ERA14FA255

The pilot's decision to depart from a soft runway with a tailwind and toward obstructions, and his failure to follow the manufacturer's recommended procedures for the takeoff. Contributing to the accident were the degradation of airplane and engine performance due to the high density altitude and the pilot's failure to properly configure the airplane's carburetor heat.

The pilot was conducting a local personal flight in the airplane with three passengers onboard. He was departing from a turf and sand-covered runway that had a usable length of 2,600 ft. Although a relatively clear area was located beyond one end of the runway, the pilot elected to depart in the opposite direction toward a heavily forested area with trees that were about 70 ft tall. After a takeoff run requiring about half of the runway's available length, the airplane began climbing at an abnormally steep angle. The airplane climbed above the trees at the departure end of the runway, stopped climbing, rolled to the right, descended into the trees, and impacted the ground. A post-impact fire consumed the majority of the airplane. Examination of the wreckage at the accident site revealed no evidence of any preimpact mechanical failures or malfunctions of the airframe or engine that would have precluded normal operation. Review of video recorded both onboard and from outside the airplane showed that the pilot did not use the manufacturer's recommended procedure for a takeoff from a turf (soft) runway with obstacles ahead. The procedure called for 25 degrees of flaps, and the pilot used no flaps. Further, the procedure called for the pilot to raise the nose wheel off the ground as soon as possible, take off at the lowest possible airspeed, and accelerate to 78 mph before climbing; the pilot did none of these steps. The video also showed that the pilot elected to depart with a slight prevailing tailwind. While the estimated velocity of the tailwind was only 3 knots, this tailwind may have increased the airplane's takeoff distance by as much as 15 percent. Additionally, the calculated density altitude of 1,900 ft resulted in an estimated additional 20 percent increase in the takeoff distance and an estimated 10 percent reduction in rate of climb once the airplane was airborne. The video showed that, during the takeoff, the engine tachometer indicated an rpm of about 2,000, which was less than the published minimum static rpm of 2,325 for the engine at its maximum throttle setting. While the accuracy of the tachometer's calibration could not be verified due to damage sustained during the accident, one potential cause for this discrepancy was the position of the carburetor heat selector handle. Video and statements from the airplane's owner suggest that the pilot had left the selector in an intermediate position, although the appropriate position for the takeoff phase of flight was the off position. Taking off with the selector in an intermediate position would potentially result in a loss of engine performance consistent with that observed on the tachometer.

The airplane was not equipped with either a cockpit voice recorder or flight data recorder, nor was it required to be., Video footage of the accident flight was captured by a witness on the ground, and by passengers onboard the airplane during the accident flight. Ground Witness Video Recording The video began with the ground based observer standing behind and to the right of the aircraft as it idled in the parking area. The right flap was in the retracted/up position. Engine noise increased and the aircraft began to taxi. The aircraft briefly stopped after it began rolling without a reduction in engine noise. It then quickly began rolling again as it turned left to back taxi down the unpaved landing strip. At this time, the left flap came into view and appeared to be in the retracted/up position. The movement of the rudder during this turn was to the left and was consistent with the pilot inputting left rudder pedal to a ground steering turn. The airplane taxied normally as a white cloud of fine dust formed behind the airplane. There were no visible preaccident mechanical anomalies that would have precluded normal operation. The video next cut to a view airplane at the far end of the runway. The airplane's engine could be heard at a high idle power setting. At approximately 02:06, an increase in engine noise was heard immediately followed by a slight decrease in engine noise followed by the sound quickly returning to roughly the original level. A second slight decrease in engine noise was heard with a quick recovery to the original noise level. The aircraft was then heard at an increased power level until approximately 02:30 when the engine noise could be heard reducing to a volume level consistent with a high idle power setting. From 02:52 to 04:08; the video showed the airplane at the far end of the runway. Engine noise at this time was consistent with the airplane at a high power setting. A trail of fine white dust appeared behind the airplane as it began its takeoff roll and started moving toward the camera location at an increasing rate with the nose wheel on the ground. At 03:13.29 the airplane rotated and left the ground. The airplane then entered a steep positive pitch attitude as it continued to travel toward the departure end of the runway. At 03:18.28, the airplane was perpendicular to the ground camera observer in a steep positive pitch attitude. The airplane continued to travel toward the departure end of the runway in a steep pitch attitude slowly gaining altitude. By 03:29.22 the airplane's shadow crossed a stand of trees at the departure end of the runway. At this time, the shadow was consistent with the airplane being in the immediate region of the tree line at the departure end of the runway. Shortly after, at 03:33.20 the airplane was shown behind the first stand of trees as it moved further away from the camera. By 03:35.00 the airplane began rolling right from a previously slightly left wing high bank attitude. Around 03:37.01 the airplane again rolled slightly right. At 03:40.12 the camera operator accident captured a clear view of the windsock. Around the same group of frames multiple thuds are heard, followed by the sound of trees and or tree limbs cracking. The camera operator and bystanders react to what they have observed and no other useable information was captured. The recording ended at 04:08.21. The airplane's pitch angle during the takeoff portion of flight was able to be estimated using still images from the witness's video recording. At 03:18.28, the accident airplane had become visually aligned with the ground camera operator. An electronic software method was used to replace measuring with a protractor. A still frame at 03:18.28 was chosen for this estimation when, the airplane was aligned normal to the camera's field of view. The video from this portion of the recording was cropped to a horizontal 16:9 format and rescaled to a larger size. This resulted in the image being magnified without distortion. A crop size and scale factor was chosen that would fill a 16:9 aspect ratio frame that included both the airplane and the ground in the same image. The orientation of the ground to the camera was modeled in the image measurement software using a singular line. Two points were chosen on either side of the image to account for the camera's rotation at the moment of image capture. Two points were also selected on a paint line along the fuselage that represented roughly a zero pitch angle when the aircraft was in level flight. Comparison of these lines indicated that the airplane was at an approximate 18 degree, nose up pitch angle when it passed by the camera. Onboard Video Recordings Video recordings were able to be recovered from a camcorder that was on the airplane during the accident flight. Review of the video recording showed that the position of the airplane's occupants were as follows: - Male adult pilot: Left front seat - Young male passenger: Front right seat - Adult female passenger No.1: Rear left seat - Adult female passenger No.2: Rear right seat The videos were determined to be captured by both rear seat adult female passengers. The first onboard video recording began with the airplane rolling out from the parking area near a parked low wing airplane, and a housing structure. The runway makeup was mostly turf with patches of sand scattered throughout. The airplane lined up on the runway to back taxi and came to a stop. At the start of the second onboard video recording, the airplane was aligned with the runway and the pilot appeared to be engaged in an engine run-up procedure. Throughout the run-up portion of the video, different portions of the instrument panel were captured. Among numerous instrument indications, the following pertinent indications and settings were observed during this segment of the video: - The master switch was in the "ON" position. - The electric fuel pump switch was in the "ON" position. - The fuel quantity indicators for both the left and right fuel tanks were reading near the top demarcation of both associated gauges. - Oil pressure reading was approximately mid-range. - Fuel pressure was approximately mid-range. - Oil temperature was approximately mid-range. - The mixture control was in the full rich position. - Green colored painter's style tape was visible over the carburetor heat control lever. The lever appeared to be secured by the tape in a position somewhere between mid-range and the lever's travel towards the off position. - The handle for the wing flaps was in the down position (flaps up position). The next video began with the airplane at an unknown throttle setting and engine noise could be heard at a level consistent with a run-up check. The front passenger door appeared to be closed and secured. The pilot's right hand was on the throttle and he was looking down towards the tachometer which was indicating approximately 1,800 rpm. The next video captured the following pertinent occurrences: - At 00:03, a slight change in engine noise was detected and then quickly returned to a normal level by 00:06. - At 00:07, a second engine noise level drop was heard and engine noise recovery was obtained around 00:10. During this time the frame rate of the camcorder detected recorded propeller motion consistent with the change in engine rpm. - At 00:13, the pilot adjusted the attitude indicator. - At 00:16, the pilot was holding and looking toward a white laminated checklist. - At 00:17, the pilot reached toward the throttle quadrant with his right arm. - At 00:21, the engine noise came down to a lower rpm setting, close to idle. - At 00:30, the pilot stated, "controls free, watch yourself." - At 00:32, the right control wheel was observed to turn to the right, then move aft, and then turn to the left, and then move forward in a wings level position. - At 00:37, the camera panned to the right wing. The right win