CEN11FA263

NTSB accident investigation · Piper PA-32R-300 · Fredricktown, MO · March 29, 2011

Accident · FatalField investigationFinal report
Date
March 29, 2011
Place
Fredricktown, MO
Injuries
3 fatal
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N4085FPiper PA-32R-300
Defining event
Enroute-cruise: Controlled flight into terr/obj (CFIT)
Weather
Night
Status
Completed · report November 5, 2012
Report
Approved by Office Director
NTSB office
Central Region
Parties
Federal Aviation Administration, Lycoming Engines, Piper Aircraft Corp.
Case key
78753

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

The pilot's decision to attempt to maintain visual flight by descending below an area of deteriorating forecast weather to an altitude that did not provide adequate terrain clearance.

Findings · 4

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 · Not attained/maintainedPiper PA-32R-300: 6 casesAll aircraft: 1,310 casesProbable cause
Personnel issuesPersonnel issues › Miscellaneous · PilotPiper PA-32R-300: 1 caseAll aircraft: 29 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

The airplane was reported missing and global positioning system data showed that it descended below 1,700 feet mean sea level (msl) 11 nautical miles south-southwest of the accident site. The airplane impacted rising terrain at an elevation of about 1,353 feet msl while on a north-northeasterly heading. The airplane configuration and the wreckage path were consistent with an impact while the airplane was in cruise flight. The pilot was not instrument rated, and the airplane's descent was likely the pilot's attempt at maintaining visual conditions at night by flying below a forecast ceiling. The pilot's airman medical certificate issued in 2007 had expired. He had disqualifying heart disease that had not been reported to or evaluated by the Federal Aviation Administration. The pilot's recent flight experience and the airplane's maintenance history could not be determined due to the unavailability of current logbooks. Postaccident examination of the airplane revealed no mechanical anomalies that would have precluded normal operation.

Factual narrative

HISTORY OF FLIGHT On March 29, 2011, the wreckage of a Piper PA-32R-300, N4085F, was found in a wooded area about 9 miles west-southwest of Fredricktown, Missouri, after an alert notice was issued due to a family concern of a missing aircraft on March 28, 2011. The non instrument rated private pilot and two passengers were fatally injured. The airplane sustained substantial damage to the fuselage and wings. The airplane was registered to Neplusultra Corp and operated by the pilot under the provisions of 14 CFR Part 91 flight. Night marginal visual meteorological conditions prevailed at the time of the accident. The flight originated from Flagler County Airport, Palm Coast, Florida, and was en route to Chippewa Valley Regional Airport, Eau Claire, Wisconsin. An invoice from a fixed base operator (FBO) at Ormond Beach Municipal Airport (OMN), Ormond Beach, Florida, dated March 26, 2011, at 1034 eastern daylight time, showed a charge for a tie down for N4085F. A credit card receipt from the same FBO, dated March 26, 2011, at 1353 eastern daylight time, showed a charge for 67 gallons of 100 low lead fuel charged to Neplusultra Corp. There was no contact with N4085F for weather and flight plan services in the 45 days preceding the accident. There was also no Direct User Access Terminal Service access for these services. PERSONNEL INFORMATION The pilot, age 61, was issued a private pilot certificate with an airplane single-engine land rating, which was followed by the issuance of a multi-engine land ratings on January 15, 1977. The pilot was last issued an airman medical certificate dated September 27, 2007. At that time, he reported his total pilot flight time as 2,900 hours and his flight time in the past 6 months as 20 hours. Pilot logbooks were requested from the pilot's family by the Federal Aviation Administration (FAA). The pilot logbooks were not received following the request. AIRCRAFT INFORMATION The 1976 Piper PA-32R-300, serial number 32R-7680427, was registered to Neplusultra Corp. The airplane was powered by a Lycoming IO-540-K1G5, serial number L-18419-48A, engine. The aircraft logbooks were requested from the pilot's family by the FAA. The aircraft logbooks were not received following the request. METEOROLOGICAL INFORMATION The Chicago (CHIC) Aviation Area Forecast (FA) issued March 26, 2011, at 2045 central daylight time (CDT), and was valid for clouds and weather until March 27, 2011, at 0900 CDT. The CHIC FA outlook was valid for March 27, 2011, from 0900 to 1500 CDT. The CHIC FA included northwestern (NWRN), southwestern (SWRN), northeastern (NERN), and southeastern (SERN) sections of Missouri. The forecast for these sections were as follows: NWRN: overcast - 3,000 feet mean sea level (MSL); cloud tops - 15,000 feet MSL. At 0700: broken - 15,000 MSL; cloud tops - flight level 180. Outlook is visual flight rules (VFR). SWRN: overcast - 3,000 feet MSL; cloud tops - 15,000 MSL; visibility 3 statute miles (SM), mist. Outlook was forinstrument flight rules (IFR) due to ceiling and mist. At 1100 conditions becoming marginal visual flight rules due to ceilings and mist. NERN: overcast - 8,000 feet MSL; cloud tops - 15,000 feet MSL. Outlook was VFR. SERN: overcast - 2,000 feet MSL; cloud tops - 15,000 feet MSL; visibility - 3 to 5 SM; mist. Outlook was IFR due to ceilings. The Farmington Regional Airport (FAM), Farmington, Missouri, automated weather observing system (AWOS), was located about 15 nautical miles (NM) and 020 degrees from the accident site, at an elevation of about 946 feet MSL. On March 27, 2011, FAM AWOS recorded the following observations: 0035 CDT: visibility - 10 SM; overcast - 800 feet above ground level (AGL) 0055 CDT: visibility - 10 SM; scattered - 800 feet AGL; broken - 1,500 feet AGL; overcast - 5,500 feet AGL 0115 CDT: visibility - 10 SM; few - 800 feet above ground level AGL; scattered - 1,500 feet AGL; overcast - 5,500 feet AGL 0135 CDT: visibility - 10 SM; scattered - 1,000 feet AGL; broken - 1,600 feet AGL; overcast - 5,500 feet AGL 0155 CDT: visibility - 10 SM; broken - 1,000 feet AGL; overcast - 5,500 feet AGL 0215 CDT: visibility - 10 SM; overcast - 1,000 feet AGL 0235 CDT: visibility - 10 SM; broken - 1,000 feet AGL The Cape Girardeau Regional Airport (CGI), Cape Girardeau, Missouri, automated surface observing system (ASOS) was located about 54 NM and about 105 degrees from the accident site, at an elevation of about 342 feet MSL. On March 27, 2011, CGI ASOS recorded the following observations: 0008 CDT: visibility - 10 SM; overcast - 1,400 feet AGL 0053 CDT: visibility - 10 SM; overcast - 1,400 feet AGL 0113 CDT: visibility - 10 SM; overcast - 1,600 feet AGL 0153 CDT: visibility - 10 SM; broken - 1,600 feet AGL MEDICAL AND PATHOLOGICAL INFORMATION The pilot's airman medical certificate dated September 27, 2007, was a third class medical certificate with the following limitation: must wear corrective lenses. A review of the pilot's FAA airman medical records revealed that the pilot had an expired medical certificate. A review of the pilot's autopsy revealed that he had disqualifying heart disease that had not been reported to or evaluated by the FAA. An autopsy of the pilot was conducted by the Madison County Coroner on April 3, 2011. The pathologist's opinion was that the pilot died as a result of multiple injuries resulting from a plane crash. The FAA Final Forensic Toxicology Fatal Accident Report of the pilot was negative for all substances tested. WRECKAGE AND IMPACT INFORMATION The wreckage path was about 180 feet in length along an approximate heading of 028 degrees. The elevation of the main wreckage was about 1,338 feet MSL. The fuselage was in an upright position and was oriented on a tail to nose heading of about 152 degrees. The engine was separated from the airplane. The fuselage exhibited a post crash fire. The landing gear was in the retracted position, and the flap actuator extension equated to a flaps retracted position. Thesouthwestern end of the wreckage path consisted of broken tree tops estimated to be approximately 30 feet in height. There were pieces of airplane structure embedded in the tree tops. The elevation of the southwestern most tree that exhibited impact damage was about 1,325 feet MSL. The northeastern edge of the wreckage path was at an elevation of about 1,353 feet MSL. Both propeller blades were attached to the propeller hub and engine. The propeller blades exhibited S-shaped bending and chordwise twisting consistent with engine power during impact. One propeller blade was loose in the hub, and the other propeller blade exhibited leading edge damage, both of which were consistent with impact damage. Examination of the flight control system confirmed flight control continuity of all the control surfaces to the cockpit controls. The left and right wing fuel caps were in place. The outboard wing tank sections were broken open and exhibited fire damage. The cockpit fuel selector was positioned to the left fuel tank. The engine driven fuel pump was rotated by hand and a liquid consistent in smell with 100 low lead (100LL) aviation fuel was discharged. A liquid consistent in smell with 100LL was present in the fuel line from the fuel pump to the fuel servo, in the fuel line from the fuel servo to the fuel manifold/flow divider, and within the fuel manifold/flow divider. The fuel servo screen was unobstructed. Borescope examination of the cylinder assemblies revealed no mechanical anomalies. The engine was rotated by turning the propeller with the top spark plugs removed. Air was drawn into and expelled through the top spark plug holes. Engine, engine valve train, and engine accessory section continuity was confirmed. The engine oil filter did not have a date of installation nor an engine time at installation of the oil filter annotated on it. The engine oil filter element did not contain debris. The engine oil suction screen did not contain debris. The propeller governor was separated from the engine and exhibited impact damage. Examination of the governor oil screen revealed no debris. The ignition harness sustained impact damage. Both magnetos were rotated by hand and were able to generate a spark upon rotation. The engine driven instrument pneumatic pump was attached to engine. The pump was removed from the engine and rotated by hand using the pump's drive coupling, which was unbroken. During rotation, air was expelled from its outlet. The emergency locater transmitter (ELT) was found along the debris path. The ELT housing was broken apart and its internal components were not found. TESTS AND RESEARCH A Garmin GPSMAP 296 hand-portable GPS unit was recovered from the airplane wreckage and downloaded by the National Transportation Safety Board Vehicle Recorder Division. Recorded GPS data showed that the last calculated velocity and direction of travel was 128 knot ground speed with a track of 0.7 degrees magnetic approximately 11 NM west ofFredricktown, Missouri. The GPS altitude showed a descent below approximately 1,700 feet to 1,374 feet.

Aircraft

Registration
N4085F
Reported as
Piper PA-32R-300
Category
Airplane
Serial number
32R-7680427
Engine
Lycoming IO-540 SER, 300 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Part 91
Operator
Pilot
Registered owner
Neplusultra Corp
Airworthiness certificate
Standard, Normal
Departed
XFL · Palm Coast, FL
Destination
EAU · Eau Claire, WI

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
61
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land, Multi-engine land
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
2,900 total

Weather

Conditions
Night
Wind
20° at 7 knots
Visibility
10 statute miles
Lowest ceiling
1,000 ft broken
Temperature
30 °F, dew point 27 °F
Altimeter
30.02 inHg
Observed at
FAM, 15 nm away

Docket · 12

The files NTSB released with the investigation on August 14, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.9 MB in all.