NTSB CAROL · Event
Event ATL96FA037
Aircraft involved
Probable cause & findings
improper re-assembly of the engine induction air filter by maintenance personnel, during an annual inspection, which resulted in a loss of engine power during takeoff; failure of the pilot to abort the takeoff before lift-off; and failure of the pilot to obtain and/or maintain sufficient airspeed, which resulted in a stall.
Factual narrative
HISTORY OF FLIGHT
On January 19, 1996, about 1235 eastern standard time, a Piper PA-28-161, N114AV, collided with the ground during an uncontrolled descent at Fort Pierce, Florida. The airplane was operated by the pilot under the provisions of Title 14 CFR Part 91, and visual flight rules. A flight plan was not filed for the personal flight. Visual meteorological conditions prevailed. The private pilot and one passenger were seriously injured while a second passenger was fatally injured; the airplane was substantially damaged. The flight was originating at the time of the accident. The airplane departed runway 27 at St. Lucie County International Airport, Fort Pierce, Florida. Three witnesses stated that the time between the boarding of the airplane and the takeoff roll was very quick. According to air traffic controllers the airplane had a takeoff roll of approximately 5000 feet. The witnesses also stated that the airplane was at approximately 200 - 300 feet when it began a right hand turn, and then appeared to stall, resulting in a descending spin. According to witnesses, the airplane collided with the ground right wing first.
PERSONNEL INFORMATION
According to the operator, the individual listed as the first pilot rented the airplane. Additionally, he was listed as the pilot on the form used by the operator to record flight time. He was also the only occupant of the airplane who possessed a pilot certificate issued by the Federal Aviation Administration (FAA). The pilot was issued a FAA private pilot certificate on February 13, 1995, based on his Austrian pilot license, number 9793. In his report of the accident, on NTSB Form 6120.1/2, the pilot listed his total flight hours as 320, with 40 hours in the same make and model airplane he was operating at the time of the accident. According to the report he had a total of ten hours within the 90 days prior to the accident, and five total hours within the 30 days prior to the accident. The flight hours within the last 30 and 90 days respectively, were not listed as having been flown in the accident make and model airplane. The pilot's report indicated that his last medical examination was conducted on July 5, 1995. There was no record of a FAA medical certificate. The pilot did not provide any information regarding any flight checks within the previous 24 months. In his report, the pilot indicated that he had no recollection of the flight. The right seat belt and shoulder harness where the fatally injured passenger sat showed no signs of impact strain, or use during flight prior to the accident.
AIRCRAFT INFORMATION
Information on the airplane is included in this report under the data field labeled "Aircraft Information".
WRECKAGE AND IMPACT INFORMATION
During wreckage examination, the intake system sponge filter was found in, and blocking the carburetor intake throat. The inner carburetor air filter retainer was found to be absent, thus allowing the sponge to enter the intake throat. The mechanic who last worked on the system and replaced the filter, stated he must have improperly installed the wire screen. Service Letter, number 891, dated March 4, 1981 suggests an air induction filter retainer improvement; re-installing a one-piece retainer screen which would replace two separate retainers, one for each side of the sponge filter. This one-piece filter screen prevents the improper re-installation of air filter assemblies. This Service Letter pertains to both PA-28-151 and PA-28-161 models.
MEDICAL AND PATHOLOGICAL INFORMATION
A toxicological test was performed on the pilot detecting Naproxen in the system, with no traces of ethanol or other drugs. Naprosyn (naproxen) is indicated for the treatment of rheumatoid arthritis, osteoarthritis, juvenile arthritis, ankylosing spondylitis, tendinitis and bursitis, and acute gout. It is also indicated in the relief of mild to moderate pain and for the treatment of primary dysmenorrhea. There are no side effects issued from the use of this drug which would alter the pilots ability to operate the airplane. Information on this drug was found in The Physicians' Desk Reference, published by Edward R. Barnhart, 1990.
ADDITIONAL INFORMATION
The aircraft wreckage and logbooks were released to: Florida Flyers USA 3131 Jet Center Terr. 7N Ft. Pierce, Florida 34946 According to the air traffic controller in the airport tower, about 5,000 feet of the runway was used for the takeoff roll. Witnesses reported that after lift-off, the airplane climbed about 200 to 300 feet above the runway and entered a steep right turn. The nose then dropped, and the airplane collided with the ground, adjacent to the runway. Presumably, due to injury, the pilot was unable to recall the occurrence. During a postaccident examination of the airplane, a foam-like material, used for the carburetor air intake filter, was found lodged in the carburetor throat; and one half of the retaining screen (to hold the foam) was absent. According to the aircraft records, the airplane had received an annual inspection three days before the accident flight, during which the filter was replaced. The airplane had been operated for an unspecified time following the inspection. Piper Service Bulletin 891 had been issued to provide for a one piece retainer for the filter, which would have precluded the filter from being drawn into the induction system. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1996_ATL96FA037.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
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- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
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