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NTSB investigation record

ERA16FA169

Completed

Piper Pa32· N43576

Date
April 25, 2016
Location
Boone, NC
Conditions
VMC
Record
Published September 25, 2020

Primary finding

Probable cause

The pilot's delayed decision to conduct a go-around following an unstabilized landing approach and his subsequent failure to maintain clearance from trees near the end of the runway.

Investigator assessment

Analysis narrative

The private pilot and two passengers were conducting a local flight from the pilot's home airport. One witness stated that his attention was drawn to the airplane due to its "very fast" landing approach. The airplane then disappeared from his view; shortly thereafter, he saw a plume of smoke in the area of a golf course on the northwest side of the airport. Several witnesses on the golf course stated that the airplane appeared to be taking off, and noted that it was "struggling," that it was "too low," and was "bobbing up and down." The airplane impacted a stand of 75-ft-tall pine trees and came to rest on the golf course, where it was consumed by a post-crash fire. The rear seat passenger was fatally injured; the pilot and front seat passenger received serious injuries. Neither the pilot nor the passenger could recall the events of the accident flight. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation. The landing runway measured 2,700 ft long by 40 ft wide. Given the witness observation of the airplane's fast approach speed, it is likely that the pilot initiated a go-around due to excessive airspeed and/or a lack of runway remaining on which to stop; however, it could not be determined when the pilot began the go-around maneuver. The airplane's low altitude as it climbed away from the runway suggests that the pilot may have initiated the go-around near touchdown or possibly even after touching down. Had the pilot started the go-around earlier, after recognizing the airplane's unstabilized approach due to excessive airspeed, he would have allowed more time to re-configure the airplane, establish a positive rate of climb, and clear the trees near the end of the runway. However, the late go-around placed the airplane in close proximity to the trees, from which the pilot subsequently failed to maintain lateral clearance.

Source record

Factual narrative

The airport's runway was oriented on 13°/31° and measured 2,700 ft in length and 40 ft in width. The runway surface was asphalt and there were 25 ft trees about 150 ft from the runway 31 departure end. The FAA Airplane Flying Handbook, Chapter 8, "Approaches and Landings," states, "To land within a short-field or a confined area, the pilot must have precise, positive control of the rate of descent and airspeed to produce an approach that clears any obstacles, result in little or no floating during the round out, and permit the airplane to be stopped in the shortest possible distance." The handbook defines a stabilized approach as one that "permits the airplane to reach the desired touchdown point at an airspeed that results in minimum floating just before touchdown; in essence, a semi-stalled condition. To accomplish this, it is essential that both the descent angle and the airspeed be accurately controlled." The handbook further describes the characteristics of a stabilized short field landing approach, stating: [Short-field landing] procedures generally involve the use of full flaps and the final approach started from an altitude of at least 500 feet higher than the touchdown area. An excessive amount of airspeed could result in touchdown too far down the runway threshold or an after-landing roll that exceeds the available landing area. The handbook further states that go-arounds, or rejected landings, should be performed whenever landing conditions are not satisfactory. It also states, The go-around maneuver is not inherently dangerous in itself. It becomes dangerous only when delayed unduly or executed improperly. Delay in initiating the go-around normally stems from two sources: 1. Landing expectancy or set – the anticipatory belief that conditions are not as threatening as they are and that the approach is surely terminated with a safe landing, 2. Pride – the mistaken belief that the act of going around is an admission of failure – failure to execute the approach properly. The improper execution of the go-around maneuver stems from a lack of familiarity with the three cardinal principles of the procedure: power, attitude, and configuration. At 1255, the recorded weather at Watauga County Hospital Heliport (TNB), Boone, North Carolina, about 1 mile north of the accident site, included wind from 330° at 4 knots, 10 statute miles visibility, scattered clouds at 6,000 ft above ground level, temperature 21°C, dew point 6°C, and an altimeter setting of 30.11 inches of mercury. The pilot, age 68, held a private pilot certificate with a rating for airplane single-engine land, and a Federal Aviation Administration (FAA) third-class medical certificate issued July 2, 2015, with a limitation for corrective lenses. On the pilot's application for that medical certificate, he reported 604 total hours of flight experience. The pilot could not recall his flight experience and his logbook was not recovered; therefore, his total flight experience at the time of the accident and his experience in the accident airplane make and model could not be determined. The pilot-rated passenger, age 44, held a commercial pilot certificate with ratings for single-engine land and instrument airplane. He also held a private pilot certificate with ratings for multi-engine land, and an FAA second-class medical certificate with no noted limitations. On the pilot-rated passenger's most recent application for a FAA medical certificate, he reported a total flight experience of 2,600 hours. The pilot-rated passenger succumbed to his injuries 34 days after the accident, and his logbook was not recovered; therefore, his total flight experience at the time of the accident could not be determined. The single-engine airplane was manufactured in 1974 and was powered by a Lycoming IO-540-K1A5 engine equipped with a Hartzell HC-C2YK-1, controllable-pitch propeller. A review of maintenance logbook records showed an annual inspection was completed on June 16, 2015, at a recorded airframe total time of 7,718.5 hours and an engine total time of 4,073 hours. Further review of the airplane records revealed that the engine was overhauled on August 27, 1992. The last maintenance was performed on January 31, 2016, at which time the engine had accumulated about 2,255 hours since overhaul. The airplane was owned by the pilot and based at NC14. Examination of the accident site revealed that the airplane initially impacted a stand of 75-ft-tall pine trees. Parts of the left wing and freshly cut branches were observed throughout the stand of pine trees. A wreckage path extended from the trees, continued on a magnetic heading about 310° and extended about 126 ft to the main wreckage, which came to rest on a golf course. The main wreckage consisted of the fuselage, the rudder and vertical stabilizer, and the left and right stabilators. The outboard section of the left wing was fragmented along the wreckage path. The right wing was located with the main fuselage and it was consumed by fire. A post-impact fire consumed the cockpit, cabin, and baggage area. The instrument panel and avionics were destroyed by fire. No useful information was obtained from the instrumentation or avionics equipment. The engine control levers were not attached to the quadrant and were impact and fire damaged. Both control yokes were impact separated, broken and fire damaged. The T-bar with aileron sprocket and chain were examined. The aileron and stabilator cables were attached. The rudder pedals were pushed forward against the forward bulkhead. The firewall was severely impact damaged. The engine mount was attached to the firewall, and the engine was attached to the mount. The nose landing gear was attached to the mount. The nose gear steering rods were bent and impact separated from the steering horn. The flap control handle and bracket were attached to the fuselage floor and exhibited a flaps-retracted position. The flap operating torque tube was attached to its location in the fuselage and was also in the retracted position. The fuel selector valve was located and the selector valve arm was positioned in the right tip tank detent position. The fuel selector displayed impact and fire damage and the internal fuel filter was melted. All switches and circuit breakers were impact and fire damaged. Examination of the empennage revealed that the vertical fin with left and right stabilator sections was attached by the floor pan of the fuselage and impact and fire damaged. The rudder was attached to the vertical stabilizer at its hinge points. The rudder sector control cables were attached. Movement was noted going forward to the cabin area. The rudder trim position could not be determined. The stabilator control cables and trim control cables were attached and traced forward to the cabin area. Control cable continuity was traced forward to the flight control "T"-bar assembly. All cables exhibited postimpact fire damage. The left wing was separated from the fuselage. Both fuel tanks were breached and destroyed. All lower wing skins were destroyed by ground fire. The flap was attached at the inboard end. The outboard section was impact and fire damaged. The aileron was destroyed. The aileron control sector was bent and twisted. Both aileron cables were attached. Cable continuity was traced to the control chains in the forward cabin area. The left main landing gear assembly was attached to the main wing spar and fire damaged. The stall warning vane was destroyed. The right main landing gear was destroyed by postimpact fire. The right flap and aileron were destroyed by impact and fire. The primary and balance cables were attached. Control cable continuity was traced through all cable breaks from tension overload to the forward cabin area. Both cables were found attached to the aileron control chain. The engine remained attached to the

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