# NTSB CEN12FA158: Piper PA-28-180, N4824L, Osborn, MO, February 14, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 14, 2012, 16:30 local (22:30 UTC) - Place: Osborn, MO - Coordinates: 39.701389, -94.400833 - Nearby events: https://openairdocs.org/map.md?lat=39.7014&lon=-94.4008&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report June 24, 2013 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA-Kansas City FSDO - NTSB case key (mKey): 82901 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12FA158 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82901/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82901 - Page: https://openairdocs.org/ntsb/CEN12FA158 ## Probable cause The pilot’s decision to conduct low-level passes above a residence and his failure to maintain sufficient altitude. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [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) - [Object/animal/substance: tree(s)](https://openairdocs.org/ntsb-findings/03022020): Environmental issues › Physical environment · Effect on equipment; cases with it: [Piper PA-28-180, 14 cases](https://openairdocs.org/ntsb-findings/03022020/cases.md?model=7102808), [All aircraft, 933 cases](https://openairdocs.org/ntsb-findings/03022020/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: Low altitude operation/event](https://openairdocs.org/ntsb-events/220) (defining event); cases with it: [Piper PA-28-180, 3 cases](https://openairdocs.org/ntsb-events/220/sequence.md?model=7102808), [All aircraft, 780 cases](https://openairdocs.org/ntsb-events/220/sequence.md) - [Maneuvering-low-alt flying: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-180, 96 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102808), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The airplane was observed making two low-level (just above tree level) passes in front of a witness’s house. The witness made a video recording of the first pass. She reported seeing and hearing the airplane strike trees on the second pass before impacting the ground. An on-scene examination revealed airplane and tree damage consistent with the witness’s description of events. Examination of the airplane’s wreckage revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. ## Factual narrative HISTORY OF FLIGHT On February 14, 2012, about 1630 central standard time, a Piper PA-28-180, N4824L, impacted trees and terrain while maneuvering near Osborn, Missouri. The pilot and passenger were fatally injured. The airplane sustained substantial damage to the fuselage and both wings. The aircraft was registered to and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight, which was not on a flight plan. The flight originated from the East Kansas City Airport (3GV), Grain Valley, Missouri, at an undetermined time. A witness that lived in the house on the property where the accident took place reported that her husband called and told her that a friend would be flying by in an airplane. She said that she heard a small plane operating near the house and went outside. The witness reported that the airplane approached from the southeast, banked around the house and passed in front of the house just east of the trees that were in front of the house. She said that the airplane then circled behind the house and made a second pass. As the airplane was making the second pass, the witness heard the airplane hit two trees and then saw the airplane strike the ground and cartwheel into a small field north of the house. The witness had used the video recording capabilities of her cellular telephone to record the airplane in flight and provided a copy of the recording for use in the investigation. The recorded video showed the accident airplane making a low-level flight past the front of the house; however, the video did not capture the accident sequence. In the video, the airplane appeared to be just above treetop level traveling from the south to the north. After passing the house, the airplane began a right turn at which point the recording ended. PERSONNEL INFORMATION The 68 year old pilot held a commercial pilot certificate with airplane single-engine land, airplane multiengine land, airplane single-engine seaplane, glider, and instrument airplane ratings issued on September 25, 2008. He was issued a third-class airman medical certificate, with a restriction for glasses for near vision, on December 27, 2010. A review of the pilot’s flight logbooks indicated that he had accumulated 5,798 hours total flight experience. His most recent flight review as required by 14 CFR Part 61.56 was accomplished on January 4, 2011. AIRCRAFT INFORMATION The accident airplane was a Piper model PA-28-180, serial number 28-4166. It was a four-place, low wing, single engine airplane, with a tricycle landing gear configuration. The airplane was powered by a 180-horsepower Lycoming O-360 four-cylinder, reciprocating engine. The airplane’s most recent annual inspection was completed on July 8, 2011. The total airframe time was not recorded in the logbook entry for that date. The previous annual inspection was completed on June 12, 2010, and the total airframe time asof that date was 1,876.27 hours. METEOROLOGICAL INFORMATION Weather conditions recorded by the Rosecrans Memorial Airport, St. Joseph, Missouri, Automated Surface Observing System (ASOS), located about 25 miles west of the accident site, at 1653, were; wind from 180 degrees at 6 knots, visibility 10 miles, broken clouds at 11,000 feet above ground level, temperature 7 degrees Celsius, dew point 1 degree Celsius, and altimeter 29.86 inches of mercury. WRECKAGE AND IMPACT INFORMATION The airplane impacted trees and an open agricultural field adjacent to a house in a rural area. A broken tree limb was observed and was estimated to be about 25 feet above the ground. The main wreckage of the airplane came to rest about 350 feet north of the last tree impacted. The airplane’s right wing was separated from the fuselage at the root and came to rest between the last tree impacted and the main wreckage. The flap and aileron remained attached to the wing and the outboard 5 feet of the wing was crushed rearward. There was a semi-circular indentation about one foot inboard from the wing tip that was consistent with a tree impact. The indentation had crushed the leading edge rearward to a depth of about one-half of the wing's chord. The remainder of the airplane came to rest with the fuselage inverted. The left wing was partially separated from the fuselage and was lying parallel to the bottom of the fuselage. The tail surfaces remained attached to the aft fuselage and appeared undamaged. The cabin section of the fuselage had been partially consumed by a post-impact fire. The engine and propeller remained attached to the airframe. Examination of the control system confirmed continuity from the cockpit area to the tail surfaces. Continuity of the aileron control system revealed breaks in the control cables; however, all of the cable breaks exhibited signatures consistent with overstress. Examination of the airplane’s wreckage revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was performed at the First Call Morgue, Kansas City, Kansas, on February 16, 2012. The pilot's death was attributed to injuries received in the accident. Toxicology testing was performed by the FAA Civil Aerospace Medical Institute. Testing results found 2.31 ug/ml cyanide detected in the pilot’s blood. This finding was consistent with post mortem diffusion resulting from the post-impact fire. All other tests were negative for substances in the screening profile. ## Aircraft - Registration: [N4824L](https://openairdocs.org/deregistered/N4824L-2017-10-19), registration cancelled 2017-10-19, S/N 28-4166, built 1967 (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: 28-4166 - Engines: LYCOMING O-360 180 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 8, 2011 - Departed: 3GV, Grain Valley, MO - Destination: 3GV, Grain Valley, MO ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; commercial; airplane ratings: single-engine land, single-engine sea, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; last flight review January 4, 2011; seat: left; toxicology performed; flight hours: 5,798 total ## Weather - Conditions: Visual (VMC), Day - Wind: 180° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: 11,000 ft broken - Temperature: 45 °F, dew point 34 °F - Altimeter: 29.86 inHg - Observed at: STJ, 25 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 20120214002179A](https://openairdocs.org/incident/20120214002179A), Feb 14, 2012: Piper PA-28-180, Osborn, MO, Destroyed, 2 fatal. Pilot and passenger were conducting a fly-by at a farm owned by friends of the passenger. After completing one circuit around the house at low altitude, the… ## Docket (8 files) The files NTSB released with the investigation on April 30, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82901. 13.6 MB in all. - Summary of video of accident airplane (item 1, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391460&FileExtension=.PDF&FileName=Summary%20of%20video%20of%20accident%20airplane-Master.PDF - Toxicological Report (item 2, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391462&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Photo 1 - Overview of accident site (item 3, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391465&FileExtension=.PDF&FileName=Photo%201%20-%20Overview%20of%20accident%20site-Master.PDF - Photo 2 - View of right wing (item 4, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391569&FileExtension=.PDF&FileName=Photo%202%20-%20View%20of%20right%20wing-Master.PDF - Photo 3 - View of fuselage (right side) (item 5, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391467&FileExtension=.PDF&FileName=Photo%203%20-%20View%20of%20fuselage%20(right%20side)-Master.PDF - Photo 4 - View of fuselage (left side) and left wing (item 6, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391468&FileExtension=.PDF&FileName=Photo%204%20-%20View%20of%20fuselage%20(left%20side)%20and%20left%20wing-Master.PDF - Photo 5 - View of tree (item 7, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391471&FileExtension=.PDF&FileName=Photo%205%20-%20View%20of%20tree-Master.PDF - Sheriff's report and witness statements (item 8, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40391486&FileExtension=.PDF&FileName=Sheriff%27s%20report%20and%20witness%20statements-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.