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NTSB investigation record

ERA13FA385

Completed

Piper Pa-28-161· N9089N

Date
August 29, 2013
Location
Danville, VA
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The student pilot's failure to maintain control and climb the airplane during a go-around maneuver. Contributing to the accident was the flight instructor's failure to provide adequate oversight of the student pilot by ensuring that the cockpit was free of distractions.

Investigator assessment

Analysis narrative

Several eyewitnesses reported observing the airplane performing several takeoffs and landings. One witness stated that, during one landing attempt, the airplane was low, that a go-around maneuver was initiated, and that the airplane banked sharply left and right during the maneuver. The witness reported that the second landing attempt was successful and that the airplane was then taxied back to the beginning of the runway for another takeoff. During the accident approach, the airplane was observed flaring too high and banking left. One witness stated that the pilot added power and categorized the subsequent climbout as very shallow just before the airplane impacted an antenna and terrain. A postimpact fire ensued. Examination of the wreckage revealed no abnormalities or malfunctions that would have precluded normal operation. Review of flight school records revealed that the student pilot's first solo flight was 4 days before the accident and that the flight was 0.8 hour long. It could not be determined if the first solo flight was considered the student pilot's supervised solo or if the accident flight was considered the supervised solo. The flight school's standard operating procedure was to "completely go through all requirements twice"; therefore, although the accident flight was the student pilot's second solo flight, it should still have been supervised by the flight instructor. The flight instructor reported that the student pilot was scheduled to fly about an hour earlier than when the accident flight initiated; however, due to work requirements, the student pilot had to delay the flight. The flight instructor stated that the student was "upset" about the delay. He said that they conducted three takeoffs and landings together, which took about 30 minutes, and that he then exited the airplane for the student pilot's solo flight. The flight instructor reported that, when the student pilot departed on the solo flight, he witnessed a "beautiful" landing and then went inside to check on another student. He subsequently observed the student pilot conduct more landings, which he categorized as "good." A cell phone was located inside a thermally damaged case. The cell phone was found off; however, when activated, it indicated that a missed call occurred around the time of the accident. According to the manufacturer, the cell phone may overheat and shut down when exposed to high temperatures and will not register a call when powered off. Therefore, it is likely that the cell phone was on and that the pilot was aware of the incoming call when it was received. Although the investigation could not determine if the student pilot had become distracted by a cell phone call, the flight instructor further stated that the student was very focused on learning but that he was distracted when his cell phone rang. However, the flight instructor did not require the pilot to turn the cell phone off during flight. The flight instructor was in a position of authority and operational control and should have taken steps to ensure that the student was not distracted by the cell phone while flying.

Source record

Factual narrative

HISTORY OF FLIGHT On August 29, 2013, about 1945 eastern daylight time, a Piper PA-28-161, N9089N, was destroyed when it impacted an on airport instrument landing system (ILS) glide slope antenna, the ground, and then a postaccident fire ensued at Danville Regional Airport (DAN), Danville, Virginia. The student pilot, was fatally injured. Visual meteorological conditions prevailed and no flight plan was filed for the local solo flight which was conducted under the provisions of Title 14 Code of Federal Regulations Part 91. According to several eyewitnesses, the airplane was observed performing repeated takeoffs and landings to runway 2. During one of the landing attempts the airplane "appeared too low;" the airplane's engine power could be heard increasing, and a go-around maneuver commenced. During the initial go-around the airplane rolled "sharply left…then sharply right" before it began to climb out. On the second attempt, the landing was "normal" and the airplane taxied back to the beginning of the runway for takeoff. During the accident approach, the airplane "flared high, then rolled left" and then began to climbout "very shallow" and "appeared level" prior to impacting the antenna. The witnesses reported hearing the engine power increase and just prior to impacting the antenna and then engine power decreased. Based on certificated flight instructor (CFI) and eyewitness interviews the actual number of landing attempts could not be conclusively determined. PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) and General Aviation Flight, Inc., the flight school, the pilot, age 42, held a student pilot certificate dated August 14, 2013, which was also a third-class medical certificate. At the time of certificate issuance, the student pilot reported 8.8 total flight hours. Although, at the time of this writing the student pilot's logbook had not been located, flight school records showed the student had accumulated about 13 total flight hours, of which, an estimated 1.6 of those hours were solo flight. The student's first flight was accomplished on June 24, 2013. The first solo flight recorded in the flight school's record was on August 25, 2013 and was 0.8 hours in duration. The flight school documentation further stated "SOP [Standard Operating Procedure] is to completely go through all requirements twice and then to review selected ones as per student needs and desires." AIRCRAFT INFORMATION According to FAA records, the airplane was issued an airworthiness certificate on December 11, 1986, and was registered to General Aviation, Inc on December 5, 1986. It was powered by a 160-hp Lycoming O-320-D3G engine, serial number RL-13625-39E, driving a Sensenich 2-bladed propeller. The airplane's most recent inspection, noted as an annual inspection in the logbook, was accomplished on August 6, 2013. At the time of that inspection the airplane had 13,976.8 total hours of time in service. The engine's most recent inspection, noted as a 100-hour inspection in the logbook, was accomplished on August 6, 2013, at 4,211.1 hours of total time in service and 1,876.2 total hours since major overhaul with a recorded tachometer time of 13,976.8 hours. At the time of the inspections the tachometer was recorded as 3,976.8 hours. Prior to the accident flight the aircraft tachometer was recorded as 4020.6 hours. The most recent recorded fueling was accomplished on August 27, 2013, at DAN. The airplane had been fueled with 20.1 gallons of fuel. METEOROLOGICAL INFORMATION The 1953 recorded weather observation at DAN included wind from 050 degrees at 5 knots, 10 miles visibility, clear skies, temperature 26 degrees C, dew point 21 degrees C; altimeter setting 29.99 inches of mercury. On the day of the accident, official sunset was at 1950, end of civil twilight was at 2016. AIRPORT INFORMATION The airport was a publically owned airport and at the time of the accident did not have a control tower. There were two runways designated runway 2/20, and runway 13/31. However, at the time of the accident, the airport was under construction and runway 13/31 was closed. Runway 2/20 was normally 6,502 feet long; however, due to construction, it was 3,028 feet long and 150 feet wide. The airport elevation was 571 feet above mean sea level. The ILS glide slope antenna was located about 900 feet from the runway threshold to runway 2 and about 175 feet from the west side of the paved portion of runway 2/20. The airport, at the time of the accident had numerous published Notices to Airman (NOTAM) and some of them that affected the landing runway were: • DAN 06/009 DAN RWY 2/20 RWY LGTS PCL OTS EXC LOW INTST • DAN 04/007 DAN RWY 2/20 NORTH 3474 CLSD WEF 1304251528 • DAN 03/040 DAN RWY 2/20 CLSD TO ACFT WITH APCH SPEED IN EXCESS OF 121 KTS • DAN 03/035 DAN RWY 2/20 CLSD TGL • DAN 03/027 DAN RWY 20 PAPI OTS • DAN 03/026 DAN RWY 2 PAPI OTS • DAN 03/021 DAN NAV ILS RWY 2 OM OTS WEF 1303251200-1401151200 • DAN 03/017 DAN NAV ILS RWY 2 GP/LLZ OTS WEF 1303251200 • DAN 03/016 DAN RWY 2 ALS OTS WEF 1303251200 • DAN 03/015 DAN RWY 2 REIL OTS WEF 1303251200 WRECKAGE AND IMPACT INFORMATION The ILS glide slope antenna exhibited impact damage 39.5 feet above ground level (agl). Ground scars were present between the runway and taxiway "A." The left wing was collocated with the ILS glide slope antenna. The accident flight path was oriented on a 346 degree heading and the debris path began about 20 feet prior to ILS glide slope antenna and consisted of the left wing beginning at the wing root and included the entire wing. The debris path terminated 176 feet past the antenna. The debris path included a ground scar in a position consistent with the right wing impacting the ground in a right wing low attitude. The impact mark was located 105 feet from the antenna. Two propeller strike marks were also located along the debris path. The marks were 31 inches apart and the first strike mark was about 5 inches in depth. The second mark consisted of the propeller assembly including both blades and the propeller hub. The main wreckage came to rest on a heading of 129 degrees. Nose and Cockpit Section The engine and cockpit exhibited fore-to-aft crushing and thermal damage. The engine remained attached to the firewall via the tubular mounts. The propeller was found separated from the engine and was located along the debris field and one of the blades, which was imbedded in the ground, exhibited minimal S-bending and leading edge damage. The ignition switch was found with the key remaining in it; however, due to thermal damage it could not be determined on the actual position. The fuel selector valve remained attached to the side wall; however, due to thermal damage the position of the switch could not be determined. According to the CFI, the selector valve was likely in the "LEFT" position when he exited the airplane prior to the student departing on the solo flight just prior to the accident. Both front seats remained attached to their respective seat tracks. The rear seats remained attached to their attach points. The left shoulder harness buckle remained attached the left side of the belt buckle. One side of the seat belt in the rear seat remained attached to the fuselage structure; however, no other seatbelts or buckles were located. The flap lever, located between the two pilot seats, was in the bottom detent, which correlated to the flaps "UP" position, which also correlated to the flap position found on both wings. The main entry located on the right side of the airplane was thermally damaged; however, the door latch was in the locked position. A cellular phone was located in the wreckage, in a carrying case, and the case had extensive thermal damage. Removing the phone from the case revealed it was not on; and after it was turned on for examination it revealed that a missed call was receive

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