CEN15FA181

NTSB accident investigation · Piper J-4A · Pine River, MN · March 28, 2015

Accident · FatalField investigationFinal report
Date
March 27, 2015, 18:35 local (Mar 28, 2015, 00:35 UTC)
Place
Pine River, MN
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N30341Piper J-4A
Defining event
Takeoff: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed · report December 7, 2016
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA
FAA report
20150327003499A
Case key
90942

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot' failure to maintain adequate airspeed after takeoff, which resulted in the airplane's wing exceeding its critical angle-of-attack and a subsequent aerodynamic stall. Contributing to the accident was the pilot's decision to conduct the flight without obtaining a flight review or refresher training.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Experience/qualifications: recent experiencePersonnel issues › Experience/knowledge · PilotPiper J4A: 1 caseAll aircraft: 76 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper J4A: 4 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper J4A: 1 caseAll aircraft: 1,681 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Capability exceededPiper J4A: 1 caseAll aircraft: 990 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot was making a local personal flight. One witness who saw the airplane just after it became airborne reported that it sounded normal but that it was flying at a low altitude and a slow speed over the runway. Several witnesses reported seeing the airplane flying around treetop level with the wings "wobbling" back and forth. According to these witnesses, the airplane banked to the left, its nose rose, and then the airplane entered a descending spiral. Examination of the accident site, which was located about 0.25 miles from the departure end of the runway, indicated that the airplane impacted the terrain in an open field in a nose-down attitude. A review of the pilot's logbook revealed that he did not have a current flight review nor had he logged any flights in the past 1.5 years. A postaccident examination of the airplane did not reveal any failure or malfunction of the flight controls, even though its annual inspection was overdue by 1 year 8 months. Debris was found in both the engine's oil and fuel screens; however, the amount of debris was not enough to have caused a loss of engine power. No airframe or engine anomalies were observed that would have precluded normal operations. The witness observations and the airplane's nose-down attitude at impact are consistent with the pilot allowing the airspeed to decrease to the point where the wing's critical angle-of-attack was exceeded. As a result, the airplane entered an aerodynamic stall and departed controlled flight. It is likely that the pilot's lack of recent flight experience contributed to his failure to maintain adequate airspeed. If he had obtained a flight review or refresher training before making the flight, the accident may have been prevented.

Factual narrative

The accident airplane was a 1940 Piper J4A, serial number 4-1168. It was a single engine, high wing, two-place airplane with fixed conventional landing gear. The fuselage and wings were fabric covered. The airplane was previously owned by the pilot's father and the pilot became a co-owner of the airplane in July 2011. The pilot had signed off as having performed the most recent annual inspection on the airplane and engine. The tachometer time at the time of the accident was 1,273.86. A review of the aircraft logbook showed the last annual inspection was conducted on July 9, 2012, at a tachometer time of 1,267.2 hours and aircraft total time of 2,860.2 hours. The airplane had been flown 6.66 hours since this last inspection. According to the logbook, the annual last inspection was dated August 1, 1991. The airplane was equipped with a 65-horsepower, Continental A65-8F engine. The engine logbook contained an entry dated July 9, 2012, stating that the engine was disassembled and overhauled. The tachometer time was listed as being 1,267.2 hours with a 0 time since overhaul. On March 27, 2015, at 1835 central standard time, a Piper J-4A airplane, N30341, collided with the terrain shortly after takeoff from the Pine River Regional Airport (PWC), Pine River, Minnesota. The private pilot and passenger were both fatally injured. The airplane was substantially damaged. 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 operated on a flight plan. The local flight was originating at the time of the accident. A pilot who had landed at the airport just prior to the accident reported she heard the airplane as it took off and that it sounded "normal for an older plane." She stated the airplane was very low above the runway with the wings wobbling back and forth. This witness also stated the ground speed was very slow, perhaps 20 miles per hour. She stated the wings stopped rocking for a bit, but the airplane remained slow and just above the treeline as it crossed Highway 1 at the south end of the runway. The witness stated she looked away and heard an unusual noise just before the airplane impacted the ground. Another witness reported seeing the airplane flying toward the south just after it took off. This witness reported it was very noticeable that the airplane was "wobbling" back and forth at a low altitude. Once the airplane reached Highway 1, it banked to the left and the nose rose. The nose then descended and the airplane entered a nose dive to the ground. Numerous witnesses reported seeing the airplane at a low altitude, with the wings "wobbling" before it banked left and descended to the ground. An autopsy of the pilot was performed on March 28, 2015, at the Ramsey County Medical Examiner's Office, Saint Paul, Minnesota. The autopsy report attributed the death to multiple traumatic injuries.A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute, Oklahoma City, Oklahoma. The results for tests performed were negative with the exception of: Ephedrine detected in Urine Ephedrine NOT detected in Blood (Cavity) Pseudoephedrine detected in Urine Pseudoephedrine detected in Blood (Cavity) Weather conditions recorded at PWC at 1834 were: Wind from 150 degrees at 4 knots; visibility 10 miles or greater; ceiling 8,000 feet overcast; temperature 0 degrees Celsius; dew point -13 degrees Celsius; altimeter 30.13 inches of mercury. The pilot, age 43, held a private pilot certificate with airplane single-engine land rating, issued on June 13, 2000. The pilot was issued a third-class medical certificate on September 27, 2013. This certificate did not contain any limitations. The pilot also held an airframe and powerplant mechanic certificate. The pilot's logbook was reviewed during the investigation. The logbook contained entries from August 26, 1999 through September 29, 2013. The pilot's total flight time was listed as 428.1 hours with 6.7 hours in the accident airplane make and model. The pilot's family stated the last time he flew, that they were aware of, was in 2013 and that the pilot was good about logging his flight time. The most recent flight review signoff in the pilot's logbook was dated April 6, 2012. The airplane impacted an open field about 1/4 mile from the departure end and 20 degrees to the left of the extended centerline of runway 16. Damage to the airplane and ground scars indicate the airplane was in a nose down, left wing low attitude when it impacted the terrain. Both wings, the forward fuselage, and cockpit sustained impact damage. The nose of the airplane impacted the terrain pushing the engine, firewall, and instrument panel rearward into the cockpit area. The floor of the cockpit was crushed upward. The fuselage, aft of the cockpit seats, was intact with minor bending of the tubular frame. The empennage was intact. The right wing was bent downward, but it remained attached to the fuselage. The outboard leading edge of the right wing was flattened aft by impact forces. The inboard leading edge of the wing at the fuselage was crushed aft. This area contained yellow paint transfers indicating that it contacted the engine cowling where the transfer of red paint was visible. The lift struts remained attached to the fuselage. The remainder of the wing sustained little impact damage. According to local authorities, the left wing of the airplane was partially separated from the fuselage attach point. Both lift struts were separated from the fuselage. First responders removed the wing and cut the aileron control cables to gain access to the occupants. The left wing sustained impact damage along the entire length of the wing. A ground scar was visible that correlated with the left wing tip. The outboard section of the left wing was bent up and rearward. The fuel tank was ruptured. Firstresponders reported that fuel was leaking from the tank. There was an odor of fuel around the accident site the day after the accident. Flight control cable continuity was established from the cockpit flight controls to their respective flight control surfaces. The propeller remained attached to the engine crankshaft. One propeller blade was bent aft was lying under the engine. The other blade was straight. Both blades exhibited minor chordwise scratches. Neither blade exhibited any twisting. The fuel selector was in the on position. The rear of the engine sustained impact damage. The firewall was crushed into the rear of the engine. The oil tank, magnetos, and exhaust tubes and muffler sustained impact damage. Half of the housing case on each magneto was missing which prevented testing the magnetos. However, a visual inspection revealed that other than impact damage, the magnetos appeared capable of normal operation. The top spark plugs were removed from the cylinders. The number 4 spark plug was fractured from impact damage. The plugs appeared to be normal with light carbon deposits. The oil dipstick indicated just below 4 quarts of oil in the oil sump which was crushed, but not ruptured. The oil screen was removed and a moderate amount of metal particles were on the screen and inside the screen housing. There was no indication that the engine suffered from a lack of lubrication. The propeller was turned by hand. Thumb compression and suction were noted on all of the cylinders. Continuity was established from the front of the engine rearward to the magneto drive gears. Continuity was also established to the cylinder valve springs and rocker arms. The carburetor was removed from the engine and examined. The throttle valve control arm linkage remained intact and attached to the carburetor. The throttle plate was intact and operable. The metal float was secured and intact. Approximately 1 ounce of fuel was drained from the carburetor bowl. The fuel was pale yellow in color, which appeared to be automotive fuel. The fuel did not contain any debris. The thumb screen was removed. Both the screen and the screen housing contained debris, although not enough to have completely blocked the fuel flow. The exhaust system sustained impact damage. The muffler sustained impact damage which matched the impact damage on the surrounding muffler shroud.

Aircraft

Registration
N30341
Reported as
Piper J-4A
Category
Airplane
Serial number
4-1168
Built
1940
Airframe hours
2,870
Engine
Cont Motor A-65-8, 65 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 9, 2012 · 10 hours before
Departed
PWC · Pine River, MN
Destination
PWC · Pine River, MN
Airport
PWC · Pine River Regional Airport, runway 16, 3,000 × 75 ft, asphalt
Equipment
None

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
43
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
April 6, 2012
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
428.1 total · 6.6 in this make and model · 387.7 as pilot in command · 0 in the last 90 days · 0 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
150° at 4 knots
Visibility
10 statute miles
Lowest ceiling
8,000 ft overcast
Temperature
32 °F, dew point 9 °F
Altimeter
30.12 inHg
Observed at
PWC, 5 nm away

Docket · 6

The files NTSB released with the investigation on November 23, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 10.3 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.