# NTSB CEN11LA399: Piper PA-36-300, N57885, Highmore, SD, June 17, 2011 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: June 17, 2011, 12:00 local (17:00 UTC) - Place: Highmore, SD - Coordinates: 44.572223, -99.39167 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.5722&lon=-99.3917&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report May 3, 2012 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA-RAP-FSDO - NTSB case key (mKey): 80806 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11LA399 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/80806/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=80806 - Page: https://openairdocs.org/ntsb/CEN11LA399 ## Probable cause The pilot did not maintain control of the airplane while maneuvering at low altitude. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-36-300, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103612), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-36-300, 1 case](https://openairdocs.org/ntsb-events/240/sequence.md?model=7103612), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-36-300, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103612), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot departed for the flight to spray a field located about 4 miles north of the airport. When the pilot did not return within the expected time frame, the operator sent airplanes out to look for him. The wreckage was located in an open field about 1/4 mile from the field that was being sprayed. No witnesses to the accident were identified; however, one person reported seeing the airplane spraying in the area. Impact damage indicated that the airplane struck the terrain in a steep nose-down, left-wing-low attitude, consistent with a loss of control event. Postaccident examination of the airplane revealed no evidence of any failures or malfunctions with either the airframe or engine that would have precluded normal operation. ## Factual narrative HISTORY OF FLIGHT On June 17, 2011, at 1200 central daylight time, a Piper PA-36-300, N57885, operated by Wilbur-Ellis, collided with the terrain following a loss of control in Highmore, South Dakota. The commercial pilot received fatal injuries. The airplane received substantial damage. The aerial application flight was operating under 14 Code of Federal Regulations Part 137. Visual meteorological conditions prevailed and no flight plan was filed. The flight originated from the Highmore Municipal Airport, Highmore, South Dakota, about 1130. The operator stated the pilot departed for the flight to spray a 40 acre plot located about 4 miles north of the airport. When the pilot did not return within the expected 30 to 40 minute time frame, the operator sent two airplanes out to look for him. The wreckage was located at 1230. There are no known witnesses to the accident; however, a local farmer reported seeing the airplane spraying in the area. PERSONNEL INFORMATION The pilot, age 31, held a commercial pilot certificate with airplane single-engine land and instrument-airplane ratings. He held a second-class medical certificate issued March 1, 2010. The medical certificate contained a limitation that the pilot must wear corrective lenses. The pilot’s logbook contained entries dated between March 30, 2001, and March 24, 2011. According to the logbook the pilot had a total flight time of about 916 hours, of which, 71 hours were in the accident make and model of airplane. The pilot had worked for Wilbur-Ellis for approximately 1 1/2 years prior to the accident. AIRCRAFT INFORMATION The single-seat, low-wing, conventional-gear airplane, serial number 36-7760046, was manufactured in 1977. The airplane was registered to the operator. The total time on the airframe at the time of the accident was not determined. However, the airplane had an annual inspection completed on June 1, 2011, at which time the total airframe time was recorded as being 2,848 hours. The airplane was powered by a 300-horsepower, Lycoming IO-540-K1G5 engine, serial number L-21944-48A. The factory overhauled engine was installed in the airplane on July 18, 1994. The last annual inspection performed on the engine was on June 1, 2011. The time since major overhaul listed at the time of the inspection was 900 hours. The airplane was equipped with a SATLOC Airstar global positioning system. The M-3 box which records and stores historical track data was not located after the accident. METEOROLOGICAL INFORMATION A review of the recorded surface observation weather data from the Pierre Regional Airport (PIR), Pierre, South Dakota, located 50 miles west of the accident site, revealed conditions at 1153 were: wind from 250 at 14 knots gusting to 23 knots; visibility 10 miles; few clouds at 3,100 feet above ground level; temperature 23 degrees Celsius; dew point 16 degree Celsius; and altimeter setting 29.65 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was located in an openfield about one quarter mile east of the field that the pilot was spraying. The initial impact resulted in 1 1/2 foot deep crater in the ground. The engine was separated from the airframe and located near the initial ground impact. The airplane was located about 30 feet beyond the engine. Both of the main gear separated from the airframe and were located beyond the main wreckage. The airplane came to rest on its left side. The cockpit and forward fuselage area sustained substantial impact damage. The empennage remained attached to the fuselage. The horizontal stabilizer, elevator, vertical stabilizer, and rudder received minor impact damage. Both wings remained partially attached to the fuselage. A substantial amount of impact damage was visible along the leading edge of both wings. The right wing tip sustained minor impact damage and it was partially attached to the wing. The right wing aileron and flap remained attached to the wing. The left wing tip was crushed. The left wing strobe and navigation lights were located near the initial impact mark. The left wing flap remained attached to the wing. The left wing aileron was separated from the wing and it was located near the main wreckage. Control cable continuity was established to the elevator, rudder, and right aileron. The left aileron control cable continuity was established from the cockpit to the wing. The engine sustained substantial impact damage. The engine crankshaft could not be fully rotated by hand due to impact damage along with the bending and twisting of the propeller blades. Both magnetos were removed from the engine for examination. The left magneto produced a spark on all terminals when rotated by hand. The right magneto sustained impact damage and would not produce a spark. The magneto was opened and it was determined that the insulator on the contact point assembly was fractured. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on June 20, 2011, by the clinical Laboratory of the Black Hills, Rapid City, South Dakota. The final diagnosis was reported as multiple blunt force injuries, cardiomegaly, and hepatic steatosis. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol or drugs were found in the blood. ## Aircraft - Registration: [N57885](https://openairdocs.org/deregistered/N57885-2011-12-22), registration cancelled 2011-12-22, S/N 36-7760046, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA-36-300 - Registry model: [Piper PA-36-300](https://openairdocs.org/model/piper-pa-36-300) (registry code 7103612) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 36-7760046 - Airframe hours: 2848 - Engines: LYCOMING IO-540 SER 300 horsepower reciprocating - Damage: Substantial damage - Flight: Aerial application, Part 137 - Operator: Wilbur-Ellis - Registered owner: Wilbur-Ellis - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, June 1, 2011 - Departed: Highmore, SD - Destination: Highmore, SD ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 31; injuries: fatal; commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review March 8, 2010; seat: center; toxicology performed; flight hours: 916 total, 71 in this make and model, 787 as pilot in command ## Weather - Conditions: Visual (VMC), Day - Wind: 250° at 14 knots, gusting 23 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 73 °F, dew point 61 °F - Altimeter: 29.64 inHg - Observed at: PIR, 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 20110617016529A](https://openairdocs.org/incident/20110617016529A), Jun 17, 2011: Piper PA-36-300, Highmore, SD, Destroyed, 1 fatal. On June 17, 2011, pilot [privacy data omitted] took off in N57885, a Piper PA-36-300 for an aerial application flight. The field he was spraying was… ## Docket (11 files) The files NTSB released with the investigation on April 2, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=80806. 9.2 MB in all. - FAA Inspector's Statement (item 1, .PDF, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364817&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Redacted.PDF - Toxicological Report (item 2, .PDF, 69 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40364818&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Retention / Release of Wreckage Form (item 3, .PDF, 48 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40365020&FileExtension=.PDF&FileName=Retention%20%2F%20Release%20of%20Wreckage%20Form-Master.PDF - Photo 01. Main Wreckage of N57885 (item 4, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363422&FileExtension=.PDF&FileName=Photo%2001.%20Main%20Wreckage%20of%20N57885-Master.PDF - Photo 02. Main Wreckage of N57885 (item 5, .PDF, 873 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363424&FileExtension=.PDF&FileName=Photo%2002.%20%20Main%20Wreckage%20of%20N57885-Master.PDF - Photo 03. Front View of N57885 (item 6, .PDF, 897 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363425&FileExtension=.PDF&FileName=Photo%2003.%20%20Front%20View%20of%20N57885-Master.PDF - Photo 04. Main Wreckage of N57885 (item 7, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363426&FileExtension=.PDF&FileName=Photo%2004.%20%20Main%20Wreckage%20of%20N57885-Master.PDF - Photo 05. Main Wreckage of N57885 (item 8, .PDF, 785 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363427&FileExtension=.PDF&FileName=Photo%2005.%20%20Main%20Wreckage%20of%20N57885-Master.PDF - Photo 06. Main Wreckage of N57885 (item 9, .PDF, 878 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363429&FileExtension=.PDF&FileName=Photo%2006.%20%20Main%20Wreckage%20of%20N57885-Master.PDF - Photo 07. Engine and Main Wreckage of N57885 (item 10, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363430&FileExtension=.PDF&FileName=Photo%2007.%20%20Engine%20and%20Main%20Wreckage%20of%20N57885-Master.PDF - Photo 08. Engine - N57885 (item 11, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40363431&FileExtension=.PDF&FileName=Photo%2008.%20%20Engine%20-%20N57885-Master.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.