Undetermined · NTSB CEN23FA304

PIPER PA28 — Osage Beach, MO

2 fatal Low-time pilot
DateJuly 13, 2023
LocationOsage Beach, MO
AircraftPIPER PA28
Purpose of flightPersonal
ConditionsDay · Visual Meteorological Cond
Phase / occurrencePrior to flight Miscellaneous/other
Pilot age22
Pilot total time240 hrs · Low time
Time in typeUnknown
Fatalities2, 1 serious

Probable cause

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.

NTSB findings

  • Personnel issues-Task performance-Use of equip/info-Aircraft control-Pilot
  • Personnel issues-Psychological-Attention/monitoring-Task monitoring/vigilance-Pilot
  • Personnel issues-Action/decision-Action-Incorrect action selection-Pilot
  • Aircraft-Aircraft systems-Flight control system-Elevator control system-Incorrect use/operation
  • Aircraft-Aircraft oper/perf/capability-Performance/control parameters-Angle of attack-Capability exceeded

What happened

The surviving passenger reported that the airplane did not seem to be climbing as well as it should have during the takeoff for the local sightseeing flight. The passenger believed the pilot was perhaps fighting the flight controls for an unknown reason. Shortly after takeoff, the airplane made a “violent turn” to the right, and it seemed like the airplane went straight down. The turn to the right and the airplane going straight down seemed to happen at the same time. The airplane came to rest nose down near multiple large trees. The accident site was about 0.55 mile from the departure end of the runway. 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.

Examination of the wreckage did not reveal any preimpact mechanical malfunctions or failures with the airframe or the engine that would have precluded normal operation. During the examination, the stabilator trim was found in the full nose-up position. The takeoff checklist for the airplane included instructions to properly set the stabilator trim before takeoff. The passenger did not recall if the pilot used the checklist or adjusted the stabilator trim once before takeoff. It is likely that the stabilator trim position resulted in the airplane's extreme nose-up attitude, which led to an exceedance of the airplane's critical angle of attack and an aerodynamic stall during the takeoff.

It is also likely the stabilator trim was left at the setting from when the airplane landed at the airport the day before. It was undetermined why the pilot did not set the stabilator trim before takeoff.

An editorial "what led to it / how to avoid it" analysis for this accident is generated separately and will appear here.

View the official NTSB docket →