Aviation safety investigations & reports

Piper Aircraft Corp PA-32R-300, VH-ITR

Investigation number:
Status: Completed
Investigation completed


The pilot was conducting a private flight from King Island to Moorabbin in a Piper PA32R (Lance) with five passengers. The group had flown from Moorabbin to King Island two days earlier.

A witness saw the aircraft appear to accelerate normally along runway 35, becoming airborne before the intersection with runway 28 after a take-off roll of about 430 m. A short distance beyond the runway intersection, at a height of about 100 ft, the aircraft pitched steeply nose up and banked left about 30 degrees. The aircraft appeared to hang in the air momentarily, with the engine at high power, before banking further left in a nose high attitude and being lost to sight behind trees. The aircraft impacted the ground in a steep nose-down, left wing low attitude, tearing off the left wing, before sliding along the ground for about 65 m and coming to rest on runway 28.

The airport groundsman reached the accident site quickly, and shortly after was joined by three other people, all of whom assisted the injured. A fire truck arrived at the site 15 to 20 minutes after the accident and an ambulance arrived in about 30 minutes.

The pilot and passengers remained strapped in their seat belts throughout the accident. The pilot, front seat passenger, and a passenger occupying the rear left seat suffered fatal injuries. The three remaining passengers suffered serious injuries. Those who sustained the least injuries were the two passengers in the two aft facing centre seats.

Five minutes after the accident the automatic weather station at King Island airport recorded the wind velocity as 059 degrees at 18 kts, gusting to 25 kts. The outside air temperature was 20.6 degrees Celsius. Conditions were described by a witness as sunny, with no cloud and good visibility. A pilot who took off from King Island about 30 minutes after the accident reported experiencing strong wind gusts and windshear.

The pilot held a valid private pilot licence endorsed for single-engine aeroplanes below 5,700 kg maximum takeoff weight, equipped with retractable undercarriage and constant speed propeller. She had a total flying experience of 172 hours, including 7.7 hours in the Piper Lance, and 1.2 hours in a Piper Cherokee Six.

An investigation subsequently found no defects with the airframe or engine that may have contributed to the accident. The landing gear was extended at impact, consistent with the position of the landing gear selector. The wing flaps were set 10 degrees down, and the engine had been producing power.

The pilot's seat was found locked on its rails in a position appropriate for the pilot's size when controlling the aircraft. The aircraft was equipped with the standard manual trim wheel on the floor as well as an electric trim switch on the pilot's control column. The stabilator trim setting, evidenced by the indicator in the cockpit, and confirmed by the trim jack position, was found slightly forward of neutral.

An emergency locator transmitter (ELT) located in the rear fuselage was armed but had not activated on impact. Subsequent tests found the ELT to have been serviceable. The reason why the ELT did not activate was not determined. The pilot also carried a marine EPIRB for the over-water Bass Strait crossing between King Island and Moorabbin.

Fuel records indicate that the pilot probably departed Moorabbin with full fuel tanks and subsequently took off from King Island with an estimated 286 L of AVGAS remaining.

During the night after the accident police weighed most of the bags found on the aircraft. They described the baggage as having been dampened externally by fire-fighting foam, leaving the contents dry. A small amount of gear remained with the wreckage until the following day. Rain saturated some of this remaining gear. Two of the survivors subsequently attempted to recall where the baggage had been positioned in the aircraft prior to the accident. They also provided estimates of baggage weights. Their recall was enhanced because the pilot had insisted they weigh themselves and their baggage using scales before the flight. These scales were reported to over-read slightly. No evidence was found that passengers had added unweighed items to their luggage. The gear carried in the nose locker was estimated to total about half of the 45 kg allowable weight. The weight of gear behind the rear seats ranged from about 35 kg using passenger estimates, to possibly 83 kg using the police weights, which included an unknown factor for dampness. The maximum allowable baggage weight behind the rear seats was 45 kg. Several items of luggage were distributed throughout the cabin.

Using the baggage weights recalled by the passengers, the estimated takeoff weight at King Island was probably slightly below the maximum allowable. Using the damp baggage weights provided by the police, the aircraft may have been up to 48 kg above the maximum allowable takeoff weight.

The aircraft was originally fitted with a two-bladed propeller. Records show that in 1994 a three-bladed propeller was fitted, which was 7.2 kg heavier. An approved supplement for the three-bladed propeller was included in the flight manual, but a revised weight and balance sheet referred to in the supplement, was missing. The additional weight of the three bladed propeller would have had the effect of offsetting a tail-heavy condition rather than aggravating it.

Because of the disruption to the baggage following the accident and associated rescue efforts, and because of doubt as to the exact location of individual items of baggage and the unknown weight factor for the damp baggage, it was impossible to accurately determine the position of the aircraft centre of gravity. Based on information provided by the passengers, the centre of gravity was probably within the aft limit. Using baggage weights provided by the police, the centre of gravity could have been slightly less than 7 mm aft of the approved limit at the time of the accident. The pilot was reported to have been familiar with weight and balance calculations.

The Pilot's Operating Handbook for the PA-32-300 contains a general statement which indicates that if the centre of gravity is too far aft an aircraft may rotate prematurely on takeoff, or tend to pitch up during climb, with an associated reduction in longitudinal stability. This can lead to inadvertent stalls and even spins, with spin recovery becoming more difficult as the centre of gravity moves aft of the approved limit. The handbook also states: "The stall characteristics of the Cherokee Lance are conventional. An approaching stall is indicated by a stall warning horn which is activated between 5 and 10 kts above stall speed". One of the surviving passengers described the last sounds she heard before impact as a beeping noise.

The Pilot's Operating Handbook provided takeoff ground roll data based on either flaps up or flaps 25 degrees down. At maximum allowable gross weight with flaps up, under the prevailing conditions, the calculated ground roll was about 415 m for the takeoff at King Island. In accordance with the Approved Flight Manual for the aircraft, the maximum permissible crosswind component for takeoff and landing was 17 kts. The estimated crosswind component for the takeoff ranged between 16kts and 23 kts.


Considering the aircraft manufacturer's performance data, the 430 m estimated takeoff ground roll at King Island was realistic for a normal takeoff. With a crosswind component near or slightly above the 17 kt limit, the pilot may have experienced a higher than average workload during the takeoff.

The reason why the aircraft adopted a nose-high attitude could not be determined. Although the aircraft may have taken off with a centre of gravity at or slightly beyond the aft limit, it is considered unlikely that condition by itself could have caused the pilot to run out of pitch control. However, the aircraft may have encountered windshear shortly after take-off, which the pilot may have tried to counteract by raising the nose of the aircraft, resulting in a decrease in airspeed. In that situation an aft centre of gravity may have aggravated any tendency for the nose to pitch up.

From the witness description it is apparent that the aircraft suffered a significant loss of airspeed shortly after take-off and probably encountered at least a partial wing stall. The beeping noise heard by a passenger shortly before ground impact was probably the stall warning horn responding to a low airspeed condition. With the aircraft being so low to the ground when the left wing dropped, the pilot probably did not have sufficient height to recover before ground impact.

The pilot was relatively inexperienced, particularly with regard to the Piper Lance, and she may have encountered wind conditions during a critical phase of flight that exceeded her ability to adequately cope with.

Significant Factors

  1. The centre of gravity of the aircraft was at or near the aft limit.
  2. Gusting, strong wind conditions were conducive to low-level windshear.
  3. The limited flying experience of the pilot with regard to the conditions encountered.

General details
Date: 26 November 1998   Investigation status: Completed  
Time: 1355 hours ESuT    
Location   (show map): King Island, Aero.    
State: Tasmania   Occurrence type: Collision with terrain  
Release date: 11 December 1999   Occurrence category: Accident  
Report status: Final   Highest injury level: Fatal  

Aircraft details

Aircraft details
Aircraft manufacturer Piper Aircraft Corp  
Aircraft model PA-32  
Aircraft registration VH-ITR  
Serial number 32R-7780427  
Type of operation Private  
Damage to aircraft Destroyed  
Departure point King Island, TAS  
Departure time 1355 hours ESuT  
Destination Moorabbin, VIC  
Crew details
Role Class of licence Hours on type Hours total
Pilot-in-Command Private 8 172
  Crew Passenger Ground Total
Fatal: 1 2 0 3
Serious: 0 3 0 3
Total: 1 5 0 6
Last update 13 May 2014