N8225N

Substantial
Fatal

PIPER PA28S/N: 28-25430

Accident Details

Date
Thursday, July 13, 2023
NTSB Number
CEN23FA304
Location
Osage Beach, MO
Event ID
20230713192625
Coordinates
38.121106, -92.688330
Aircraft Damage
Substantial
Highest Injury
Fatal
Fatalities
2
Serious Injuries
1
Minor Injuries
0
Uninjured
0
Total Aboard
3

Probable Cause and Findings

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.

Aircraft Information

Registration
N8225N
Make
PIPER
Serial Number
28-25430
Engine Type
Reciprocating
Year Built
1969
Model / ICAO
PA28P28A
Aircraft Type
Fixed Wing Single Engine
No. of Engines
1

Registered Owner (Historical)

Name
ADAMS JEFFREY D
Address
1005 N FOLGER ST
Status
Deregistered
City
CARROLLTON
State / Zip Code
MO 64633-1827
Country
United States

Analysis

HISTORY OF FLIGHTOn July 13, 2023, about 1157 central daylight time, a Piper PA-28-140 airplane, N8225N, sustained substantial damage when it was involved in an accident in Osage Beach, Missouri. The pilot and one passenger sustained fatal injuries. One passenger sustained serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

The pilot flew the airplane from its home base at the Carrollton Memorial Airport (K26), Carrollton, Missouri, to the Grand Glaize-Osage Beach Airport (K15), Osage Beach, Missouri. The airplane arrived at K15 on July 12, 2023, about 1030. According to the airport manager, the airplane did not refuel at the airport.

The purpose of the flight was to take the two passengers on a sightseeing flight in the local area to view scenery around the Lake of the Ozarks. According to the owner of the airplane, the airplane should have had about 25 gallons of fuel onboard for the flight. The surviving passenger reported that the flight was going to last about 30 minutes.

During the preflight inspection of the airplane, the pilot did not mention any concerns with the airplane to the passenger. The pilot did not ask the two passengers for their weights before departing, nor did the pilot conduct a safety briefing with the two passengers. The pilot was sitting in the front left seat, the surviving passenger was in the front right seat, and the other passenger was in the rear left seat. The two passengers did not use the available lap belt restraint systems for the flight. The passenger stated that he did not recall if the pilot used a checklist after they boarded the airplane. He also stated that he does not recall if the pilot adjusted the manual trim before or during the takeoff.

The airplane departed from runway 32 at K15. During the takeoff, it seemed like the airplane was not climbing as much as it should have according to the passenger. Also, during the takeoff, it seemed that the pilot was perhaps fighting the flight controls for an unknown reason. The pilot then said, “what the [expletive].” The passenger did not know what the pilot meant by saying that. Shortly after the pilot said that statement out loud, the passenger reported the airplane entered a “violent turn” to the right, and it seemed like it went straight down. The turn to the right and the airplane going straight down seemed to happen at the same time. The pilot did not say anything else after the “what the [expletive]” statement.

The passenger reported that he and the other passenger did not touch the flight controls in the airplane at any time, nor did he hear any sputtering or coughing noises from the engine during the runup or the takeoff. The passenger did not recall seeing any cockpit lights illuminate or hear any cockpit alarms activate during the takeoff. The passenger did not recall any events after the descending right turn.

The airplane came to rest nose down near multiple large trees. The accident site was about 0.55 mile from the departure end of runway 32. 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. PERSONNEL INFORMATIONThe father of the pilot reported that his son was scheduled to take his certificated flight instructor check ride on July 18, 2023. A review of Federal Aviation Administration (FAA) records showed that the pilot had successfully passed the Fundamentals of Instructing examination on March 31, 2023, and the Flight Instructor Airplane examination on May 26, 2023. AIRCRAFT INFORMATIONThe owner of the airplane reported there were no known mechanical issues with the airplane. A review of the airframe and engine maintenance records revealed no outstanding mechanical anomalies with the airplane.

The airplane had a manual trim system. The manual trim control was located on the top of the cockpit, on the interior roof. The airplane was equipped with a stall warning system that includes a red light that illuminates on the left side of the instrument panel between 5 and 10 mph above the stall speed.

A calculation of weight and balance numbers showed the airplane was within limitations for the accident flight.

According to the Piper Cherokee 140 B Owner’s Handbook, the takeoff checklist states, “trim tab set.” The airplane was equipped with a stabilator, as opposed to a stabilizer-elevator configuration. METEOROLOGICAL INFORMATIONThe estimated density altitude for the closest meteorological reporting station was 3,552 ft above mean sea level. AIRPORT INFORMATIONThe owner of the airplane reported there were no known mechanical issues with the airplane. A review of the airframe and engine maintenance records revealed no outstanding mechanical anomalies with the airplane.

The airplane had a manual trim system. The manual trim control was located on the top of the cockpit, on the interior roof. The airplane was equipped with a stall warning system that includes a red light that illuminates on the left side of the instrument panel between 5 and 10 mph above the stall speed.

A calculation of weight and balance numbers showed the airplane was within limitations for the accident flight.

According to the Piper Cherokee 140 B Owner’s Handbook, the takeoff checklist states, “trim tab set.” The airplane was equipped with a stabilator, as opposed to a stabilizer-elevator configuration. WRECKAGE AND IMPACT INFORMATIONAn examination of the airframe confirmed flight control continuity. The trim tab jackscrew was found extended above the drum, with about 17 threads exposed (about 1 and ¾ inch), that corresponded to a full nose-up stabilator trim setting. The stall warning system lift detector was intact, and the switch was heard to make an audible “click” when actuated.

The engine crankshaft was rotated by turning the crankshaft propeller mounting flange and continuity of the crankshaft to the rear gears and to the valvetrain was observed. Compression and suction were observed from all four cylinders. The interiors of the cylinders were observed using a lighted borescope and no anomalies were noted.

The two-blade aluminum propeller was found separated from the engine. The propeller bolts were found broken, and the propeller and starter ring gear separated from the engine crankshaft flange. The propeller showed some chordwise scratching on both blades, on both the forward and aft faces. One blade was found with slight aft bending and the other blade was bent, about ¾ span from the root, rearward about 80 degrees.

There were no preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. ADDITIONAL INFORMATIONThe FAA Airplane Flying Handbook FAA-H-8083-3C discusses when an elevator stall may occur and states in part:

This situation may occur during a go-around procedure from a normal landing approach or a simulated, forced-landing approach, or immediately after a takeoff, with the trim set for a normal landing approach glide at idle power. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy of the pilot was performed by Southwest Missouri Forensics, Ozark, Missouri. The autopsy report was reviewed by the NTSB Investigator-In-Charge. According to the autopsy report, the cause of death was blunt force injuries, and the manner of death was accident.

Toxicology testing was performed at the Federal Aviation Administration Forensic Sciences Laboratory. The test results were negative for substances tested.

Data Source

Data provided by the National Transportation Safety Board (NTSB). For more information on this event, visit the NTSB Records Search website. NTSB# CEN23FA304