CEN11FA253

NTSB accident investigation · Piper PA46-350P · Monroe, MI · March 29, 2011

Accident · FatalField investigationFinal report
Date
March 29, 2011, 16:04 local (20:04 UTC)
Place
Monroe, MI
Injuries
3 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N619VHPiper PA46-350P
Defining event
Maneuvering-low-alt flying: Part(s) separation from AC
Weather
Visual (VMC) · Day
Status
Completed · report November 26, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
Piper Aircraft, Inc., Lycoming, Federal Aviation Administration
FAA report
20110329010319A
Case key
78711

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

On this page

Probable cause

The pilot's demonstration of poor judgment by attempting a high-speed pass several feet above the runway and his subsequent failure to maintain clearance from the runway.

Findings · 7

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Incorrect use/operationPiper PA 46-350P: 6 casesAll aircraft: 1,310 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Incorrect use/operationPiper PA 46-350P: 15 casesAll aircraft: 1,681 casesProbable cause
Propeller system: propeller blade sectionAircraft › Aircraft propeller/rotor · Damaged/degradedPiper PA 46-350P: 1 caseAll aircraft: 51 casesProbable cause
Aircraft capability: climb capabilityAircraft › Aircraft oper/perf/capability · Attain/maintain not possiblePiper PA 46-350P: 1 caseAll aircraft: 183 casesProbable cause
Aircraft capability: cG/weight distributionAircraft › Aircraft oper/perf/capability · Incorrect use/operationPiper PA 46-350P: 3 casesAll aircraft: 66 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

**This report was modified on 6/10/13. Please see the docket for this accident to view the original report.** While flying an approach, the pilot attempted to contact one of his flight instructors. A witness reported and radar data showed the airplane approaching the runway at a higher-than-normal speed. As the airplane leveled low over the runway, the propeller began striking the runway surface. The damage from repetitive propeller strikes resulted in a loss of the thrust and airspeed necessary for flight. The airplane impacted the ground and subsequently caught fire. The postaccident examination of the wreckage confirmed that the airplane was configured with the landing gear and flaps retracted. No mechanical anomalies were observed that would have precluded normal operation of the airplane. Weight and balance estimates of the airplane indicated that the pilot was operating the airplane outside of its certified weight and center of gravity limits. Forensic toxicology performed on the pilot showed the presence of Hydrocodone and Dihydrocodeine, indicative of the pilot using disqualifying sedating cough or pain medications. These medications can impair performance in high workload environments. The level of medication found in the pilot’s blood at the time of the accident could not be determined. Additionally, Nortriptyline was detected in the pilot’s tissues. While the medications could have had degrading effects on the pilot’s performance, the investigation was not able to determine what role they may have played in the accident sequence.

Factual narrative

HISTORY OF FLIGHT On March 29, 2011, about 1604 eastern daylight time, a Piper PA46-350P, N619VH, impacted a field southeast of the departure end of runway 21 at Custer Airport (TTF), Monroe, Michigan. The certificated private pilot and two passengers were fatally injured. The airplane sustained substantial damage to the fuselage. The airplane was registered to Triple F Aviation LLC and was operated by the pilot under the provisions of 14 CFR Part 91. Visual meteorological conditions prevailed and a flight plan had been filed for the flight that departed from Bedford County Airport, Bedford, Pennsylvania, about 1426, and was en route to TTF. A witness reported that the airplane was unusually low and still flying at a high rate of speed with its landing gear retracted when it flew over Stewart Road. The airplane continued at a high rate of speed as it crossed over the trees adjacent to runway 21. Radar data indicated that the airplane's ground speed was 132 knots, at an altitude of 800 feet, and a heading of 207 degrees when it was about 0.5 miles from runway 21 (4,997 feet by 100 feet, grooved asphalt). A second witness said that the pilot attempted to contact a flight instructor who had previously flown with the pilot while the airplane was approaching TTF. The flight instructor was employed at a TTF fixed base operator and was also a Federal Aviation Administration (FAA) Safety Team (FAAST) Representative. Another witness reported that he saw the airplane in a turn with "little speed." The airplane then "just dropped." The left wing and nose hit the ground simultaneously. PERSONNEL INFORMATION The pilot, age 58, held a private pilot with an instrument rating. He was issued a third class airman medical certificate on December 2, 2009, with the following limitation: "must have available glasses for near vision." At the time of his medical certificate application, he reported a total flight time of 1,600 hours. His last flight review was April 6, 2010. The pilot had no FAA record of previous incidents, accidents, or enforcement actions. AIRCRAFT INFORMATION The 2006 Piper PA46-350P airplane, serial number 4636402, was powered by a Lycoming TIO-540-AE2A engine, serial number L-12591-61A. The airplane was equipped with a Hartzell HC-I13YR-1RF, serial number HK1264B, 3-blade, composite propeller. The airplane had the following maximum weights and center of gravity (CG) range: Ramp weight: 4,358 lbs Takeoff weight: 4,340 lbs Landing weight: 4,123 lbs CG at maximum ramp weight: 144.14 - 147.1 inches According to FAA airman records, the pilot reported a weight of 175 lbs. Department of Motor Vehicle records list the right front passenger weight as 183 lbs and the rear-seat passenger as 207 lbs. The Piper PA46-350P has a usable main fuel tank capacity of 120 gallons. Prior to departure from TTF, the airplane main fuel tanks were topped off and 5 gallons of fuel was added to each wing tip tank. According to Piper Aircraft estimates of airplane weight andbalance, the airplane total weight was 4,474 lbs and with a CG of 142.24 inches when it originated from TTF. With a fuel consumption of 31 gallons, the airplane total weight was 4,288 lbs and a CG of 141.89 inches. These CGs were based upon the rear-seat passenger being seated in the aft most seat. According to a weight and balance form for the airplane dated January 5, 2007, the airplane had a useful load of 1,168.96 lbs. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was conducted by the Office of the Wayne County Medical Examiner, Detroit, Michigan, on March 30, 2011. The cause of death was cited as: '...multiple injuries sustained as a pilot of plane that crashed." The FAA Final Forensic Toxicology Fatal Accident Report reported the following for substances tested: Volatiles - No ethanol detected in urine Atenolol detected in Liver - Atenolol detected in Kidney - 0.082 (ug/mL, ug/g) Dihydrocodeine detected in Urine - 0.216 (ug/ml, ug/g) Hydrocodone detected in Urine - Nortriptyline detected in Liver - Nortriptyline detected in Kidney WRECKAGE AND IMPACT INFORMATION The airplane wreckage was located at global positioning system coordinates and elevation: 41 degrees 55.663 minutes North, 083 degrees 26.041 minutes West or approximately 1,800 feet southeast of the departure end of runway 21. The tail to nose wreckage heading was about 220 degrees. The wreckage exhibited impact and fire damage to the fuselage. Examination of the main wreckage revealed that the landing gear was in the retracted position and the flaps were in the retracted position. The propeller was attached to the hub but was separated at the propeller blade roots. The separation features were consistent with a propeller strike. Examination of runway 21 noted 37 marks within the runway surface consistent with propeller slash marks that began about 2,000 feet down runway 21. Material consistent with the airplane propeller was located in the area of the slash marks. Sixteen slash marks beginning about 2,000 feet down the runway were separated beginning with 21 inches and with a range of about 21 - 29.5 inches. The remainder of the slash mark spacing ranged from about 29.5 to 40 inches. Examination of the wreckage revealed no mechanical anomalies that would have precluded normal operation.

Aircraft

Registration
N619VH
Reported as
Piper PA46-350P
Category
Airplane
Serial number
4636402
Airframe hours
851.2
Engine
Lycoming TIO-540-AE2A, 350 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Part 91
Operator
Pilot
Registered owner
Triple F Aviation LLC
Last inspection
Annual · February 7, 2011
Departed
HMZ · Bedford, PA
Destination
TTF · Monroe, MI
Flight plan
IFR
Airport
TTF · Custer Airport, runway 21, 4,997 × 100 ft, asphalt

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
58
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
April 6, 2010
Seat
Left
Toxicology
Performed
Flight hours
1,600 total

Weather

Conditions
Visual (VMC) · Day
Wind
170° at 6 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
43 °F, dew point 18 °F
Altimeter
30.23 inHg
Observed at
TTF

Docket · 14

The files NTSB released with the investigation on July 31, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.1 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.