# NTSB ATL04FA016: Piper PA-23-250, N63942, Cordesville, SC, October 13, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 13, 2003, 19:57 local (23:57 UTC) - Place: Cordesville, SC - Coordinates: 33.160831, -79.834999 - Nearby events: https://openairdocs.org/map.md?lat=33.1608&lon=-79.8350&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 7, 2005 - Report: Approved by Office Director - Parties: Textron Lycoming, FAA Columbia FSDO - 13, The New Piper Aircraft, Inc. - NTSB case key (mKey): 58187 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL04FA016 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/58187/pdf - Page: https://openairdocs.org/ntsb/ATL04FA016 ## Probable cause The pilot's failure to maintain adequate airspeed, which resulted in an inadvertent stall and subsequent uncontrolled descent into trees and the ground. A factor was physical impairment. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, descent - physical impairment, pilot in command - airspeed - not maintained, pilot in command (cause) - light condition - night - stall - inadvertent, pilot in command (cause) - In flight collision with object, descent - uncontrolled - object - tree(s) - terrain condition - ground ## Analysis The flight was cleared to descend to 3,000 feet, the pilot acknowledged, and no further radio communication was received from the pilot. Radar data showed the last recorded position for the flight was approximately 20 miles northeast of the airport at 2,900 feet, then the target disappeared from radar. Two witnesses approximately two nautical miles east of the accident site reported hearing what sounded like "back fire," "fireworks," and "crackling." One witness reported he saw the airplane flying west over the treeline, then he heard the sound of an impact. The wreckage was found in a heavily wooded area amid charred trees and burned pine straw, the engines were embedded approximately five feet in the ground, and the chordline of the wings was approximately perpendicular to the ground. Examination of the airframe and engines revealed no evidence of mechanical malfunction was observed. The toxicology report for the pilot stated "bupropion, bupropion metabolite, sertraline, and desmethylsertraline were detected in the liver, and bupropion metabolite and sertraline were detected in the kidney." A review of medical records maintained by the pilot's physician revealed the pilot had been prescribed drugs containing bupropion (Wellbutrin) and sertraline (Zoloft) to treat symptoms of depression. A physician's note dated July 14, 2003, stated, "Doing very well on Zoloft ... and Wellbutrin ... . Depression - stable." The records also revealed the pilot had a history of atrial fibrillation and was prescribed the drug sotalol. The pilot reported none of his medical diagnoses or medications on any applications for FAA Airman Medical Certificate. ## Factual narrative HISTORY OF FLIGHT On October 13, 2003, at 1957 eastern daylight time, a Piper PA-23-250, N63942, registered to Air Mango, Ltd., and operated by the commercial pilot, collided into trees and terrain and caught fire in the Francis Marion National Forest, Cordesville, South Carolina. The personal flight was operated under the provisions of Title 14 CFR Part 91 with an instrument flight plan filed. Visual meteorological conditions prevailed. The pilot received fatal injuries, and the airplane sustained substantial damage. The flight departed East Hampton Airport, East Hampton, New York, about 1549 on October 13, 2003. The flight was en route to Charleston International Airport, Charleston, South Carolina. According to air traffic control records, about 1942, the pilot contacted the Myrtle Beach approach controller while transitioning the airspace at 8,000 feet above mean sea level (MSL) and requested to begin a descent as soon as possible. The pilot was cleared to descend to 6,000 feet MSL, and was instructed to contact Charleston Approach. At 1948:37, the pilot established contact with the Charleston West Radar approach controller. A review of recorded radar data revealed the flight was approximately 40 miles from the airport descending through 7,000 feet MSL. At 1950:13, the pilot stated, "charleston six three nine four two would like to keep it coming down if you can arrange that." The controller cleared the pilot to descend and maintain 3,000 feet MSL, the pilot acknowledged, and no further radio communication was received from the pilot. A review of recorded radar data showed the flight began its descent, and the last recorded position for the flight was approximately 20 miles northeast of the airport at 2,900 feet MSL. The air traffic controller stated the airplane's target on the radar screen disappeared, and neither a primary nor a secondary return was observed. Two witnesses approximately two nautical miles east of the accident site reported their observations. One witness stated she was in her yard, and she heard what sounded like "a normal plane," then she heard "something that sounded like fireworks." She stated she looked up and saw only the lights of the airplane and heard "crackling" noises. A second witness stated he was on his porch and he heard an airplane engine noise that sounded like "back fire." He looked for the airplane and saw it directly overhead flying west, then he heard it back fire again, and five or ten seconds later he heard the sound of an impact. The witness telephoned the local 911 operator to report the accident. PERSONNEL INFORMATION The pilot held a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane. The pilot also held a flight instructor certificate for airplane single-engine land issued February 13, 1991, and expired February 28, 1993. The pilot held a second class medical certificate issued November 13, 2002, with the restriction "must wear corrective lenses." The pilot's log book was not recovered for examination. The pilot reported 5,500 civilian flight hours on his most recent application for airman medical certificate. AIRCRAFT INFORMATION The Piper PA-23-250 was manufactured in 1978 and was powered by two Lycoming IO-540-C4B5, 250-horsepower engines. The maintenance logbooks were not recovered for examination. Work orders provided by a maintenance facility revealed an annual inspection was completed November 20, 2002, at an airframe total time of 4760.3 hours, right engine time since major overhaul of 857.8 hours, and left engine time not recorded. The airplane's fuel tanks were topped off with 97.7 gallons of fuel prior to departure from East Hampton, New York. WRECKAGE AND IMPACT INFORMATION The wreckage was found in a heavily wooded area, and wreckage debris was scattered approximately 70 feet along a path heading approximately 250 degrees magnetic from a tree freshly broken 50 feet above the ground. The fuselage, wings, and engines were found amid charred trees and burned pine straw approximately 25 to 35 feet west of the broken tree, and the empennage was separated and found approximately 35 feet west of the fuselage. The fuselage, including the cockpit, instrument panel, and cabin were crushed and fire-damaged. The rudder bar was damaged and separated, and the left rudder cable was attached to the rudder bar. The right rudder cable was separated from the rudder bar, and the right rudder cable with the attachment was found near the rudder bar. The aileron chain was separated, and control cables in the center fuselage were encased in melted metal and not identified. The left fuel valve and the right fuel valve were fire-damaged; examination revealed the valves could be positioned to all ports and no obstructions were observed. The left wing was crushed and fire-damaged. Approximately six feet of the inboard wing, including the engine nacelle, was embedded in the ground on the left side of the fuselage area. The chordline of the wing was approximately perpendicular to the ground. The inboard section of the wing was crushed from the leading edge aft to the main spar, the middle section of the wing was crushed, fragmented, and fire-damaged, and the outboard wing was crushed and separated. The fuel tanks were breached. The main landing gear was damaged and partially extended, and the actuator measurement was consistent with the stowed position. The flap was separated and on the ground adjacent to the trailing edge of the wing. The aileron was separated from its attachments and in two pieces. The aileron cables were separated from the bellcrank arm and separated near the wing root. The bellcrank was damaged and attached to a separated section of wing. The right wing was crushed and fire-damaged. Approximately eight feet of the inboard right wing, including the engine nacelle, was embedded in the ground on the right side of the fuselage area. The chordline of the wing was approximately perpendicular to the ground. The inboard section of the wing was crushed from the leading edge aft to the main spar, and the outboard section of the wing was crushed, fragmented, and fire damaged. The fuel tanks were breached. The main landing gear was damaged and partially extended, the actuator was separated, and its measurement was consistent with the stowed position. The flap was crushed and fire-damaged and was partially attached to the trailing edge of the wing at the outboard hinge. The aileron was separated from its attachments and in two pieces; the inboard section was crushed around a tree near the right wing, and the outboard section was approximately 35 feet west of the fuselage. The aileron control cable and balance cable were separated outboard of the engine mount, and the bellcrank was not located. The vertical stabilizer was crushed, and approximately three feet of the upper section was separated. The rudder was crushed and fire-damaged, and approximately 40 inches of the upper section was separated. The lower section of the rudder was attached to the rudder horn, and the rudder stops were in place. The left rudder cable was attached to the rudder horn, and the right rudder cable was attached to a separated arm of the rudder horn; rudder control cable continuity was established from the horn attachments to a fire-damaged area at the fuselage center. The left inboard section of the stabilator was crushed aft to the spar, and the outboard stabilator with the trim tab was crushed and separated. The right stabilator was crushed and separated at the root with the trim tab attached. Stabilator control cable continuity was established from the balance weight to a fire-damaged area at the fuselage center. The left engine was embedded approximately five feet in the ground. The propeller, hub, and spinner were separated from the crankshaft flange and were found on the ground along the wreckag ## Aircraft - Registration: [N63942](https://openairdocs.org/deregistered/N63942-2015-05-13), registration cancelled 2015-05-13, S/N 27-7854075, built 1978 (OpenAirDocs) - Reported make and model: Piper PA-23-250 - Registry model: [Piper PA-23-250](https://openairdocs.org/model/piper-pa-23-250) (registry code 7102308) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 27-7854075 - Airframe hours: 4760.3 - Engines: Lycoming TIO-540-C4B5 250 horsepower reciprocating; Lycoming IO-540-C4B5 250 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Gordon Larimore Gray III (president Air Mango Ltd) - Registered owner: Air Mango, Ltd. - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 20, 2002 - Departed: KHTO, East Hampton, NY - Destination: KCHS, Charleston, SC - Flight plan: IFR - Airport: KCHS, Charleston International, runway 21, 7,000 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 54; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; toxicology performed; flight hours: 5,500 total ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: 9,000 ft broken - Temperature: 73 °F, dew point 64 °F - Altimeter: 29.95 inHg - Observed at: KCHS, 19 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20031013027509A](https://openairdocs.org/incident/20031013027509A), Oct 13, 2003: Piper PA23250, Cordsville, SC, Destroyed, 1 fatal. (-23) On 11/13/03 larry gray departed (hto) east hampton, NY in his PA-23-250 registration N63942 at around 4PM and filed IFR direct for (chs) charleston, SC.… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.