# NTSB CEN10LA055: Piper PA-28-180, N7736N, Naytahwaush, MN, November 14, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: November 13, 2009, 19:02 local (Nov 14, 2009, 01:02 UTC) - Place: Naytahwaush, MN - Coordinates: 47.255001, -95.507499 - Nearby events: https://openairdocs.org/map.md?lat=47.2550&lon=-95.5075&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report December 20, 2010 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA-MSP-FSDO - NTSB case key (mKey): 75071 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN10LA055 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/75071/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=75071 - Page: https://openairdocs.org/ntsb/CEN10LA055 ## Probable cause The non-instrument rated pilot's decision to continue the flight into known instrument meteorological conditions resulting in spatial disorientation and impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Effect on operation; cases with it: [Piper PA-28-180, 2 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=7102808), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-180, 25 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102808), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-180, 12 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7102808), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401) (defining event); cases with it: [Piper PA-28-180, 8 cases](https://openairdocs.org/ntsb-events/401/sequence.md?model=7102808), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Enroute-cruise: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120); cases with it: [Piper PA-28-180, 14 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7102808), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The non-instrument rated pilot received an outlook weather briefing about 6 hours before the accident flight. The briefer informed the pilot that instrument flight conditions existed and were expected to continue with improvement expected the following day. There were no records of additional weather briefings before the accident flight. Weather and global positioning system data showed that the airplane flew into an area of instrument weather conditions about 210 nautical miles into the 290 nautical mile night cross-country flight. The GPS data showed that in the last minute of the flight the airplane turned left from a heading of about 340 degrees to 300 degrees, followed by a right turn to a heading of 015 degrees which corresponded to the last recorded position. The airplane's average groundspeed during the last 20 seconds of the recorded data was about 120 knots. The recorded cloud base heights at airports near the accident site were as low as 400 feet overcast east of the accident site with higher cloud bases to the west of the accident site. It is likely that the sustained turn sequences while in night instrument meteorological conditions resulted in spatial disorientation. The airplane impacted trees and terrain, and a post-impact fire ensued. No pre-impact anomalies were found with respect to the airplane or its systems. ## Factual narrative HISTORY OF FLIGHT On November 13, 2009, about 1902 central standard time, a Piper PA-28-180, N7736N, piloted by a private pilot, was destroyed by impact forces and a post-impact fire near Naytahwaush, Minnesota. The airplane was on a cross-country flight and impacted trees and the ground about 106 nautical miles from the intended destination. The 14 CFR Part 91 personal flight was operating in instrument meteorological conditions and was not on a flight plan. The pilot, who was the sole occupant, was fatally injured. The airplane departed from the Airlake Airport (LVN) near Lakeville, Minnesota, at 1708 and was en route to the Hallock Municipal Airport (HCO), Hallock, Minnesota. Radar data showed that the accident airplane departed LVN and continued about 330 degrees north-northwest and climbed to a pressure altitude of about 2,300 feet. Due to radar coverage limitations, the radar track only contained data for approximately the first 70 miles of the 335 mile flight. A handheld global positioning system (GPS) receiver was recovered from the airplane. The GPS data showed that the airplane departed LVN and proceeded on a heading of about 330 degrees at an average groundspeed of about 110 knots. The recorded flight path data did not include altitude information. The airplane’s ground track was not a straight line, wavering at times as much as 5 miles either side of a straight line course between LVN and HCO. During the last minute of the flight the airplane turned left from a course of about 340 degrees to 300 degrees, followed by a right turn which continued until the last recorded position. The airplane’s course at that point was about 015 degrees. The last recorded position of the airplane, at 1902:47, was 47-14-07.26 north latitude, 95-08-26.4 west longitude. The airplane's average groundspeed during the last 20 seconds of the recorded data was about 120 knots. The airplane crashed about 184 nautical miles from the departure airport. The approximate distance between LVN and HCO was 290 nautical miles. PERSONNEL INFORMATION The 32-year-old pilot held a private pilot airman certificate with a single engine land airplane rating. He did not have an instrument rating. The pilot successfully completed the practical test for his pilot certificate on October 12, 2009. A family member estimated that the pilot had about 100 hours of total flight experience at the time of the accident. The pilot’s flight logbook was not recovered during the investigation. The pilot also held a third class airman medical certificate issued on March 3, 2009. The medical certificate listed that the pilot must wear corrective lenses when exercising the privileges of his airman certificate. AIRCRAFT INFORMATION The airplane was a 1968 Piper model PA28-180, serial number 28-5179. The airplane was configured to seat 4 occupants including the pilot and was constructed primarily of aluminum. It was a low-wing monoplane and had a fixed tri-cycle landing gear. The airplane’s enginewas a Lycoming O-360 engine rated to produce 180 horsepower. METEOROLOGICAL INFORMATION The accident occurred in a remote area of northern Minnesota. The closest weather reporting stations to the accident site were: Bemidji Regional Airport (BJI), about 33 miles and 55 degrees from the accident; Fosston Municipal Airport (FSE), about 27 miles and 335 degrees from the accident site; Detroit Lakes Airport (DTL), about 33 miles and 212 degrees from the accident site; and Park Rapids Municipal Airport (PKD), about 30 miles and 137 degrees from the accident site. At 1851 the recorded weather at BJI was: Wind 340 at 5 knots; 7 statute miles visibility; overcast clouds at 400 feet above ground level (agl); temperature 4 degrees Celsius (C); dew point 4 degrees C; altimeter setting 29.70 inches of mercury (in-hg). At 1911 the recorded weather at BJI was: Wind 350 at 6 knots; 7 statute miles visibility; overcast clouds at 400 feet agl; temperature 4 degrees C; dew point 4 degrees C; altimeter setting 29.69 in-hg. At 1854 the recorded weather at FSE was: Wind 360 at 4 knots; 10 statute miles visibility; broken clouds at 9,000 feet agl, overcast clouds at 11,000 feet agl; temperature 4 degrees C; dew point 2 degrees C; altimeter setting 29.70 in-hg. At 1914 the recorded weather at FSE was: Wind 360 at 3 knots; 10 statute miles visibility; overcast clouds at 10,000 feet agl; temperature 3 degrees C; dew point 2 degrees C; altimeter setting 29.70 in-hg. At 1856 the recorded weather at DTL was: Wind 350 at 5 knots; 10 statute miles visibility; scattered clouds at 400 feet agl, scattered clouds at 7,500 feet agl; temperature 3 degrees C; dew point 1 degree C; altimeter setting 29.71 in-hg. At 1916 the recorded weather at DTL was: Wind 350 at 5 knots; 10 statute miles visibility; broken clouds at 600 feet agl; temperature 3 degrees C; dew point 1 degree C; altimeter setting 29.71 in-hg. At 1851 the recorded weather at PKD was: Wind 340 at 3 knots; 10 statute miles visibility; broken clouds at 1,000 feet agl, overcast clouds at 1,700 feet agl; temperature 5 degrees C; dew point 3 degrees C; altimeter setting 29.68 in-hg. At 1906 the recorded weather at PKD was: Wind 010 at 6 knots; 10 statute miles visibility; light rain; broken clouds at 800 feet agl, overcast clouds at 1,500 feet agl; temperature 5 degrees C; dew point 3 degrees C; altimeter setting 29.68 in-hg. COMMUNICATIONS At 1047 on the day of the accident, the pilot contacted the Princeton Automated Flight Service Station (FCF/AFSS), and obtained an outlook weather briefing for a visual flight rules (VFR) flight from LVN to HCO at 1800 that day. The AFSS briefer informed the pilot that the route of flight would take the airplane through an area covered by an AIRMET for instrument flight rules (IFR) conditions and that those conditions were expected to continue throughout the day and evening hours. The briefer informed the pilot that the stationary front was expected to be just north of the Minneapolis at1800 and that low clouds were to be expected along and behind the frontal boundary. The briefer informed the pilot that the front was expected to move into western Wisconsin the following morning (November 14, 2009), with improving conditions throughout the following day. No record of additional weather briefings was found. WRECKAGE AND IMPACT INFORMATION The airplane impacted into trees in a remote wooded area. The empennage remained attached to the aft fuselage. The outboard sections of both wings had separated from the inboard wing sections. The cockpit, forward fuselage, and inboard wings were almost totally consumed by the post impact fire. An examination of the airplane did not reveal any apparent pre-impact defects. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on November 19, 2009, at the Fairview University Medical Center Mesabi morgue in Hibbing, Minnesota. The final diagnosis listed multiple severe traumatic injuries and postmortem fire related injuries. A “Final Forensic Toxicology Fatal Accident Report”, prepared by the FAA, was negative for all tests performed. ## Aircraft - Registration: [N7736N](https://openairdocs.org/deregistered/N7736N-2013-05-09), registration cancelled 2013-05-09, S/N 28-5179, built 1968 (OpenAirDocs) - Reported make and model: PIPER PA-28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-5179 - Engines: LYCOMING O-360 SER 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Departed: LVN, Lakeville, MN - Destination: HCO, Hallock, MN ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review October 12, 2009; seat: left; toxicology performed; flight hours: 100 total ## Weather - Conditions: Instrument (IMC), Night - Wind: 340° at 5 knots - Visibility: 7 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 39 °F, dew point 39 °F - Altimeter: 29.70 inHg - Observed at: BJI, 28 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 20091113051809A](https://openairdocs.org/incident/20091113051809A), Nov 13, 2009: Piper PA-28-180, Destroyed, 1 fatal. The aircraft struck a tree while enroute from klvn to khco. The private pilot was not instrument rated and was flying in IMC conditions at night. The local… ## Docket (5 files) The files NTSB released with the investigation on September 16, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=75071. 654 KB in all. - Toxicological Report (item 1, .PDF, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336247&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Downloaded GPS data (item 2, .CSV, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336249&FileExtension=.csv&FileName=Downloaded%20GPS%20data-Master.csv - GPS Plots of accident flight (item 3, .PDF, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336253&FileExtension=.PDF&FileName=GPS%20Plots%20of%20accident%20flight-Master.PDF - Weather information (item 4, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336255&FileExtension=.PDF&FileName=Weather%20information-Master.PDF - Transcript of weather brief (item 5, .PDF, 164 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336257&FileExtension=.PDF&FileName=Transcript%20of%20weather%20brief-Redacted.PDF 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.