# NTSB CEN16FA212: Piper PA 28-140, N6223W, Wishek, ND, June 9, 2016 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 9, 2016, 15:21 local (20:21 UTC) - Place: Wishek, ND - Coordinates: 46.24472, -99.544723 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=46.2447&lon=-99.5447&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report January 9, 2018 - Report: Approved by Office Director - NTSB office: Central Region - Parties: Lycoming Engines, Flight Standards District Office, Piper Aircraft Inc - NTSB case key (mKey): 93353 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN16FA212 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93353/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93353 - Page: https://openairdocs.org/ntsb/CEN16FA212 ## Probable cause The pilot's failure to maintain adequate airspeed during a climbing turn after takeoff, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall. Contributing to the accident was the pilot's self-induced pressure to quickly transport his cousin for urgent dental care. ## 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-28-140, 103 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102802), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters](https://openairdocs.org/ntsb-findings/01062000): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28-140, 7 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md?model=7102802), [All aircraft, 1,269 cases](https://openairdocs.org/ntsb-findings/01062000/cases.md) - [Personality/attitude: motivation/respond to pressure](https://openairdocs.org/ntsb-findings/02021025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28-140, 2 cases](https://openairdocs.org/ntsb-findings/02021025/cases.md?model=7102802), [All aircraft, 53 cases](https://openairdocs.org/ntsb-findings/02021025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28-140, 44 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102802), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot was flying his aunt and cousin to a location where his cousin could receive urgent dental care. The pilot was a member of the flying club that owned the airplane, and another member of the flying club reported that he thought that the pilot and his passengers were rushing as they prepared to leave. A witness located on the airport ramp saw the airplane take off, climb with a nose-high attitude, turn right, and rapidly pitch down to a nose-low attitude. The airplane was found in a lake 1/2 mile from the airport. Downloaded data from an onboard GPS navigation device were consistent with the observations of the witness and indicated that the airplane began to turn right at 160 ft above ground level with a groundspeed of 48 knots. The right turn continued for 20 seconds during which time the airplane climbed about 40 ft and its groundspeed ranged from 53 to 59 knots. The airplane then rapidly descended into the lake. The damage to the airplane indicated that it impacted the lake in a near-vertical, nose-down attitude with low forward velocity. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The GPS data, the witness report, and the damage to the airplane were consistent with the pilot failing to maintain sufficient airspeed during a climbing turn after takeoff, which resulted in the airplane's wing exceeding its critical angle of attack and an aerodynamic stall. The purpose of the flight was for an urgent medical issue. The pilot's rushed activities before flight, and his actions immediately after takeoff to enter a climbing turn at low altitude without ensuring sufficient airspeed, are consistent with the effects of self-induced pressure. ## Factual narrative The airplane was manufactured in 1964 and was equipped with a Lycoming O-320-E3D engine and a Sensenich two-blade, all-metal propeller. On April 1, 2016, the airplane underwent an annual inspection at an airframe total time of 3,459 hours and 1,235 hours since the engine had last been overhauled. The accident occurred about 21 hours after this inspection. The airplane was equipped with a red stall warning light on the instrument panel but was not equipped with a stall warning horn. The flaps-retracted stall speeds listed in the airplane's flight manual were 64 mph (calibrated airspeed) at 0° of bank and 73 mph (calibrated airspeed) at 40° of bank, which equates to 56 knots at 0° of bank and 64 knots at 40° of bank. These stall speeds were based on a maximum gross weight of 2,150 pounds. At the time of the accident, the airplane's weight was estimated to be about 300 pounds less than maximum gross weight. On June 9, 2016, about 1521 central daylight time, a Piper PA-28-140 airplane, N6223W, impacted a lake while departing from Wishek Municipal Airport (6L5), Wishek, North Dakota. The pilot and two passengers were fatally injured, and the airplane was substantially damaged. The airplane was registered to the Cherokee Flying Club and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions existed at the time of the accident. The personal flight departed without a flight plan and was destined for Bismarck Municipal Airport (BIS), Bismarck, North Dakota. According to the pilot's parents, the pilot was flying his aunt and cousin to Bismarck so that his cousin could receive urgent dental care. The pilot was a member of the flying club that owned the airplane. Another member of the club, who spoke with the pilot about 10 minutes before the airplane's departure, reported that he thought that the pilot and passengers were rushing as they prepared to leave. A witness located on the airport ramp saw the airplane depart on runway 14 and climb out with a nose-high attitude. According to the witness, after entering a right turn, the airplane rapidly pitched down to a nose-low attitude. Downloaded data from a portable GPS navigation device found in the airplane revealed that the airplane made a right turn after takeoff at 160 ft above ground level and 48 knots groundspeed. The right turn continued for the next 20 seconds during which time the airplane climbed about 30 ft and its groundspeed was between 53 and 59 knots. During the next 8 seconds, the airplane rapidly descended about 200 ft and impacted a lake about 1/2 mile southwest of the airport. On June 10, 2016, the North Dakota Department of Health medical examiner in Bismarck, North Dakota performed an autopsy on the pilot. The cause of death was blunt force injuries with drowning. The FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma performed toxicology tests on the pilot. The results were negative for alltests conducted. At 1552, the weather observation station at BIS, located about 60 miles northwest of the accident site, reported the following conditions: wind 160° at 6 knots, 10 miles visibility, clear skies, temperature 33°C, dew point 15°C, and altimeter setting 29.67 inches of mercury. The pilot, age 20, held a private pilot certificate with an airplane single-engine land rating, which was issued on November 9, 2015. On July 22, 2015, the pilot was issued a third class medical certificate with no restrictions. According to an insurance application dated January 12, 2016, the pilot had accumulated 55 total flight hours of which 17 hours were in the accident airplane. The flying club member who spoke with the pilot before the flight stated that the pilot had flown the airplane a few times since returning from college in mid-May, including a flight on the evening before the accident. The pilot's logbook was not available for review. The portable GPS navigation device found in the airplane, a Garmin Aera 560, was recovered from the accident site and evaluated by the NTSB Recorder Laboratory. For further details, see the GPS Factual Report in the public docket for this investigation. Examination of the airplane at the accident site revealed that the airplane came to rest in a nose-down attitude in about 4 ft of water. The damage to the airplane was consistent with a near-vertical descent with a low forward velocity at impact. Following recovery from the lake, the airplane and engine were examined in a nearby hangar. Both wings were intact and remained attached to the fuselage by the main wing spars. The main landing gear assemblies were attached to their respective wings, and both wing flaps were retracted. The flight control surfaces remained attached to their respective airframe surfaces. No anomalies were noted with the flight control system. Stabilator and aileron control continuity were established from the respective controls to the "T" bar chain. Stabilator trim continuity was established from the trim tab to the trim crank handle in the overhead panel, and the stabilator trim barrel indicated a neutral trim setting. Rudder control continuity was established from the rudder to the rudder pedal assembly. Both fuel tank caps were installed, and both fuel tank vents were found clear of debris. The fuel selector valve was in the right-wing fuel tank position. A functional check of the fuel selector valve, using low pressure air, revealed that the valve was functional. The fuel pump operated normally when hand rotated, and the carburetor was disassembled and no anomalies were noted. The propeller remained attached to the engine, and the spinner was attached to the spinner bulkhead and crushed aft. The propeller blades were minimally damaged with one blade having minor abrasions on the leading edge of its tip. The top Champion REM40E sparkplugs were removed from the cylinders. All displayed a normal worn condition when compared to the ChampionAviation Service Manual (AV6-R). After cleaning with compressed air and contact cleaner, both magnetos sparked normally at all leads during rotation. The four cylinders remained attached to the crankcase. The rocker covers were removed, and no preaccident anomalies were noted with the rockers, rocker shafts, or valve springs. A borescope inspection of the four cylinders revealed no anomalies with the pistons, cylinder barrels, cylinder heads, valves, or valve seats. The engine exhaust system was found impact damaged; however, the heat muff was intact with no significant cracks or exhaust erosion. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. ## Aircraft - Registration: [N6223W](https://openairdocs.org/deregistered/N6223W-2018-07-12), registration cancelled 2018-07-12, S/N 28-20264, built 1964 (OpenAirDocs) - Reported make and model: PIPER PA 28-140 - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-20264 - Year built: 1964 - Airframe hours: 3459 - Engines: LYCOMING O-320 SERIES 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 1, 2016, 21 hours before - Departed: 6L5, Wishek, ND - Destination: BIS, BISMARCK, ND - Airport: 6L5, Wishek Muni, runway 14, 3,460 × 60 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 20; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review November 9, 2015; seat: left; restraint: lap only; toxicology performed; flight hours: 60 total, 22 in this make and model, 5 in the last 90 days, 5 in the last 30 days, 0.5 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 160° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 91 °F, dew point 59 °F - Altimeter: 29.67 inHg - Observed at: KBIS, 60 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 20160609005449A](https://openairdocs.org/incident/20160609005449A), Jun 9, 2016: Piper PA-28-140, Wishek, ND, Destroyed, 3 fatal. On June 9, 2016, about 1527 central daylight time, a Piper PA-28-140 airplane, N6223W, Impacted terrain while departing from Wishek Municipal Airport (6L5),… ## Docket (8 files) The files NTSB released with the investigation on December 12, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93353. 2.0 MB in all. - GPS Factual Report (item 1, .PDF, 3 photos, 668 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458729&FileExtension=.PDF&FileName=GPS%20Factual%20Report-Master.PDF - Attachment 1 (GPS Data) (item 2, .CSV, 1 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458730&FileExtension=.csv&FileName=Attachment%201%20(GPS%20Data)-Master.csv - Conversion Memorandum (item 3, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458731&FileExtension=.PDF&FileName=Conversion%20Memorandum-Master.PDF - Photos (item 4, .PDF, 5 photos, 820 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458732&FileExtension=.PDF&FileName=Photos-Master.PDF - Witness Statement (item 5, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458733&FileExtension=.PDF&FileName=Witness%20Statement-Master.PDF - Statement of Airplane's Co-owner (item 6, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458734&FileExtension=.PDF&FileName=Statement%20of%20Airplane%27s%20Co-owner-Master.PDF - Excerpt of Airplane Flight Manual (item 7, .PDF, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458735&FileExtension=.PDF&FileName=Excerpt%20of%20Airplane%20Flight%20Manual-Master.PDF - Toxicological Report (item 8, .PDF, 197 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40458736&FileExtension=.PDF&FileName=Toxicological%20Report-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.