# NTSB CEN14FA034: Piper PA 23-250, N6068Y, Caledonia, MN, November 1, 2013 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 1, 2013, 15:15 local (20:15 UTC) - Place: Caledonia, MN - Coordinates: 43.595275, -91.501388 - Nearby events: https://openairdocs.org/map.md?lat=43.5953&lon=-91.5014&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) - Highest injury: Fatal - Injuries: 3 fatal, 1 serious - Status: Completed, report November 5, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA FSDO, Piper Aircraft, Lycoming Aircraft Engines - NTSB case key (mKey): 88371 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14FA034 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88371/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88371 - Page: https://openairdocs.org/ntsb/CEN14FA034 ## Probable cause The pilot's loss of control for reasons that could not be determined because the postaccident airplane examination did not reveal any anomalies that would have precluded normal operation. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Piper PA-23-250, 7 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=7102308), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240); 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: Unknown or undetermined](https://openairdocs.org/ntsb-events/000) (defining event); 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: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-23-250, 16 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102308), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot, a pilot-rated passenger seated in the front right seat, and two additional passengers departed on a cross-country flight in a twin-engine airplane. As they neared an airport, about halfway to their final destination airport, the pilot was cleared by an air traffic controller to conduct an instrument approach to the airport; shortly afterward, the pilot cancelled the clearance. There was no further communication with the pilot. The airplane was found about 590 feet northeast of the runway by a resident who happened to notice the wreckage. Examination of the airframe and engines revealed residual fuel was at the site and in both engines' fuel system components. The landing gear and the flaps were in the retracted positions. The examination did not find any abnormalities with the airframe or engines that would have prevented normal operation. The surviving passenger, who had flown with the pilots on numerous occasions, stated that they would typically stop for a break about halfway to their destination airport, but he could not recall any of the accident details. ## Factual narrative HISTORY OF FLIGHT On November 1, 2013 around 1515 central daylight time (CDT), a Piper Aztec, PA-23-250 airplane, N6068Y, impacted terrain near the Houston County Airport (KCHU), Caledonia, Minnesota. The private rated pilot, a pilot rated passenger, and one passenger were fatally injured; one passenger received serious injuries. The airplane was substantially damaged. The airplane was registered to Garlam Aviation, Troy, Michigan, and operated by a private individual under the provisions of 14 Code of Federal Regulations Part 91 as a cross-country flight. Visual meteorological conditions prevailed and an instrument flight rules (IFR) plan was filed. The flight originated from the Oakland/Troy Airport (KVLL), Troy, Michigan, about 1100 CDT and was en route to KCHU. There were no reported witnesses to the accident; however, a local resident discovered the airplane wreckage and alerted authorities. The surviving passenger later reported that his first recollection was wakening up in the hospital. He stated that he could not remember any details surrounding the accident, nor did he recall any comments made to the first responders. In subsequent conversations with the passenger, he still could not recall any details of the accident; however, he did recall events prior to, and shortly after takeoff. He was the first one to arrive at airport, followed afterwards by the others. The pilots conducted a preflight, opened tanks, went under the wing to sample the fuel, and looked at the airplane. The pilot had sandwiches for everyone; he remembered the airplane taxiing out and the run up, and then flying along. He then remembered waking up in the hospital. PERSONNEL INFORMATION The pilot held a private pilot certificate with ratings for airplane single and multiengine land, and instrument-airplane. The pilot held a third class medical certificate that was issued on June 12, 2013, with the restriction, "must wear corrective lenses". At the time of the exam the pilot reported 400 total flight hours and 3 hours in last six months. The pilot rated passenger held a private pilot certificate with ratings for airplane single and multiengine land, and instrument-airplane. The pilot held a third class medical certificate that was issued June 15, 2012, with the restriction, "must wear lenses for distant, have glasses for near vision". At the time of the exam the pilot reported 2,150 total flight hours and 10 hours in the previous six months. AIRCRAFT INFORMATION The Piper PA-23-250, Aztec, is a twin-engine, low-wing airplane with retractable landing gear, and Hartzell 2-bladed, constant speed, full-feathering propellers. The airplane was powered by two Lycoming IO-540 reciprocating engines. A review of maintenance records revealed the airplane's last annual inspection was on March 12, 2013, with an aircraft time at 4, 768 hrs. The right engine tachometer time read 1,440 hours since overhaul and the left engine tachometer time read 1,108 hours since overhaul.METEOROLOGICAL INFORMATION At 1553, the automated weather observation facility located at the La Crosse Municipal Airport, (KLSE), La Crosse, Wisconsin located about 20 miles northeast of the accident site, reported wind from 320 degrees at 7 knots, visibility 10 miles, a broken ceiling at 3,700 feet, temperature 51 Fahrenheit (F), dew point 38 F, and a barometric pressure of 29.64 inches of mercury. COMMUNICATIONS and RADAR INFORMATION Prior to departure, the pilot contacted a Flight Service Station (FSS) and received a weather briefing for the route of flight. The pilot then filed an IFR flight plan from KVLL to KCHU, with an en route time of two and a half hours and five and a half hours of fuel on board. According to a review of air traffic control communications, prior to reaching KCHU, the pilot was cleared for the GPS-A approach; the pilot canceled his IFR clearance about 1405. There was no further communication with the pilot, nor any reported distress calls. AIRPORT INFORMATION Houston County Airport (KCHU) is a public use airport, located about 3 miles south of Caledonia, Minnesota. The airport is unattended and does not have a control tower; pilots are to use the Common Traffic Advisory Frequency (CTAF). The airport features a single asphalt runway 13-31, which is 3,499-foot long and 77 foot wide. The field elevation is 1,179 feet mean sea level (msl). WRECKAGE AND IMPACT INFORMATION The accident site was located about 590 feet northeast of KCHU's runway, in an open soybean field. The wreckage path consisted of several ground scars and airplane pieces which extended approximately 100 feet from the main wreckage on a 260 degree heading. The first impact point was a ground scar which contained remains of a green navigation light lens. From the first impact point, about 24 feet from the green lens fragments, the ground scar contained several cuts; the next major ground scar contained the airplane's nose baggage door and fragmented pieces of windshield. Both wings had extensive damage, and were twisted in an upward position from the wing roots. The airplane's fuel bladders, located in the wings, were compromised, however, a small amount of fuel was found in the tanks. The left engine and engine mount had mostly separated from, but remained next to, the left wing. The right engine had totally separated from the wing and was located about 15 feet to the right of the main wreckage. The ground scars and wreckage were consistent with the airplane's right wing impact, followed by the right engine and fuselage impact. The airplane came to rest in an upright position, turned about 180-degrees, and facing the first impact point. The landing gear and flaps were in the retracted positions. Control continuity was established from the tail control surfaces to the forward section of the fuselage; aileron continuity was established out to the left and right bellcranks; the right aileron bellcrank had impact damage. MEDICAL AND PATHOLOGICAL INFORMATIONThe Mayo Clinic, Rochester, Minnesota, conducted autopsies on the pilot and pilot rated passenger. The causes of death were determined to be "multiple blunt force injuries". The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology tests on the pilot and pilot rated passenger. These tests were negative for carbon monoxide, ethanol, and tested drugs. TEST AND RESEARCH The wreckage was recovered and examinations of the airplane's engines were conducted. Continuity was established from the front of the crankshaft to the rear gear drive section of each engines, and through their valve trains. The top set of sparkplugs were removed, each engine was rotated by hand; each cylinder produced suction and compression during a thumb test. Both magnetos were removed from each engine; all four rotated freely and produced a spark on each terminal. The engines fuel flow dividers were removed and opened, along with the fuel pumps, and fuel servos. The units contained residual fuel and appeared clear of any contaminants. Both propellers remained attached to their respective engines, and had similar signatures. For identification purposes the propeller blades are referred to as blade A or B. The left engine's propeller blade A appeared straight and absent any polishing or scoring; blade B was bent towards the cambered side, about 12 inches from the hub to about a 45-degree angle. The blade had only minor leading edge polishing near the tip of the blade. The right engine's propeller also had one blade (blade B) bent towards the cambered side, starting about 12 inches from the hub, to about a 45-degree angle. Blade B had only minor leading edge polishing, outboard of the deicing boot. Blade A was relatively straight and absent any scuffs or scoring on the blade. No abnormalities were found that would have prevented the engines from producing rated power. ADDITIONAL INFORMATION The surviving passenger stated that he didn't know why they would be at Caledonia; however, typically they would pick a place about half-way to their destination, to exercise the dogs, use the restroom, and to refuel the airplane. He added that he'd flown with them numerous times, and never observed anything unsafe with the pilots or airplane. The usual routine would be to put the airplane away full of fuel. ## Aircraft - Registration: [N6068Y](https://openairdocs.org/deregistered/N6068Y-2018-01-05), registration cancelled 2018-01-05, S/N 27-3265, built 1966 (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 TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 27-3265 - Year built: 1966 - Engines: LYCOMING IO-540 SER reciprocating; LYCOMING IO-540 SER reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Garlam Aviation Co - Registered owner: Garlam Aviation Co - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 14, 2013, 4,768 hours before - Departed: KVLL, Troy, MI - Destination: KCHU, Caledonia, MN - Flight plan: IFR - Airport: KCHU, Houston County ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: lap only; toxicology performed; flight hours: 357 total - Pilot-rated passenger; age 79; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: right; restraint: lap only; flight hours: 2,150 total ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: 3,700 ft broken - Temperature: 52 °F, dew point 37 °F - Altimeter: 29.63 inHg - Observed at: KLSE, 20 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 20131101020899A](https://openairdocs.org/incident/20131101020899A), Nov 1, 2013: Piper PA-23-250, Caledonia, MN, Destroyed, 3 fatal. Aircraft wreckage was noticed in a field approximately 650 feet northeast of approach end of runway 31 at chu. Aircraft appears to have been travelling in a… ## Docket (14 files) The files NTSB released with the investigation on October 28, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88371. 20.5 MB in all. - Electronic Devices 17 - Specialist's Factual Report (item 1, .PDF, 549 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40407230&FileExtension=.PDF&FileName=Electronic%20Devices%2017%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Overview - Google Earth (item 2, .PDF, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418264&FileExtension=.PDF&FileName=Overview%20-%20Google%20Earth-Master.PDF - Pilot Records Excerpts (item 3, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418265&FileExtension=.PDF&FileName=Pilot%20Records%20Excerpts-Redacted.PDF - Aircraft Maintenance Records Excerpts (item 4, .PDF, 745 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418266&FileExtension=.PDF&FileName=Aircraft%20Maintenance%20Records%20Excerpts-Redacted.PDF - Weather Report (item 5, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418270&FileExtension=.PDF&FileName=Weather%20Report-Master.PDF - Memo - Passenger (item 6, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418276&FileExtension=.PDF&FileName=Memo%20-%20Passenger-Redacted.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 178 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418268&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 57 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418269&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Reports (item 9, .PDF, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418267&FileExtension=.PDF&FileName=Toxicological%20Reports-Master.PDF - Photo 1 - Crash Site Overview (Photo Provided by Private Individual) (item 10, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418271&FileExtension=.PDF&FileName=Photo%201%20-%20Crash%20Site%20Overview%20(Photo%20Provided%20by%20Private%20Individual)-Master.PDF - Photo 2 - Crash Site (Photo Provided by Private Individual) (item 11, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418272&FileExtension=.PDF&FileName=Photo%202%20-%20Crash%20Site%20(Photo%20Provided%20by%20Private%20Individual)-Master.PDF - Photo 3 - Accident Site (Photo Provided by Private Individual) (item 12, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418273&FileExtension=.PDF&FileName=Photo%203%20-%20Accident%20Site%20(Photo%20Provided%20by%20Private%20Individual)-Master.PDF - Photo 4 - Wreckage (item 13, .PDF, 4.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418274&FileExtension=.PDF&FileName=Photo%204%20-%20Wreckage-Master.PDF - Photo 5 - Wreckage Path (item 14, .PDF, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40418275&FileExtension=.PDF&FileName=Photo%205%20-%20Wreckage%20Path-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.