BFO93FA189

NTSB accident investigation · Piper PA-24-250 · Akron, OH · September 29, 1993

Accident · FatalField investigationFinal report
Date
September 29, 1993, 16:30 local (20:30 UTC)
Place
Akron, OH
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Enroute
Aircraft
N6489PPiper PA-24-250
Weather
Visual (VMC) · Day
Status
Completed · report December 2, 1994
Report
Approved by Office Director
FAA report
19930929036939A
Case key
8764

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

Continued flight by the pilot to an altitude that was not appropriate without supplemental oxygen, which resulted in a loss of aircraft control due to hypoxia and subsequently exceeding the design stress limits of the aircraft. Factors related to the accident were: the adverse weather conditions, and continued flight by the pilot into known adverse weather conditions.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Loss of control - in flightCruise
Weather condition - cloudsFactor
Weather condition - rainFactor
Flight into known adverse weather - continuedPilot in commandFactor
Oxygen system - not installed
Proper altitude - exceededPilot in commandCause
Aircraft control - not maintainedPilot in commandCause
Incapacitation(anoxia/hypoxia)Pilot in commandCause
Airframe/component/system failure/malfunctionDescent - uncontrolled
Design stress limits of aircraft - exceededCause
Wing,spar - overload
Wing - separation
Stabilizer - overload
Stabilizer - separation
In flight collision with terrain/waterDescent - uncontrolled

Analysis

During a VFR cross-country, an in-flight breakup of the airplane occurred. Wreckage was scattered over about a 1.5 mile area. There was evidence the right wing failed in positive overload about 9' inboard from the wing tip & struck the right horizontal stabilizer, which separated. No pre-existing defect was noted. The pilot was in contact with cleveland air route traffic control center when he reported an altitude of 16,500' MSL & 'in the soup.' Radar data from center showed the airplane made several altitude & heading excursions during a 30 minute period before the accident. Just before disappearing from radar, the flight track deviated to the right. A witness saw the plane descending minus a large section of one wing after hearing a loud 'pop.' According to federal aviation regulations, no person may operate a civil aircraft at cabin pressure altitudes above 14,000' MSL unless the required minimum flight crew is provided with & uses supplemental oxygen. An exam of the wreckage indicated there was no supplemental oxygen aboard the plane.

Factual narrative

History of flight

On Wednesday, September 29, 1993, at 1630 eastern daylight time, N6489P, a Piper PA-24-250, owned by Aire Austin Inc. of Austin, Minnesota, and piloted by John Pluto of Austin, Minnesota, collided with terrain following an uncontrolled descent at Akron, Ohio. Visual meteorological conditions prevailed at Akron, and a flight plan was not filed. The certificated commercial pilot and his two passengers were fatally injured. The airplane was destroyed. The personal flight was conducted under 14 CFR 91, and had originated in Austin, Minnesota. The destination was Harrisburg, Pennsylvania.

The pilot and passengers were on a VFR (visual flight rules) flight to attend a car show in Hershey, Pennsylvania. He had obtained a weather briefing at Fostoria, Ohio, where he stopped to refuel. According to the briefer, he provided a briefing which indicated rain showers and marginal VFR weather on the pilot's route of flight. He stated that the pilot told him that the tops of the clouds on his flight from Minnesota were 13,000 feet. Radar data obtained from the Cleveland Air Route Traffic Control Center showed the airplane at 17,500 feet and making several turns. The pilot's last transmission to the air traffic controller at Cleveland Center was, "I am at 16,500 feet and in the soup."

Radar data recorded at the Federal Aviation Administration's Cleveland Air Route Traffic Control Center (ARTCC) were obtained for the accident aircraft. The radar data provide the latitude, longitude, and altitude of the airplane for approximately 13 minutes in an area west of the Akron Fulton International Airport. The radar data indicate the airplane's altitude varied from 17,500 feet MSL to 3,800 feet MSL and then began a descending right turn. The last recorded radar return shows the airplane descending through 3,800 feet MSL at a ground speed of over 150 knots. Details of the study are attached to this report.

According to Federal Aviation Regulation FAR 91.211, no person may operate a civil aircraft of U.S. registry at cabin pressure altitudes above 14,000 feet (MSL) unless the required minimum flight crew is provided with and uses supplemental oxygen during the entire flight time at those altitudes.

A witness reported seeing the airplane "coming through the cloud layer...I heard a pop sound then I saw the plane spinning without one wing."

The accident occurred during the hours of daylight, at 41 degrees 3 minutes North and 81 degrees 30 minutes West.

Personnel information

The pilot held a commercial pilot certificate with single and multiengine land ratings. According to FAA records, the pilot's total flight time listed by him on his last FAA medical certificate was "over 1100 hours."

Aircraft information

The 1960 year model Piper PA-24-250 airplane, serial no. 24-1608 was equipped with a Lycoming O-540-A1B5 engine, serial no. L- 2744-40. According to the engine log book, the airplane had accumulated over 2816 hours of total flight time. This time was recorded on the last annual inspection that was completed on January 4, 1993. Examination of the airplane indicated that supplemental oxygen was not installed.

Meteorological information

The 1950 hours surface weather observation for Akron Canton Regional Airport, about 8 miles south of the accident site was as follows:

"Sky condition, 2600 feet scattered; Ceiling, 3500 feet broken; visibility, 7 miles in light rain; temperature, 49 degrees (F); dew point, 42 degrees (F); wind condition, 220 degrees at 6 knots; and altimeter, 30.16 inches."

Wreckage and impact information

The aircraft impacted the ground in a near-vertical attitude and much of the forward section of the aircraft had penetrated the ground. The vertical attitude was confirmed by forward-to-aft compression buckling of the left wing. Some soil had been displaced by the impact and a crater approximately 4 feet deep was created by the aircraft. The wreckage was oriented on a 270 degree magnetic bearing and most of the wreckage was in the crater.

Examination of the wreckage did not determine flight control continuity because of damage. The wreckage was scattered over about a 1.5 mile area. The right wing main spar was bent upward in positive overload approximately 9 feet inboard from the wing tip. Paint transfer from the separated wing onto the right side of the elevator indicated that the separated wing struck a 3 foot section of the right elevator separating it. Both separated wing and elevator sections were located about 1.5 miles from the main wreckage. Sections of the right wing panel, aileron and right flap were found along the wreckage path. Examination of the airframe did not reveal any pre-existing deficiencies.

Examination of the engine revealed that all the cylinders remained attached to the crankcase. The propeller separated and was located in the crater along with the engine. Due to the damage of the engine an examination was not done.

Medical and pathological information

A Medical Examination was done by Dr. William A Cox Medical Examiner for the State of Ohio, on September 30, 1993. According to the Medical Examiner's report, the pilot died as a result of the injuries received in the accident. Toxicological test results were negative for all screened drugs and volatiles.

Additional information

According to the FAA Flight Training Handbook, the characteristics of hypoxia are:

Hypoxia is a condition that results from having insufficient amount of oxygen in the body. There is a tendency to associate hypoxia only with flights at high altitude. Alcohol, many drugs used for medication, and heavy smoking can diminish the blood's ability to absorb oxygen or reduce the body's tolerance to hypoxia. In exposure to altitudes below 10,000 feet, the effects of hypoxia on the pilot are mild and considered acceptable. From 12,000 to 15,000 feet, though, impairment of judgment, memory alertness, and coordination are affected; and headache, drowsiness and either a sense of well-being or of irritability may occur. At cabin-pressure altitudes above 15,000 feet, peripheral vision deteriorates to a point where only central vision remains and cyanosis (blueness) of the finger nails and lips develops.

The wreckage was released to Harold Mesaris of Airco, the adjuster for the insurance carrier, on October 6, 1993.

Aircraft

Registration
N6489P
Reported as
Piper PA-24-250
Category
Airplane
Serial number
24-1608
Engine
Lycoming O-540-A1B5, 250 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Aire Austin Inc.
Registered owner
Aire Austin Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · January 4, 1993
Departed
FZI · Fostoria, OH
Destination
CXY · Harrisburg, PA

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
1,102 total · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
220° at 6 knots
Visibility
7 statute miles
Lowest ceiling
3,500 ft broken
Temperature
48 °F, dew point 43 °F
Altimeter
30.00 inHg
Observed at
CAK, 8 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.