# NTSB CEN20LA127: Piper PA28R, N3943T, Pleasant Plain, OH, March 19, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: March 18, 2020, 22:47 local (Mar 19, 2020, 02:47 UTC) - Place: Pleasant Plain, OH - Coordinates: 39.294166, -84.10778 - Nearby events: https://openairdocs.org/map.md?lat=39.2942&lon=-84.1078&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR initial approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Piper Aircraft, FAA, Lycoming Engines - NTSB case key (mKey): 101091 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA127 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101091/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101091 - Page: https://openairdocs.org/ntsb/CEN20LA127 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Planning/preparation: weather planning](https://openairdocs.org/ntsb-findings/02061020): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-28R-180, 3 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md?model=7102809), [All aircraft, 156 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md) - [Turbulence: convective turbulence](https://openairdocs.org/ntsb-findings/03032020): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Piper PA-28R-180, 1 case](https://openairdocs.org/ntsb-findings/03032020/cases.md?model=7102809), [All aircraft, 145 cases](https://openairdocs.org/ntsb-findings/03032020/cases.md) - [Wind: downdraft](https://openairdocs.org/ntsb-findings/03034035): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Piper PA-28R-180, 1 case](https://openairdocs.org/ntsb-findings/03034035/cases.md?model=7102809), [All aircraft, 178 cases](https://openairdocs.org/ntsb-findings/03034035/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-28R-180, 4 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7102809), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Performance/control parameters: lateral/bank control](https://openairdocs.org/ntsb-findings/01062023): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-28R-180, 3 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md?model=7102809), [All aircraft, 390 cases](https://openairdocs.org/ntsb-findings/01062023/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR initial approach: Turbulence encounter](https://openairdocs.org/ntsb-events/360); cases with it: [Piper PA-28R-180, 1 case](https://openairdocs.org/ntsb-events/360/sequence.md?model=7102809), [All aircraft, 423 cases](https://openairdocs.org/ntsb-events/360/sequence.md) - [Approach-IFR initial approach: Windshear or thunderstorm](https://openairdocs.org/ntsb-events/390); cases with it: [Piper PA-28R-180, 1 case](https://openairdocs.org/ntsb-events/390/sequence.md?model=7102809), [All aircraft, 224 cases](https://openairdocs.org/ntsb-events/390/sequence.md) - [Approach-IFR initial approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28R-180, 11 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102809), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## 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](https://openairdocs.org/deregistered/N3943T-2022-07-30), registration cancelled 2022-07-30, S/N 28R-30286, built 1967 (OpenAirDocs) - Reported make and model: Piper PA28R (180) - Registry model: [Piper PA-28R-180](https://openairdocs.org/model/piper-pa-28r-180) (registry code 7102809) (OpenAirDocs) - Registry engine: [Lycoming I0360 series](https://openairdocs.org/engine/lycoming-i0360-series) (registry code 41515, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28R-30286 - Year built: 1967 - Airframe hours: 4552 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 42; injuries: fatal; 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 ## 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 20200318004119A](https://openairdocs.org/incident/20200318004119A), Mar 18, 2020: Piper PA-28R-180, Pleasant Plain, OH, Destroyed, 1 fatal. On March 18, 2020, at approximately 10:44 p.m. eastern standard time (0244 universal time), a Piper PA-28R-180 arrow, N3943T, impacted the terrain in a wooded… ## Docket (9 files) The files NTSB released with the investigation on April 28, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101091. 17.3 MB in all. - Memorandum for the record ATC communications and adsb graphics CEN20LA127 (item 1, PDF, 4 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13327344&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20ATC%20Communications%20and%20ADSB%20Graphics%20CEN20LA127_Redacted-Rel.pdf - ADS b data table CEN20LA127 (item 2, PDF, 150 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13326416&FileExtension=pdf&FileName=ADS%20B%20Data%20Table%20CEN20LA127-Rel.pdf - Weather study (item 3, PDF, 35 pages, 4.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=9690629&FileExtension=pdf&FileName=CEN20LA127%20-%20Pleasant%20Prairie,%20OH-Rel.pdf - Witness gallagher flight path diagram CEN20LA127 (item 4, PDF, 1 page, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13326374&FileExtension=pdf&FileName=Witness%20Gallagher%20Flight%20Path%20Diagram%20CEN20LA127_Redacted-Rel.pdf - Memorandum for the record accident site observations CEN20LA127 (item 5, PDF, 1 page, 186 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13328519&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Accident%20Site%20Observations%20CEN20LA127_Redacted-Rel.pdf - Memorandum for the record airframe and engine examination findings CEN20LA127 (item 6, PDF, 6 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13325371&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Airframe%20and%20Engine%20Examination%20Findings%20CEN20LA127_Redacted-Rel.pdf - Fuel receipt from mko CEN20LA127 (item 7, PDF, 1 page, 3.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13326436&FileExtension=pdf&FileName=Fuel%20Receipt%20from%20MKO%20CEN20LA127_Redacted-Rel.pdf - CEN20LA127 electronic devices - specialist's factual report (item 8, PDF, 4 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11631487&FileExtension=pdf&FileName=CEN20LA127%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Toxicology report CEN20LA127 (item 9, PDF, 1 page, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13326446&FileExtension=pdf&FileName=Toxicology%20Report%20CEN20LA127_Redacted-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.