CEN20LA127

NTSB accident investigation · Piper PA28R · Pleasant Plain, OH · March 19, 2020

Accident · FatalClass 3 · LimitedFinal report
Date
March 18, 2020, 22:47 local (Mar 19, 2020, 02:47 UTC)
Place
Pleasant Plain, OH
Injuries
1 fatal
Damage
Destroyed
Phase of flight
Approach
Aircraft
N3943TPiper PA28R
Defining event
Approach-IFR initial approach: Loss of control in flight
Weather
Instrument (IMC) · Night/dark
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Central Region
Parties
Piper Aircraft, FAA, Lycoming Engines
FAA report
20200318004119A
Case key
101091

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

On this page

Probable cause

The pilot’s encounter with convective turbulence and low-level wind shear in dark night instrument meteorological conditions that resulted in spatial disorientation and the loss of airplane control.

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.

Turbulence: convective turbulenceEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomePiper PA-28R-180: 1 caseAll aircraft: 145 casesProbable cause
Wind: downdraftEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomePiper PA-28R-180: 1 caseAll aircraft: 178 casesProbable cause
Performance/control parameters: lateral/bank controlAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28R-180: 3 casesAll aircraft: 390 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 instrument-rated pilot was on the final segment of an instrument flight rules (IFR) flight in dark night instrument meteorological conditions (IMC). After being cleared for an RNAV approach to his intended destination, the pilot made several course deviations inbound to the initial approach fix. The pilot informed air traffic control (ATC) that he was experiencing autopilot problems, "heavy turbulence," and "heavy downdrafts." Radar and automated dependent surveillance-broadcast data showed the airplane enter a rapidly descending left turn. ATC issued a low-altitude alert to the pilot and advised him to climb to 4,000 ft immediately. The pilot did not respond, and there were no further communications from the pilot. Radar contact was lost as the airplane descended through 1,400 ft. The airplane wreckage was found severely fragmented amidst a heavily wooded area. Examinations of the airframe, flight controls, and engine did not reveal any pre-impact mechanical anomalies. The airplane was flying in an area of a stationary frontal system, which resulted in an extensive area of IFR conditions, low ceilings, low visibilities, drizzle, and rain. The weather in the accident area was conducive to low-level windshear and convective turbulence at the time of the accident. There was no record of the pilot obtaining a preflight weather briefing, and his flight plan did not list an alternate airport. The pilot’s report of heavy turbulence and downdrafts was consistent with the existing weather conditions. It is likely when the pilot encountered the turbulence and wind shear in dark night conditions, he became spatially disoriented and lost control of the airplane.

Factual narrative

On March 18, 2020, about 2245 eastern daylight time, a Piper PA-28R-180 airplane, N3943T, was destroyed when it was involved in an accident near Pleasant Plain, Ohio. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The instrument flight rules (IFR) flight originated about 1820 from Muskogee-Davis Regional Airport (MKO), Muskogee, Oklahoma. According to records obtained from the fixed base operator at MKO, the pilot purchased 30.5 gallons of 100 low lead aviation fuel prior to departure. The intended destination was Clermont County Airport (I69), Batavia, Ohio. The pilot was in communication with air traffic control (ATC) during the flight. Radar and automated dependent surveillance – broadcast (ADS-B) data showed that the airplane few northeast and climbed to 11,000 ft msl after departing MKO. About 2112 the airplane descended from 11,000 ft, and the pilot requested an RNAV approach to runway 22 at I69. At this point, the airplane was flying in dark night instrument meteorological conditions (IMC). The automated weather observation system (AWOS) at I69 reported wind from 230ºat 8 knots, visibility 7 miles with drizzle, and ceiling overcast at 600 ft agl. ATC issued the pilot radar vectors to the pilot to proceed to the FIGPU, the initial approach fix (IAF) for the RNAV approach to runway 22. The airplane was 8 miles from FIGPU when ATC instructed the pilot to maintain 3,000 ft and cleared him for the RNAV approach for runway 22. The airplane was about 2.5 miles west of FIGPU when the airplane turned westbound. ATC advised the pilot that they observed the aircraft turning westbound and asked the pilot if he required assistance. The pilot responded that he was turning back and had an autopilot malfunction. The airplane then turned southeast, and ATC asked the pilot if he was proceeding to the JERAL, another IAF on the RNAV approach for runway 22. The pilot responded in the affirmative and the controller asked the pilot if he had corrected the autopilot issue. The pilot reported that he was manually flying the airplane. The airplane was about 4.5 miles from JERAL when the airplane turned southbound. ATC advised the pilot that he appeared to be heading southbound. The pilot responded that he was experiencing "heavy turbulence" and "heavy downdrafts." The airplane then entered a rapidly descending left turn. ATC issued a low altitude alert to the pilot advised the pilot and advised him to climb to 4,000 ft immediately. The pilot did not respond and there were no further communications from the pilot. Radar contact was lost as the airplane was descended through 1,400 ft, about 14 miles north of I69 (see figure). Figure. Flightpath with Pilot/ATC Communications. The airplane wreckage was found severely fragmented amidst a densely wooded area. The area surrounding the accident site was interspersed with agricultural fields, wooded areas, and scattered residential housingadjacent to main roadways. The initial point of impact was a treetop. Impact marks were observed about 69-ft high in the tree. The wreckage was scattered throughout the wooded area on an approximate heading of 135°and came to rest near a small pond. The engine, propeller, and main instrument panel were located about 55 ft away from the main wreckage. Although there was extensive impact damage, examinations of the airframe, flight controls, and engine did not reveal any pre-impact anomalies. The National Transportation Safety Board meteorological weather study documented a stationary frontal system over the area that resulted in an extensive area of IFR conditions, with low ceilings low visibilities, drizzle, and rain. The study showed that the airplane was flying in area conducive to low-level windshear and convective turbulence at the time of the accident. There was no record of the pilot obtaining a preflight weather briefing, and his flight plan did not list an alternate airport. An autopsy on the pilot was performed by the Montgomery County Coroner, Dayton, Ohio. The cause of death was blunt force trauma. Toxicology tests, performed by the Federal Aviation Administration (FAA), Civil Aerospace Medical Institute, Oklahoma City, Oklahoma, were negative for alcohol and other drugs.

Aircraft

Registration
N3943T
Reported as
Piper PA28R (180)
Category
Airplane
Serial number
28R-30286
Built
1967
Airframe hours
4,552
Engine
Lycoming IO-360-B1E, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 12, 2020 · 31 hours before
Departed
MKO · Muskogee, OK
Destination
I69 · Batavia, OH
Flight plan
IFR

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
42
Injuries
Fatal
Certificates
Airline transport, Commercial, Private, Flight instructor
Airplane ratings
Multi-engine sea, Single-engine land, Multi-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
1,507 total · 300 in this make and model

Weather

Conditions
Instrument (IMC) · Night/dark
Wind
230° at 8 knots
Visibility
7 statute miles
Lowest ceiling
600 ft overcast
Temperature
43 °F, dew point 43 °F
Altimeter
30.03 inHg
Turbulence
Severe
Observed at
I69, 16 nm away

Docket · 9

The files NTSB released with the investigation on April 28, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 17.3 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.