# NTSB CEN14FA084: Piper PA 24-250, N8037P, Collbran, CO, December 12, 2013 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 12, 2013, 11:55 local (18:55 UTC) - Place: Collbran, CO - Coordinates: 39.228889, -107.67694 - Nearby events: https://openairdocs.org/map.md?lat=39.2289&lon=-107.6769&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering-low-alt flying: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report September 8, 2014 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Lycoming Engines, Piper Aircraft, FAA - NTSB case key (mKey): 88547 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN14FA084 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/88547/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=88547 - Page: https://openairdocs.org/ntsb/CEN14FA084 ## Probable cause The pilot’s failure to maintain adequate airspeed while maneuvering at a low altitude, which resulted in an aerodynamic stall/spin and subsequent impact with terrain. ## 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-24-250, 34 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102404), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Health/Fitness: use of medication/drugs](https://openairdocs.org/ntsb-findings/02013020): Personnel issues › Physical · Pilot; cases with it: [Piper PA-24-250, 1 case](https://openairdocs.org/ntsb-findings/02013020/cases.md?model=7102404), [All aircraft, 73 cases](https://openairdocs.org/ntsb-findings/02013020/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-24-250, 12 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7102404), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/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: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Piper PA-24-250, 12 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7102404), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Maneuvering-low-alt flying: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Piper PA-24-250, 22 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102404), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Unknown: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-24-250, 55 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102404), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot was flying the airplane with two passengers on board to search for lost cattle in mountainous terrain. Witnesses observed the airplane maneuvering at a low altitude. The airplane was reported overdue, and the wreckage was subsequently located in a sparsely wooded area. An onboard GPS unit recorded the accident flight and depicted the airplane flying several north and south legs at altitudes ranging between 300 and 500 feet above ground level before the recording ended. The airplane impacted terrain in an extreme nose-low attitude with lateral distortion of the empennage. A postaccident examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. The wreckage evidence indicated that the pilot likely failed to maintain adequate airspeed while maneuvering at a low altitude, which resulted in an inadvertent aerodynamic stall/spin and subsequent impact with terrain. Toxicology testing revealed the presence of tetrahydrocannabinol in the lung and tetrahydrocannabinol carboxylic acid in the liver and lung, which suggested the recent use of marijuana; however, insufficient evidence existed to determine whether the pilot was impaired by its use at the time of the accident. ## Factual narrative HISTORY OF FLIGHT On December 12, 2013, about 1155 mountain standard time, a Piper PA-24-250 airplane, N8037P, impacted terrain near Collbran, Colorado. The private pilot and two passengers were fatally injured. The airplane was substantially damaged. The airplane was registered to 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, which operated without a flight plan. The local flight originated from the Mack Mesa Airport (10CO), Mack, Colorado, about 1115. The pilot was flying two passengers to search for lost cattle. The airplane was observed by residents to be maneuvering at low altitude. There were no witnesses to the accident sequence. The airplane was reported as overdue and an alert notification (ALNOT) was issued. The airplane wreckage was located about 0100 on December 13, 2013. The airplane impacted a sparsely wooded area with rising terrain in the distance. PERSONNEL INFORMATION The pilot, age 49, held a private pilot certificate for airplane single engine land. On October 17, 2013, he was issued an unrestricted third class medical. On his medical application, the pilot reported an evaluation for back pain that was resolved with no further pain and full function. A review of the pilot's logbook showed the pilot accumulated 545.6 hours of total time with about 200-300 hours in make and model. The pilot's most recent flight review was accomplished on January 26, 2012, in the accident airplane. AIRCRAFT INFORMATION The single engine, low wing, Piper PA-24-250 airplane, serial number 24-3284, was manufactured in 1962. A 250-horsepower Lycoming IO-540-C1B5 engine, serial number L-388-48, powered the airplane and drove a 2-blade, metal, Hartzell HCA2VK1 propeller. A review of airframe and engine logbooks revealed that the airplane's most recent inspection was a combined 100 hour and annual inspection performed on October 10, 2013, at a total airframe and engine time of 4,086.6 hours, tachometer time of 247.2 hours, and 177.4 hours since the engine's last overhaul. METEROLOGICAL INFORMATION At 1153, an automated weather reporting facility located at the Garfield County Regional Airport (RIL), Rifle, Colorado, located 19 miles to the northwest, reported a calm wind, visibility 10 miles, a clear sky, temperature 16° Fahrenheit (F), dew point 9° F, and a barometric pressure of 30.43 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was located in a sparely wooded area about 15 miles east of Collbran, Colorado, at a measured altitude of 8,188 feet. The airplane came to rest upright with the front of the airplane aligned on a 200 degree magnetic heading. The engine and propeller were submerged in the snow packed ground and could not be accessed on site. The fuselage was broken at the firewall and the remainder of the airplane remained intact. Both wings exhibited nearly symmetrical, rearward"accordion-style" crushing. The right wing, outboard of the flap, was bent upwards near 45 degrees. The empennage was buckled in several locations and distorted about 15 degrees to the right. The vertical and horizontal stabilizers, rudder, and elevator were unremarkable. Flight control continuity was established from the flight control to all control surfaces. A majority of the cockpit instruments and controls were impact damaged. The mixture, throttle, and propeller control were in the full forward positions. The flaps were found in the retracted position. The manifold pressure gage read 16.5 inches. The tachometer displayed 249 hours. The fuel selector was found selecting the left main fuel tank; however, impact damage to the fuel selector precluded determining the switch position prior to impact. The left main tank or left auxiliary tank was opened and no fuel was detected. An undetermined amount of fuel was found in the right main tank and right auxiliary tank. No fuel stain or smell was present underneath the airplane's wings. During recovery, months later, no fuel was found in any of the tanks. The airplane was recovered to private property and was examined by the NTSB with assistance from a representative from Lycoming engines. Continuity and thumb compression were established to all cylinders. Both magnetos produced spark at each lead. All oil and fuel screens were found clear and unobstructed. No anomalies were detected with the engine. Both propeller blades displayed leading edge polishing and chordwise scratches. One of the blades was bent nearly 90 degrees aft just outboard of the blade root. The other blade remained nearly straight. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was conducted on the pilot by the Pathology Group, Grand Junction, Colorado, as authorized by the Mesa County Coroner's Office. The cause of death was the result of multiple blunt force injures and the manner of death was ruled an accident. The autopsy noted that found in the pilot's pants pocket was a small container of a "green, leafy material suggestive of marijuana." The substance was not tested to confirm its identity. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. Testing noted the following: Liver unsuitable for analysis of Tetrahydrocannabinol (Marihuana) 0.3474 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Lung 0.0039 (ug/ml, ug/g) Tetrahydrocannabinol (Marihuana) detected in Blood (Cavity) 0.0628 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Liver 0.017 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Lung 0.0096 (ug/ml, ug/g) Tetrahydrocannabinol Carboxylic Acid (Marihuana) detected in Blood (Cavity) The specimens were not obtained from sources which could accurately determine the pilot's pre-mortem blood levels of the detected substances. The levels detected in the lungs suggestrecent use, but an accurate time frame could not be determined. ADDITIONAL INFORMATION Purpose of Flight According to an associate of the pilot, the flight was conducted in order to search for missing cattle. The flight was supposed to be conducted in a two-seat Piper PA-22-108 by another pilot and one passenger. For undetermined reasons, the parameters of the flight changed and the pilot flew the two passengers in the 4- seat Piper PA-24-250. It is possible that the inclusion of a second passenger necessitated an airplane with increased occupant capacity. The pilot intended to be compensated for the flight, however the pilot did not possess a commercial pilot certificate. Garmin GPSMap 496 A Garmin GPSMap 496 was found in the wreckage. The GPS was sent to the NTSB Laboratories in Washington, D.C., for data extraction. The device contained numerous flights including the accident flight. Data points recorded the airplane as in departed the Mack Mesa Airport at 1115. The airplane flew east and remained about 4,000 feet above ground level as the terrain elevation increased. At 1138, the airplane crossed over the Vega Reservoir about 11,600 feet, and continued to the southeast about 10 miles before flying several north-south legs east of Porter Mountain. The airplane altitude varied between 300-500 feet above ground level and the airspeed between 97-139 knots. The last recorded GPS point occurred at 1155:07 at an altitude of 8,525 feet, airspeed of 136 knots, and an approximate heading of 295 degrees. This last point was approximately 1.4 miles northeast of the accident site. ## Aircraft - Registration: [N8037P](https://openairdocs.org/deregistered/N8037P-2014-06-26), registration cancelled 2014-06-26, S/N 24-3284, built 1962 (OpenAirDocs) - Reported make and model: PIPER PA 24-250 - Registry model: [Piper PA-24-250](https://openairdocs.org/model/piper-pa-24-250) (registry code 7102404) (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: 24-3284 - Year built: 1962 - Airframe hours: 4087 - Engines: LYCOMING TIO-540-C1B5 310 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, October 10, 2013, 1.6 hours before - Departed: 10CO, Mack, CO - Destination: 10CO, Mack, CO - Equipment: Handheld GPS ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 49; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review January 26, 2012; seat: left; restraint: lap only; toxicology performed; flight hours: 545.5 total, 300 in this make and model, 12 in the last 90 days, 0 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 16 °F, dew point 9 °F - Altimeter: 30.43 inHg - Observed at: KRIL, 19 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 20131212024069A](https://openairdocs.org/incident/20131212024069A), Dec 12, 2013: Piper PA-24-250, Collbran, CO, Destroyed, 3 fatal. Due to the state and location of the aircraft, we are unable to determine exactly what happened at this time. Aircraft will be retrieved via helicopter and the… ## Docket (11 files) The files NTSB released with the investigation on August 25, 2014, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=88547. 7.3 MB in all. - GPS Factual Report (item 1, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415611&FileExtension=.PDF&FileName=GPS%20Factual%20Report-Master.PDF - GPS Factual Report - Attachment 1 .csv (item 2, .CSV, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415612&FileExtension=.csv&FileName=GPS%20Factual%20Report%20-%20Attachment%201%20.csv-Master.csv - Flight Overview (item 3, .PDF, 1 photo, 329 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415613&FileExtension=.PDF&FileName=Flight%20Overview-Master.PDF - Final Portion of Flight (item 4, .PDF, 1 photo, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415614&FileExtension=.PDF&FileName=Final%20Portion%20of%20Flight-Master.PDF - EAA Notes About Recovery (item 5, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415621&FileExtension=.PDF&FileName=EAA%20Notes%20About%20Recovery-Redacted.PDF - Party Forms (item 6, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415626&FileExtension=.PDF&FileName=Party%20Forms-Redacted.PDF - Toxicology Report (item 7, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415619&FileExtension=.PDF&FileName=Toxicology%20Report-Redacted.PDF - Photo 1 - Front of Wreckage (item 8, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415615&FileExtension=.PDF&FileName=Photo%201%20-%20Front%20of%20Wreckage-Master.PDF - Photo 2 - Side View of Wreckage (item 9, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415616&FileExtension=.PDF&FileName=Photo%202%20-%20Side%20View%20of%20Wreckage-Master.PDF - Photo 3 - Propeller Blade A (item 10, .PDF, 756 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415617&FileExtension=.PDF&FileName=Photo%203%20-%20Propeller%20Blade%20A-Master.PDF - Photo 4 - Propeller Blade B (item 11, .PDF, 677 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40415618&FileExtension=.PDF&FileName=Photo%204%20-%20Propeller%20Blade%20B-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.