Wednesday, June 18, 2014

Piper PA-28-235, N8966W: Accident occurred March 27, 2005 in West Union, Iowa

NTSB Identification: CHI05FA080. 
 The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Accident occurred Sunday, March 27, 2005 in West Union, IA
Probable Cause Approval Date: 10/27/2005
Aircraft: Piper PA-28-235, registration: N8966W
Injuries: 3 Fatal,1 Serious.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

The airplane collided with the terrain following a loss of control during takeoff on a 4,248 foot long, concrete runway. A witness reported seeing the airplane travel down the centerline of the runway, lift off, and settle back onto the runway. He stated he then heard the tires squeal and the airplane lifted off again, veering to the left. He stated the airplane's attitude was fairly level at this time and he thought to himself, "Come on [pilot's name], get some airspeed." The witness stated the airplane then banked to the left. The left wing contacted the ground and the airplane caught fire and became engulfed in flames. Inspection of the airplane and engine failed to reveal any pre-impact failures/malfunctions which would have resulted in the loss of control. The flaps were found set to 25 degrees, which is the flap setting normally used for short and soft field takeoffs. The normal takeoff flap configuration is zero degrees. The pilot had received his private pilot certificate one and a half months prior to the accident. The pilot's logbook indicated he had a total flight time of 73.3 hours of which 49.5 hours in the accident airplane. Two 14-pound weights were located in the rear fuselage area of the wreckage. The airplane owner stated they usually kept the weights in the airplane to help balance the airplane's cener of gravity when there were just two adults in the front seat. The aircraft occupants during the accident flight consisted of two adults in the front seats and two children in the rear seats.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to abort the takeoff, his failure to maintain adequate airspeed during the takeoff, and the pull-up to avoid obstacles which resulted in an inadvertent stall. Factors associated with the accident were the pilot's failure to maintain directional control of the airplane, the fence, and the tree line.


On March 27, 2005, at 1425 central standard time, a Piper PA-28-235, N8966W, collided with the terrain following a loss of control while taking off on runway 17 (4,248 feet by 50 feet, dry concrete) at the Scott Municipal Airport (3Y2), West Union, Iowa. The private pilot and two passengers were fatally injured. One passenger received serious injuries. The airplane was destroyed by impact forces and a post impact fire. The local flight was originating at the time of the accident.

A witness, the pilot's father, stated he and his son flew to 3Y2 to have dinner with family. He stated they then decided to go to the airport to take family members on local sightseeing flights. He stated he flew the first flight with family members. His son was beginning the second flight of the day with family members when the accident occurred.

The witness stated his son taxied the airplane toward the end of the runway where he heard his son perform an engine run-up. He stated he was not sure if the pilot began the takeoff roll at the end of the runway or from the run-up pad. The run-up pad is located approximately 900 feet from the approach end of runway 17. The witness stated he saw the airplane travel down the centerline, it lifted off, and settled back onto the runway. He stated he then heard the tires squeal and the airplane lifted off again, veering to the left. He stated the airplane's attitude was fairly level at this time and he thought to himself, "Come on [pilot's name], get some airspeed." The witness stated the airplane then banked to the left. The left wing contacted the ground, and the airplane was engulfed in flames.


The pilot held a private pilot certificate with a airplane single-engine land rating which was issued on February 10, 2005. He also held a third-class medical certificate which was issued on July 7, 2004. The medical certificate contained the limitation that the pilot must wear corrective lenses.

According to the pilot's logbook, he had a total flight time of 73.3 hours of which 49.5 hours were logged in the accident airplane.


The accident airplane was a 1964 Piper PA-28-235, serial number 28-10543. It was certified as a four-place, normal category airplane. It was a low-wing, single-engine airplane, which incorporated fixed, tricycle landing gear.

The airplane was power by a Lycoming O-540-B4B5 engine, serial number L-8073-40. The carbureted, normally aspirated engine was rated to 235 horsepower.

According to Federal Aviation Administration records, the pilot's father owned the airplane. The records show the airplane was registered to the current owner on August 27, 2004.

All of the maintenance logbooks were inside the airplane at the time of the accident. The logbooks were burned; however, portions of the logbooks were legible. The aircraft logbook showed the last annual inspection was completed on August 25, 2004, at an aircraft total time of 2782.3 hours. The last entry in the aircraft logbook was dated January 10, 2005, and the aircraft total time was listed as 2906.44 hours.

The engine logbook was also located in the wreckage. The last annual inspection was dated August 25, 2004, at a total time of 2782.3 hours, 870.3 hours since major overhaul. This entry noted that all of the cylinders were replaced. There were three additional oil change entries for which the dates were not legible. The last of these entries showed an aircraft time of 2898.3 hours. A maintenance invoice shows this last oil change was accomplished on January 6, 2005.

The tachometer was not located in the wreckage.


The closest weather reporting station to the accident site was located at the Decorah Municipal Airport (DEH), Decorah, Iowa, approximately 18 statute miles north of the accident site. The DEH weather at 1455 was reported as wind from 230 degrees at 6 knots, 10 miles visibility, clear skies, temperature 15 degrees Celsius, dew point 3 degrees Celsius, and an altimeter setting of 29.87 inches of Mercury.


A single black tire mark, which started approximately 1,200 feet from the approach end of runway 17, was visible on the runway. The mark began on the right side of the runway centerline continuing for approximately 96 feet, gradually veering to the left of the centerline. Three tire tracks were visible in the grass beginning at the edge of the runway. These tracks continued for approximately 180 feet. The center track ended prior to the two on either side of it. A broken runway light was found just after the point where both side tracks ended. The airplane then cleared a fencerow, which contained a wire fence, small trees, and high brush, prior to impact in the open field.

The airplane impacted the field approximately 200 feet from the east edge of the runway. The ground was scorched beginning at the initial impact and fanning out in a V-shape up to the location of the main wreckage that was located approximately 300 feet from the initial impact. The flight path from the runway was 120 degrees and the main wreckage came to rest inverted with the nose of the airplane facing a heading of 220 degrees.

The initial terrain impact point contained pieces of red lens cap. This impact was followed by another impact mark, which was approximately 5-inches in depth. A strip of the door seal was found near the second impact mark. The third impact mark contained the green lens cap from the right wing tip.

The entire instrument panel and cockpit area were consumed by fire. The attach fittings on the right seat and rear bench seat were detached from their floor rails which were consumed by the fire. The left seat bottom remained attached to its floor rail with the back of the seat detached. An approximate six-foot long section of the lower portion of the left side of the fuselage was burned, but remained intact. Two 14-pound lead weights were located in the rear fuselage area.

The fuel selector was consumed by fire. A portion of the fuel selector valve was located, but fire and impact damage precluded determining which fuel tank was selected. The flap handle was found with the pin engaged in the second detent. This setting corresponds to 25 degrees of flaps. This setting was also confirmed on the flap chain sprocket and the flap rod lever which was measured to be at 5 ¾ inches.

The right wing structure was melted away from the fuselage. The wing tip was crushed upward and the inboard section of the wing was consumed by fire. The aileron remained attached to the wing. The aileron control cables were intact and continuity was established from the wing to the cockpit flight controls. The outboard flap attach point was intact. The inboard section of the flap was crushed and its associated wing attachment was destroyed by fire.

The inboard section of the left wing as well as the entire lower surface of the wing was consumed by fire. The remainng outboard section of the left wing was separated into two sections. The outboard aileron remained attached to the wing by its outboard attachment fitting. The inboard section of the aileron and its associated wing structure were consumed by fire. The left flap was destroyed by impact and fire damage. The aileron control cable continuity was established from the wing to the cockpit flight controls. One of the cables was intact. The other was separated and melted at the point of separation.

The tail was separated from the fuselage just forward of the vertical stabilizer and stabilator. The right side of the vertical stabilizer was burned through the skin. The rudder remained attached to the stabilizer. The right stabilator was consumed by fire. The left stabilator sustained impact damage. Stabilator and rudder control cable continuity was established from the control surfaces to the cockpit controls. The stabilator trim was measured to be 9 threads which corresponded to approximately 6 degrees of nose up trim.

Both main landing gear were consumed by fire. The main gear wheel/brake assemblies sustained impact and heat damage from the post impact fire. The nose gear was intact.

Inspection of the engine revealed the oil sump, fuel pump, and carburetor were consumed by fire. The magnetos were present, but had sustained severe fire damage. The vacuum pump housing was burned and the drive was melted. Because of the fire damage the engine accessories and the accessory housing were removed to facilitate engine rotation by hand. Molten metal was located around the accessory gears.

The propeller remained attached to the engine. One blade was slightly bent rearward and the outer third of the blade was twisted. The other blade contained an "S" bend beginning at the root of the blade.

All of the spark plug leads sustained fire and impact damage. The spark plugs were removed and normal wear patterns were noted. An inspection of the cylinders using a boroscope revealed the valves were intact and the piston heads exhibited normal wear patterns.

The starter was jammed up against the ring gear with rotational scoring noted on the starter gear housing. The propeller ring gear was pushed back against the engine. The propeller was removed along with the ring gear. The propeller was then reinstalled to facilitate engine rotation by hand. Then engine was rotated by hand and thumb compression was noted on all cylinders along with continuity throughout the engine.


An autopsy was performed on the pilot by the State of Iowa, Department of Public Health, on March 28, 2004.

Toxicological tests on the pilot were conducted by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. Results were negative for all tests conducted.


The pilot's father flew the airplane just prior to the accident flight. He stated he used 40 degrees of flaps during his landing and that he retracted the flaps while taxiing to the ramp. He also stated they usually used two weights, which they kept in a milk crate in the rear of the airplane, when they were flying with just two adults up front. He stated this helped balance the airplane and he got this idea from a PA-28-235 website. The pilot's father stated he remembers seeing the weights in the rear of the airplane prior to taking off from their home airport and that the accident pilot must have put them in the airplane. He stated he thought about taking them out, but didn't as they didn't make that much of a difference in the way the airplane handled. The aircraft occupants during the accident flight consisted of two adults in the front seats and two children in the rear seats.

The PA-28-235 Owner's Handbook states, "Take-offs are normally made with flaps up, to simplify operating procedure. However, for short field take-offs, and for take-offs under difficult conditions such as in deep grass or on a soft surface, distances can be reduced appreciably by lowering flaps to 25 [degrees] (second notch)."

Parties to the investigation included the FAA, Piper Aircraft, and Textron Lycoming.

MINNEAPOLIS - The sole survivor of a deadly plane crash originally blamed on pilot error is speaking out in a YouTube video, saying "It's safe to say I've been to hell and back."

Her story about what caused the crash may anger - and inspire - you.

Three people were killed in the 2005 Easter Sunday in West Union, Iowa. But remarkably Caryn Ann Stewart survived.

Just 8-years-old at the time, Caryl lost her mother Connie, her sister Sarah, and her cousin Andy Bryan, who was piloting the small private plane.

Now 17, Caryn's YouTube video describes the horror of the fiery crash that left her burned over 75 percent of her body - and her agonizing recovery.

Documents obtained by KARE 11 and our partners at USA Today show that investigators from the National Transportation Safety Board blamed Andy, her cousin, for the crash. The NTSB cited the "pilot's failure to abort the take-off" as the cause.

But our investigation found something the government investigators apparently missed.

Caryn and her father, Brian Stewart, sued the aircraft manufacturer. During a long legal battle they turned up evidence that the engine maker had known about carburetor problems for years. Those problems could cause the engine to stall unexpectedly - a potentially deadly defect, especially in flight.

"If you are at 24-thousand feet and your engine quits, you can't pull over to the side of the road," says aviation attorney Bruce Lampert.

In Iowa, the engine stalled on take-off. Court documents revealed that similar carburetor problems had been linked to earlier crashes. But there's no mention of carburetor failure in the NTSB crash report.

Caryn and her family settled their lawsuit for $19 million, much of it to pay for her past surgeries and continued medical care.

Officials from NTSB say they are committed to safety.

And in a written release today General Aviation Manufacturers Association (GAMA) - a group representing private plane manufacturers - called USA Today's investigation "sensationalistic."

But critics say, too often, government investigators are blaming pilots, and missing hidden mechanical defects.

"You can't blame six pilots in a row for the same mistake," says attorney Lampert. "There is something else going on."

But Caryn Stewart's story is more about survival than tragedy.

Even though she endured seven different reconstructive surgeries, she's battled back.

She still has visible scars. But she tells the world in her YouTube video she's an active teenager who's fought her way through hell - and back.

"The moral of the story," she says as some of her favorite music plays in the background, "just because you've gone through hell doesn't mean you can't get back from it."

Her plane crash is just one example of the problems USA Today has found. You can read their entire report here.

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