# NTSB CEN19FA084: Piper PA32R, N4922K, Goshen, IN, February 22, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: February 21, 2019, 20:04 local (Feb 22, 2019, 01:04 UTC) - Place: Goshen, IN - Coordinates: 41.527778, -85.757222 - Nearby events: https://openairdocs.org/map.md?lat=41.5278&lon=-85.7572&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming Engines, Piper Aircraft, FAA FSDO - NTSB case key (mKey): 99010 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN19FA084 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99010/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99010 - Page: https://openairdocs.org/ntsb/CEN19FA084 ## Probable cause The pilot’s failure to maintain adequate altitude for undetermined reasons during a practice circling approach in dark night visual meteorological conditions, which resulted in a collision with power lines. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Personnel issues](https://openairdocs.org/ntsb-findings/02060000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-32R-301T, 1 case](https://openairdocs.org/ntsb-findings/02060000/cases.md?model=7103220), [All aircraft, 137 cases](https://openairdocs.org/ntsb-findings/02060000/cases.md) - [Personnel issues](https://openairdocs.org/ntsb-findings/02060000): Personnel issues › Task performance · Unknown/Not determined (probable cause); cases with it: [Piper PA-32R-301T, 1 case](https://openairdocs.org/ntsb-findings/02060000/cases.md?model=7103220), [All aircraft, 137 cases](https://openairdocs.org/ntsb-findings/02060000/cases.md) - [Object/animal/substance: wire](https://openairdocs.org/ntsb-findings/03022032): Environmental issues › Physical environment · Response/compensation (probable cause); cases with it: [Piper PA-32R-301T, 2 cases](https://openairdocs.org/ntsb-findings/03022032/cases.md?model=7103220), [All aircraft, 588 cases](https://openairdocs.org/ntsb-findings/03022032/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Piper PA-32R-301T, 3 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7103220), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The pilot was conducting a practice circling approach in dark night visual meteorological conditions. The published elevation at the destination airport was 827 ft mean sea level (msl), and the published minimum altitude for the circling approach, 1.9 miles from the airport, was 1,460 ft msl. According to radar data, the airplane took off, climbed west, and then turned back to the east. The airplane then started a turn to the north about 1.2 miles east of the airport. Radar recorded the airplane at an altitude of about 1,125 ft msl before radar contact was lost. An airport security video showed the airplane flying toward the airport at what appeared to be a level attitude, followed by a flash of light; the airplane then disappeared from view. The airplane impacted 250-ft-high power lines about 1.37 miles east of the airport; the elevation at the accident site was about 867 ft msl, and the approximate altitude of the collision with the power lines was 1,117 ft msl. The video also recorded what appeared to be a ground explosion and fire, and the airplane wreckage was located adjacent to damaged power lines. There were no radio distress calls received from the pilot. Evidence of collision with the power lines was observed on the airframe and propeller. Most of the fuselage and cockpit were consumed by a postimpact fire. Flight control continuity was confirmed to the extent possible due to fire damage and melting. No evidence of preimpact mechanical malfunctions or failures with the airframe or engine were found. Engine drivetrain continuity was confirmed, and the propeller showed evidence of rotation at the time of impact. Postaccident inspection of the airport lighting revealed functionality of all systems, and the airport manager reported that the lighting was turned on at the time of the accident. During the practice circling approach, the pilot failed to maintain adequate altitude to clear the power lines. Given the available evidence, it could not be determined why the pilot was flying at an altitude insufficient to clear the wire tower. ## Factual narrative Maintenance logbooks were recovered from the accident site but were not readable due to severe fire damage. Its most recent annual inspection was completed in November of 2018. The local FBO reported that the airplane was clean, well maintained, and the interior of the plane was organized whenever it was brought in for maintenance. The published elevation at GSH was 827 ft msl. The published minimum altitude for the RNAV (GPS) RWY 9 circling approach, 1.9 miles from GSH, was 1,460 ft msl. According to the airport manager, all airport lighting was operational at the time of the accident, and the runway lighting was turned on. Postaccident inspection of the facility lighting revealed functionality of all systems. On February 21, 2019, about 2004 eastern standard time, a Piper PA-32R-301T airplane, N4922K, was destroyed when it was involved in an accident near Goshen, Indiana. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to Federal Aviation Administration and air traffic control records, the pilot departed runway 27 at Goshen Municipal Airport (GSH), Goshen, Indiana, about 1950 and contacted departure control to request local clearance to conduct a practice RNAV (GPS) RWY 9 approach and circle to land on runway 27. According to radar data, after taking off from runway 27, the airplane climbed straight west and then turned back to the east. The airplane then started a turn to the north about 1.2 miles east of GSH. The radar data ended about 1.37 miles east of the runway 27 threshold at GSH; the last radar data point showed the airplane about 1,125 ft mean sea level (msl), heading 337°, at 58 knots ground speed. A witness observed the airplane flying east of GSH. No anomalies were noted in the communications with the pilot, and there were no radio distress calls heard from the pilot. A witness who was driving near the accident site observed the airplane flying relatively low east of GSH. An airport security video showed the airplane flying toward the airport at what appeared to be a level attitude, followed by a flash of light. The airplane then disappeared from view, and the video recorded what appeared to be a ground explosion and fire. The airplane wreckage was located by first responders about 1.37 miles east of the approach end of runway 27 at GSH. The wreckage was adjacent to damaged 250-ft-high power lines. The Western Michigan University School of Medicine, Department of Pathology, Kalamazoo, Michigan, performed an autopsy of the pilot. The pilot’s cause of death was multiple blunt force and thermal injuries. The FAA's Forensic Sciences Laboratory performed toxicology testing on the pilot’s tissue samples. The toxicology tests were negative for drugs and ethanol. Small, unmeasured amounts of Losartan were detected in the blood and liver. Losartan is commonly used to treat high blood pressure and diabetes. Dark night visual meteorological conditionsprevailed, and a flight plan was not filed. Pilot logbooks were recovered from the accident site but were not readable due to severe fire damage. Local airport personnel estimated the pilot’s total flight hours at 1,500, with 600 hours in N4922K, which he flew regularly. The elevation at the accident site was 867 ft msl. Examination of the wreckage revealed evidence consistent with the airplane impacting near the top of the 250-ft-high power line wires (about 1,117 ft msl). Portions of the power line wires were found embedded around the propeller, and both wings exhibited damage consistent with contact with an electric power line. Most of the fuselage and cockpit were consumed by a postimpact fire. The landing gear were found in the extended position. Detailed examinations of the airframe and engine were completed. No evidence of preimpact mechanical malfunctions or failures was found with the airframe, and flight control continuity was established to the extent possible due to fire damage and melting. Examination of the engine did not show evidence of preimpact mechanical malfunctions or failures, and drivetrain continuity was established. The propeller blades showed evidence consistent with contact with power lines and with rotation at the time of impact. One blade exhibited a gouge and aft bending; the second blade exhibited aft bending, scratches, and dark areas consistent with thermal damage around the scratches; and the third blade exhibited aft bending, a gouge in the leading edge, and a scratch extending from the gouge to the trailing edge on the aft face of the blade. Avionics could not be examined due to fire damage. ## Aircraft - Registration: [N4922K](https://openairdocs.org/deregistered/N4922K-2019-06-14), registration cancelled 2019-06-14, S/N 3257064, built 1998 (OpenAirDocs) - Reported make and model: Piper PA32R (301T) - Registry model: [Piper PA-32R-301T](https://openairdocs.org/model/piper-pa-32r-301t) (registry code 7103220) (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: 3257064 - Year built: 1998 - Airframe hours: 2759 - Engines: Lycoming TIO-540-AH1A 300 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 28, 2018 - Departed: GSH, Goshen, IN - Destination: GSH, Goshen, IN - Airport: GSH, Goshen Minicipal Airport - Equipment: Angle of attack indicator, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 55; injuries: fatal; commercial, flight instructor; airplane ratings: single-engine sea, single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; seat: left; restraint: 4-point; toxicology performed; flight hours: 1,500 total, 600 in this make and model, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night - Wind: 270° at 7 knots - Visibility: 9 statute miles - Lowest ceiling: none - Temperature: 32 °F, dew point 25 °F - Altimeter: 30.23 inHg - Observed at: GSH ## 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 20190221011319A](https://openairdocs.org/incident/20190221011319A), Feb 21, 2019: Piper PA-32R-301T, Goshen, IN, Destroyed, 1 fatal. On February 21, 2019 at about 2005 EST, a Piper PA-32R-301T, N4922K, registered to ironhead LLC, middlebury, Indiana, was destroyed after it impacted high… ## Docket (14 files) The files NTSB released with the investigation on June 2, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99010. 53.5 MB in all. - Security video of airplane colliding with power lines (item 1, MOV, 48.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9532690&FileExtension=MOV&FileName=Security%20Video%20of%20Airplane%20Colliding%20with%20Power%20Lines-Rel.MOV - Photo array CEN19FA084 (item 2, PDF, 2 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12111961&FileExtension=pdf&FileName=Photo%20Array%20CEN19FA084-Rel.pdf - Aircraft maintenance documents CEN19FA084 (item 3, PDF, 3 pages, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12111931&FileExtension=pdf&FileName=Aircraft%20Maintenance%20Documents%20CEN19FA084_Redacted-Rel.pdf - Goshen minucipal airport managers report CEN19FA084 (item 4, PDF, 1 page, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12112665&FileExtension=pdf&FileName=Goshen%20Minucipal%20Airport%20Managers%20Report%20CEN19FA084_Redacted-Rel.pdf - Goshen municipal airport RNAV GPS rwy 9 approach CEN19FA084 (item 5, PDF, 1 page, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12112555&FileExtension=pdf&FileName=Goshen%20Municipal%20Airport%20RNAV%20GPS%20RWY%209%20Approach%20CEN19FA084-Rel.pdf - Goshen VFR sectional showing airport and surrounding obstructions CEN19FA084 (item 6, PDF, 1 page, 383 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12112489&FileExtension=pdf&FileName=Goshen%20VFR%20Sectional%20Showing%20Airport%20and%20Surrounding%20Obstructions%20CEN19FA084-Rel.pdf - Memorandum for the record airframe examinations findings CEN19FA084 (item 7, PDF, 2 pages, 147 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12111951&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Airframe%20Examinations%20Findings%20CEN19FA084_Redacted-Rel.pdf - Memorandum for the record altimeter examination findings CEN19FA084 (item 8, PDF, 2 pages, 263 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12112675&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Altimeter%20Examination%20Findings%20CEN19FA084_Redacted-Rel.pdf - Memorandum for the record engine and propeller examination findings CEN19FA084 (item 9, PDF, 1 page, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12112565&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Engine%20and%20Propeller%20Examination%20Findings%20CEN19FA084_Redacted-Rel.pdf - Memorandum for the record summary of ATC communications and radar track (item 10, PDF, 2 pages, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12112232&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Summary%20of%20ATC%20Communications%20and%20Radar%20Track_Redacted-Rel.pdf - Radar data table CEN19FA084 (item 11, PDF, 10 pages, 145 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12112685&FileExtension=pdf&FileName=Radar%20Data%20Table%20CEN19FA084-Rel.pdf - Overhead schematics of wire strike area in proximity to airport CEN19FA084 (item 12, PDF, 2 pages, 368 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12112499&FileExtension=pdf&FileName=Overhead%20Schematics%20of%20Wire%20Strike%20Area%20in%20Proximity%20to%20Airport%20CEN19FA084-Rel.pdf - Toxicology report CEN19FA084 (item 13, PDF, 1 page, 273 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12112695&FileExtension=pdf&FileName=Toxicology%20Report%20CEN19FA084_Redacted-Rel.pdf - Memorandum for the record airport lighting information CEN19FA084 (item 14, PDF, 1 page, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12321416&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Airport%20Lighting%20Information%20CEN19FA084-Rel.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.