# NTSB ATL93FA162: Piper PA-24-250, N5586P, Boone, NC, September 26, 1993 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 26, 1993, 10:15 local (14:15 UTC) - Place: Boone, NC - Coordinates: 36.200809, -81.659622 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=36.2008&lon=-81.6596&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report December 2, 1994 - Report: Approved by Office Director - NTSB case key (mKey): 3192 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL93FA162 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3192/pdf - Page: https://openairdocs.org/ntsb/ATL93FA162 ## Probable cause The pilot's improper preflight planning, his failure to retract the landing gear after departure, and his failure to maintain control of the aircraft. Factors in the accident were the high density altitude, and the mountainous terrain. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, takeoff - initial climb - weather condition - high density altitude (contributing factor) - aircraft weight and balance - exceeded, pilot in command (cause) - terrain condition - mountainous/hilly (contributing factor) - preflight planning/preparation - improper, pilot in command (cause) - gear retraction - not performed, pilot in command (cause) - stall - inadvertent, pilot in command (cause) - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE DENSITY ALTITUDE AT THE BOONE AIRPORT AT THE TIME OF THE ACCIDENT WAS 5154 FEET MSL. THE AIRCRAFT GROSS WEIGHT AT THE TIME OF THE DEPARTURE WAS 3012.3 POUNDS. THE MAXIMUM GROSS WEIGHT LISTED IN THE PILOT'S HANDBOOK IS 2900 POUNDS. WITNESSES STATED THAT THE AIRCRAFT NEVER CLIMBED MORE THAN 200 FEET ABOVE GROUND LEVEL PRIOR TO THE ACCIDENT. THE WITNESSES STATED THAT AT A POINT ABOUT 1/2 MILE FROM THE DEPARTURE END OF THE RUNWAY THE AIRCRAFT WAS IN A NOSE HIGH ATTITUDE, THE WINGS WERE ROCKING FROM SIDE TO SIDE, AND THE LANDING GEAR WAS STILL IN THE EXTENDED POSITION. THE WITNESSES STATED THAT THE AIRCRAFT'S ALTITUDE WAS BELOW THE TOPS OF THE RIDGE LINE AHEAD, AND THAT JUST PRIOR TO THE RIDGE, THE AIRCRAFT NOSE PITCHED UP TO NEAR VERTICAL, THE AIRCRAFT BANKED SHARPLY TO THE RIGHT, THE NOSE DROPPED, AND IMPACTED THE TERRAIN IN A NEAR VERTICAL NOSE DOWN ATTITUDE. THE LANDING GEAR WAS FOUND TO BE IN THE DOWN AND LOCKED POSITION. ## Factual narrative HISTORY OF FLIGHT On September 26, 1993, at about 1015 eastern daylight time, a Piper PA-24-250, N5586P, was destroyed following a collision with terrain immediately after take off from the Boone-Blowing Rock Airport in Boone, North Carolina. Both private pilots and their two passengers were fatally injured in the accident. The aircraft was being operated under 14 CFR Part 91 by the pilot. Visual meteorological conditions existed at the time, and no flight plan had been filed for the personal flight. The intended destination of the flight was Dayton, Ohio. Witnesses stated that the aircraft did not climb more than 200 feet above the ground after takeoff. They stated that the aircraft landing gear was still in the extended position at a point 1/2 mile past the departure end of the runway. The aircraft was below the top of the mountain ridge ahead of the aircraft. The witnesses stated that the aircraft wings appeared to rock back and forth after takeoff, and the nose pitched up to a near vertical attitude as the aircraft approached the ridge line. Then the aircraft banked to the right, the nose dropped, and impacted the terrain in a near vertical nose down position. The aircraft impacted the terrain approximately nine tenths of a mile off the departure end of Runway 31. PERSONNEL INFORMATION The pilot in the left front seat, Mr. Gerald L. Coon, held a private pilot certificate with airplane single engine land and instrument airplane ratings. Mr. Coon held a Class 3 Medical Certificate dated March 3, 1992. Mr. Coon's medical application dated March 3, 1992, indicated a total flight time of 1500 hours. No other record of Mr. Coon's flight experience was made available. The pilot in the right front seat, Mr.Fred C. Everly, held a private pilot certificate with airplane single engine land rating. Mr. Everly held a Class 3 Medical Certificate dated July 27, 1992. Mr. Everly's medical application dated July 27, 1992 indicated a total flight time of 104 hours. No other record of Mr. Everly's flight experience was made available. It could not be determined who was operating the controls of the aircraft at the time of the accident. Additional personnel information may be obtained in this report on page 3 under section titled First Pilot Information, and in Supplement E attached to this report. AIRCRAFT INFORMATION The Piper Comanche PA-24-250 Owner's Handbook lists a maximum gross weight for the aircraft of 2,900 pounds. The estimated gross weight of the aircraft at the time of the accident was 3,012.3 pounds.(See Weight and Balance Computations Below.) Weight and Balance Computations for N5586P on September 26, 1993. ITEM Weight Arm Moment Aircraft 1705.3 84.1 143404.6 Engine Oil 17.0 28.0 476.0 Fuel(56 Gal. INBD)* 336.0 90.0 30240.0 Fuel(20 Gal. OBD)* 120.0 95.0 11400.0 Pilot(Front LT.)** 165.0 84.8 13992.0 Pilot(Front RT.)** 188.0 84.8 15942.4 Rear Passengers(2)** 283.0 118.5 33535.5 Baggage*** 198.0 142.0 28116.0 Total 3012.3 91.99 277106.5 * Fuel Quantities Are Estimated Amounts Needed For Flight From Boone, North Carolina To Dayton, Ohio Including VFR Reserve. ** Pilot And Passenger Weights Taken After Accident. *** Actual Baggage Weight At Time Of Accident. The Owner's Handbook shows that the aircraft, at 2,900 pounds gross weight and with landing gear retracted, would be capable of climbing at a rate of approximately 950 feet per minute, at a density altitude of 5,194 feet.(See Copy of Section Four of The Pilot's Handbook Titled Rate of Climb vs Density Altitude Attached to This Report.) The owner's handbook does not indicate, and the manufacturer does not have data to indicate what the reduction in climb performance would be with a gross weight of 3012 pounds and with the landing gear extended. METEOROLOGICAL INFORMATION Witnesses in the area stated that the temperature, at the time of the accident, was about 85 degrees.(See Record of Interview Attached to This Report.) The density altitude at the time of the accident was 5,194 feet, mean sea level. Additional meteorological information may be obtained in this report on pages 3 and 4 under section titled Weather Information. AERODROME INFORMATION The Boone Airport is a private airport located in the mountainous terrain of northwestern North Carolina. It is at an elevation of approximately 3,200 feet above sea level with mountains as high as 4,660 feet above mean sea level surrounding the airport. The airport has one asphalt runway with a magnetic heading of 330 degrees and 150 degrees. The runway is 2,100 feet in length and 75 feet in width. WRECKAGE AND IMPACT INFORMATION The aircraft impacted the mountainous terrain at an altitude of 3,233 feet mean sea level, and approximately 700 feet below the top of the mountain ridge line. The fuselage of the aircraft was broken just aft of the passenger section, and the roof of the passenger section was torn away from the point of attachment at the windshield. There was continuity of the rudder and elevator control cables into the cabin area of the aircraft. Both left and right wings exhibited extensive chordwise leading edge crushing from the wing attach points outward to the wing tips. The right wing was broken, and held attached by electrical cables, at a point about 3 feet inboard of the wing tip. There was continuity of the aileron cables into the cabin area of the aircraft. The flaps were in the retracted position. The aircraft landing gear was found to be in the down and locked position. There was extensive chordwise scratching and twisting toward low pitch of the propeller blades. The engine spark plugs appeared normal in color when compared to a spark plug analysis chart. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of Mr. Coon was performed by Dr. Nordstrom of the Office of Chief Medical Examiner of North Carolina in Chapel Hill, North Carolina. The report of toxicological examination of Mr. Coon was negative for the presence of ethanol and drugs. An autopsy of Mr. Everly was performed by Dr. Nordstrom of the Office of Chief Medical Examiner of North Carolina in Chapel Hill, North Carolina. The report of toxicological examination of Mr. Everly was negative for the presence of ethanol and drugs. ADDITIONAL INFORMATION There were 198 pounds of luggage on board the aircraft at the time of the accident. The airport operator reported that the he had topped off the main fuel tanks in accordance with directions of the pilot. He stated that 33 gallons of fuel was used to fill the tanks.(See Record of Interview Attached to This Report.) The aircraft wreckage was released to insurance adjuster, Mr. James T. Bowie of THG Inflight Aviation on September 27, 1993. ## Aircraft - Registration: [N5586P](https://openairdocs.org/deregistered/N5586P-1994-05-02), registration cancelled 1994-05-02, S/N 24650 (OpenAirDocs) - Reported make and model: PIPER PA-24-250 - Registry model: [Piper PA-24-250](https://openairdocs.org/model/piper-pa-24-250) (registry code 7102404) (OpenAirDocs) - Category: Airplane - Serial number: 24-650 - Airframe hours: 2648 - Engines: LYCOMING O-540-A1A5 250 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Coon, Gerald L. - Registered owner: Kadon Corporation - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 27, 1993, 39 hours before - Destination: DAY, DAYTON, OH - Airport: NONE, Boone, runway 33, 2,100 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 1,500 total ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 4 knots - Visibility: 15 statute miles - Lowest ceiling: none - Temperature: 81 °F, dew point 61 °F - Altimeter: 30.00 inHg - Observed at: AVL, 50 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 19930926036419A](https://openairdocs.org/incident/19930926036419A), Sep 26, 1993: Piper PA24250, Boone, NC, Destroyed, 4 fatal. Over gross. High ambient temperature. Slow wobbly climb. Below ridge. Nosed up stalled. Impacted in vertical dive. 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.