# NTSB CEN12FA628: Piper PA-23-250, N4842P, Bullard, TX, September 12, 2012 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: September 12, 2012, 14:55 local (19:55 UTC) - Place: Bullard, TX - Coordinates: 32.1375, -95.432777 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=32.1375&lon=-95.4328&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report January 13, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Federal Aviation Administration, Piper Aircraft Company - NTSB case key (mKey): 85019 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN12FA628 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/85019/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=85019 - Page: https://openairdocs.org/ntsb/CEN12FA628 ## Probable cause The pilot's maneuver, which exceeded the airplane's structural limit and resulted in an in-flight breakup. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Aircraft](https://openairdocs.org/ntsb-findings/01060000): Aircraft › Aircraft oper/perf/capability · Not specified (probable cause); cases with it: [Piper PA-23-250, 1 case](https://openairdocs.org/ntsb-findings/01060000/cases.md?model=7102308), [All aircraft, 63 cases](https://openairdocs.org/ntsb-findings/01060000/cases.md) - [Wing structure](https://openairdocs.org/ntsb-findings/01035700): Aircraft › Aircraft structures · Capability exceeded (probable cause); cases with it: [Piper PA-23-250, 1 case](https://openairdocs.org/ntsb-findings/01035700/cases.md?model=7102308), [All aircraft, 48 cases](https://openairdocs.org/ntsb-findings/01035700/cases.md) - [Action](https://openairdocs.org/ntsb-findings/02041000): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-23-250, 1 case](https://openairdocs.org/ntsb-findings/02041000/cases.md?model=7102308), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02041000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Unknown or undetermined](https://openairdocs.org/ntsb-events/000); cases with it: [Piper PA-23-250, 6 cases](https://openairdocs.org/ntsb-events/000/sequence.md?model=7102308), [All aircraft, 1,703 cases](https://openairdocs.org/ntsb-events/000/sequence.md) - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-23-250, 13 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102308), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Maneuvering: Aircraft structural failure](https://openairdocs.org/ntsb-events/337); cases with it: [Piper PA-23-250, 2 cases](https://openairdocs.org/ntsb-events/337/sequence.md?model=7102308), [All aircraft, 290 cases](https://openairdocs.org/ntsb-events/337/sequence.md) ## Analysis The airplane was en route to its destination when it was observed to make several turns before it pitched nose up, climbed, rolled to the right, and then headed toward the ground nose first. Several witnesses observed airplane components floating down after the airplane. All witnesses reported hearing loud engine noises throughout the event. Impact signatures were consistent with a nose down attitude with a near vertical descent angle. Distribution of the airplane wreckage supported the observation by eyewitnesses of an inflight breakup. An examination found that both wings failed in overload with positive wing loading. In addition, there was no evidence of flight control over travel or flutter. It could not be determined whether the pilot intended to perform the abnormal maneuver or if it was the result of a physiological issue. ## Factual narrative The twin-engine, low wing, six seat, retractable landing gear airplane was manufactured in 1961 with the serial number 27-413. It was powered by two 250-horsepower Lycoming O-540-A1D5 engines driving metal, two-blade, constant speed, Hartzell HC-A2VK-2 propellers. The airplane's last annual inspection was conducted on August 31, 2012, at a total airframe time of 6,076.35 hours. The left engine's starter cable was replaced on the day of the accident. There was no record of any other recent maintenance performed on the airplane. On September 12, 2012, about 1455 central daylight time, a Piper PA-23-250 airplane, N4842P, impacted terrain following an in-flight break-up near Bullard, Texas. The commercial pilot was fatally injured and the airplane was substantially damaged. The airplane was registered to X Aviation LLC, Houston, Texas, and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed for the flight. The flight originated from the David Wayne Hooks Memorial Airport (KDWH), Houston, Texas, about 1355, and was en route to the Tyler Pounds Regional Airport (KTYR), Tyler, Texas. According to eyewitness statements, the airplane approached Lake Palestine, near Bullard, while flying several thousand feet above the ground. The airplane was observed to make several turns, pitched nose up, and climbed. The airplane then rolled to the right and headed toward the ground nose first. Several witnesses observed airplane components floating down after the airplane. All witnesses reported hearing loud engine noises throughout the event. An autopsy was performed on the pilot by Forensic Medical Management Services of Texas as authorized by the Justice of the Peace, Precinct 2, Smith County, Texas. The cause of death was blunt force injuries and the manner of death was ruled an accident. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The specimens provided were negative for ethanol and drugs. At 1453, an automated weather reporting facility at KTYR reported wind from 130 degrees at 11 knots, 10 miles visibility, few clouds at 5,000 feet, temperature 90 degrees Fahrenheit (F), dew point 64 degrees F, and a barometric pressure of 30.03 inches of mercury. The pilot, age 51, held a commercial pilot certificate for airplane single engine land, multi-engine land, and instrument airplane. He was previously issued a flight instructor certificate for airplane single engine which expired on August 31, 1983. On April 5, 2012, the pilot was issued a first class special authorization, interim issuance medical certificate due to hyperthyroidism. A review of the pilot's log book revealed that the pilot had accumulated a total of 937.7 hours, 39.4 hours of multiengine time, and 24.4 hours in the make and model of the accident airplane. He obtained his multiengine land ratingon April 28, 2012. A layout of the airplane's wings and fuselage was conducted. Both wings displayed near symmetric damage and deformation with signatures that both wings failed in overload with positive wing loading. Examination of the empennage did not reveal any signatures of over travel or flutter. The accident site was located on a road near a wooded, residential area. Damage to trees surrounding the accident site was consistent with a steep descent angle. Airplane components were located in several directions from the accident site at distances up to one-half mile. The largest concentration was within a 40 yard radius of the main wreckage, however wing components were scattered to the north and east of the accident site. Ground impact signatures consisted of two impact craters, one for left engine and one for the fuselage. The main wreckage consisted of the fuselage, empennage, rudder, elevators, both engines, and portions of both wings. The odor of fuel was detected at the accident site. The left wing was fragmented outboard of the left engine. The left flap was found at the accident site along with a portion of the left aileron. The left wing tip was found near a lake shore about 175 yards north of the accident site and the inboard portion of the aileron located about 500 yards north of the accident site. The right wing was fragmented outboard of the right engine. The right flap was found 40 yards east of the accident site along with the right aileron. A large section of the right wing was recovered from a lake about 175 yards north of the accident site, with the right wing tip was located 380 yard east of the accident site. Both engines remained attached to the wing mounts. The left engine was fractured in multiple places. The left propeller fractured at the first crankshaft web. One blade displayed leading edge polishing, deep nicks, gouges, and chordwise scratches. The opposite blade had leading edge polishing and chordwise scratches from the blade root to near mid span where it was displayed aft. The right engine's crankcase was fractured in multiple locations. The right propeller hub remained attached to the engine and one blade had fractured from the hub. Both blades displayed curling, leading edges nicks and gouges, and chordwise scratches. Flight control continuity was established from the flight controls to the rudder and elevators, and to the aileron bellcranks. The cockpit section was fragmented, torn, and displaced. The left engine's tachometer displayed 1,650 rpm with a Hobbs time of 315.4 hours and the right engine's tachometer displayed 1,450 rpm with a Hobbs time of 313.8 hours. Most of the other cockpit instruments were unreadable or destroyed. ## Aircraft - Registration: [N4842P](https://openairdocs.org/deregistered/N4842P-2013-06-26), registration cancelled 2013-06-26, S/N 27-413, built 1961 (OpenAirDocs) - Reported make and model: PIPER PA-23-250 - Registry model: [Piper PA-23-250](https://openairdocs.org/model/piper-pa-23-250) (registry code 7102308) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 27-413 - Airframe hours: 6085 - Engines: LYCOMING O-540 SERIES 250 horsepower reciprocating; LYCOMING O-540 SERIES 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 31, 2012, 9 hours before - Departed: KDWH, Houston, TX - Destination: KTYR, Tyler, TX - Flight plan: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: fatal; commercial, flight instructor; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review April 27, 2012; seat: left; toxicology performed; flight hours: 938 total, 24 in this make and model, 792 as pilot in command, 45 in the last 90 days, 14 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 130° at 11 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 90 °F, dew point 64 °F - Altimeter: 30.03 inHg - Observed at: KTYR, 15 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 20120912025339A](https://openairdocs.org/incident/20120912025339A), Sep 12, 2012: Piper PA-23-250, Bullard, TX, Destroyed, 1 fatal. Aircraft departed (dwh) at approx. 1854Z for unknown destination. At approximately 2100Z the aircraft suffered a structural failure of both wings, outboard of… ## Docket (11 files) The files NTSB released with the investigation on November 18, 2013, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=85019. 12.9 MB in all. - Witness Statements (item 1, .PDF, 940 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399091&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Map of Wreckage Distribution (item 2, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399088&FileExtension=.PDF&FileName=Map%20of%20Wreckage%20Distribution-Master.PDF - Photo 1: Wreckage overview (item 3, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399085&FileExtension=.PDF&FileName=Photo%201%3A%20Wreckage%20overview-Master.PDF - Photo 2: Left wing layout (item 4, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399086&FileExtension=.PDF&FileName=Photo%202%3A%20Left%20wing%20layout-Master.PDF - Photo 3: Right wing layout (item 5, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399087&FileExtension=.PDF&FileName=Photo%203%3A%20Right%20wing%20layout-Master.PDF - Photo 4: Left propeller (item 6, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399131&FileExtension=.PDF&FileName=Photo%204%3A%20Left%20propeller-Master.PDF - Photo 4: Right propeller (single blade) (item 7, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399132&FileExtension=.PDF&FileName=Photo%204%3A%20Right%20propeller%20(single%20blade)-Master.PDF - Photo 5: Right propeller (separated blade) (item 8, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40399133&FileExtension=.PDF&FileName=Photo%205%3A%20Right%20propeller%20(separated%20blade)-Master.PDF - Toxicological Report (item 9, .PDF, 315 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40381626&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Statement of Party Representatives to NTSB Investigation: Piper (item 10, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400311&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%3A%20Piper-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 141 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40400573&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-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.