heat box to carburetor gasket had a part number of 649974. Both carburetor screens did not contain debris and were unobstructed. The carburetor bowl did not contain debris or corrosion. The carburetor float was intact, moved freely, and had the correct drop. All of the carburetor linkages were intact and secure. The electric driven fuel pump was a Facet with no model, part, or serial number. The pump was connected to a 12 volt source of electrical power and was noted to operate with no anomalies that would have precluded normal operation. The pump could not be bench tested due to impact damage to the inlet tube base. The engine driven pump, AC, part number "154729210," serial number "AA7477," was operated using hand pressure. No anomalies were revealed that would have precluded normal operation. The fuel selector was examined and tested using a test bench. The fuel selector cover had blue staining, and the fuel selector had black colored residue near the fuel selector stem consistent with a preexisting fuel leak. The fuel selector was operated from right, to off, to left supplies using test fluid. A small intermittent leak was noted at the selector valve stem. The fuel selector operation did not reveal any anomalies that would have precluded normal operation. The Airplane Flying Handbook, FAA-H-8083-3A states, in part: Takeoffs and climbs from soft fields require the use of operational techniques for getting the airplane airborne as quickly as possible to eliminate the drag caused by tall grass, soft sand, mud, and snow, and may or may not require climbing over an obstacle. The technique makes judicious use of ground effect and requires a feel for the airplane and fine control touch... After becoming airborne, the nose should be lowered very gently with the wheels clear of the surface to allow the airplane to accelerate to VY, or VX if obstacles must be cleared. Extreme care must be exercised immediately after the airplane becomes airborne and while it accelerates, to avoid settling back onto the surface. An attempt to climb prematurely or too steeply may cause the airplane to settle back to the surface as a result of losing the benefit of ground effect. An attempt to climb out of ground effect before sufficient climb airspeed is attained may result in the airplane being unable to climb further as the ground effect area is transited, even with full power. Therefore, it is essential that the airplane remain in ground effect until at least VX is reached. This requires feel for the airplane, and a very fine control touch, in order to avoid over-controlling the elevator as required control pressures change with airplane acceleration.

Probable Cause and Findings

The pilot's improper preflight planning and decision to attempt a takeoff from a runway that was too short for conditions, which resulted in the airplane settling into terrain.

 

Source: NTSB Aviation Accident Database

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