# NTSB CEN20LA199: Piper PA28, N6461J, Pineville, LA, May 31, 2020 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Limited · Final report - Date: May 31, 2020, 13:30 local (18:30 UTC) - Place: Pineville, LA - Coordinates: 31.348333, -92.434448 - Nearby events: https://openairdocs.org/map.md?lat=31.3483&lon=-92.4344&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal, 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: FAA FSDO, Piper Aircraft, Lycoming Engines - NTSB case key (mKey): 101343 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN20LA199 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/101343/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=101343 - Page: https://openairdocs.org/ntsb/CEN20LA199 ## Probable cause The airplane’s inability to gain sufficient airspeed after takeoff due to it being at or over its maximum gross weight, which resulted in a loss of control. Contributing to the accident was the pilot’s decision to operate the airplane at or over its maximum gross weight. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Aircraft capability: maximum weight](https://openairdocs.org/ntsb-findings/01061035): Aircraft › Aircraft oper/perf/capability · Capability exceeded (probable cause); cases with it: [Piper PA-28-180, 1 case](https://openairdocs.org/ntsb-findings/01061035/cases.md?model=7102808), [All aircraft, 152 cases](https://openairdocs.org/ntsb-findings/01061035/cases.md) - [Action](https://openairdocs.org/ntsb-findings/02041000): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-180, 2 cases](https://openairdocs.org/ntsb-findings/02041000/cases.md?model=7102808), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02041000/cases.md) - [Planning/preparation: weight/balance calculations](https://openairdocs.org/ntsb-findings/02061015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-180, 1 case](https://openairdocs.org/ntsb-findings/02061015/cases.md?model=7102808), [All aircraft, 110 cases](https://openairdocs.org/ntsb-findings/02061015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28-180, 30 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102808), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis Several witnesses observed the airplane takeoff. One witness stated that the airplane seemed to struggle to clear trees at the end of the runway. The airplane made a few turns, and the wings were observed to go vertical in an “apparent stall/spin situation.” Another witness reported that the airplane was “struggling” to climb after takeoff before it descended below the trees. The airplane impacted heavily wooded terrain about 1.5 miles from the departure end of the runway. Examination of the airframe, flight controls, and engine did not reveal any pre-impact mechanical anomalies. The estimated weight of the airplane at the time of the accident was at or slightly above its maximum gross weight. Based on the witness accounts, no identified pre-impact mechanical anomalies, and its estimated weight, it is likely that the airplane did not have sufficient performance capability to climb after takeoff, resulting in a loss of control. Although ethanol was identified during toxicology testing of the pilot’s specimens, it was most likely from sources other than ingestion; therefore, its effects did not contribute to the accident. There was not enough available information regarding the pilot’s use of multiple psychoactive medications (as identified in toxicology testing) to determine if effects from the medications contributed to the accident. ## Factual narrative On May 31, 2020, at 1330 central daylight time, a Piper PA28-180, N6461J, was destroyed when it was involved in an accident near Pineville, Louisiana. The private pilot and one passenger were fatally injured, and one child passenger was seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. One witness, who was a flight instructor, reported that he saw the airplane take off from runway 36 at Pineville Municipal Airport (2L0). He stated that the airplane seemed to struggle to clear the trees at the end of the runway. The airplane then made a hard left turn about 400 ft above the ground (agl), to about a heading of 270°. The airplane then banked to a heading of 180° with the wings vertical in an "apparent stall/spin situation." The airplane then descended below the tree line. Another witness, who was also a flight instructor, reported that he saw the airplane take off and it was "struggling" to climb. When the airplane was about 400 ft agl, he saw the airplane make a left turn with about a 60°-75° bank angle. The airplane then entered a heading of about 270°, holding a very steep bank angle. It then continued the left bank to a easterly heading and disappeared behind the tree line. A third witness described the airplane entering an “accelerated stall” at and altitude of about 200-300 ft agl. There were no radio or distress calls heard from the pilot. The accident site was located in a heavily wooded area, about 1.5 miles from the departure end of runway 36 at 2L0. Local authorities rescued the surviving passenger and secured the accident site. After initial on-site examinations, the airplane wreckage was transported to a secure facility for further examinations. The estimated weight of the airplane at the time of the accident was at or slightly above its maximum gross weight. An autopsy on the pilot was performed by the Louisiana Forensic Center, Broussard, Louisiana. The cause of death was multiple blunt force injuries. Toxicology tests were performed by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. Ethanol was identified at 0.037 gm/dl in muscle but was absent in brain. N-butanol, another alcohol commonly produced in tissues after death, was identified in muscle. Fluoxetine, an antidepressant, and its metabolite, norfluoxetine, were identified in muscle and liver. Trazodone was also identified in liver, brain, and heart, but the muscle specimen was unsuitable for testing. Finally, amphetamine was identified in liver and lung, but brain and muscle tissues were unsuitable for testing. Ethanol is the intoxicant found in beer, liquor, and wine and its negative effects on pilot performance are well documented. However, ethanol may also be produced in tissues after death; in this case, the levels in different tissues may vary widely whereas after ingestion, ethanol is rapidly and evenly distributed. Fluoxetine is an antidepressant and may have mild cognitiveeffects, but the larger issue is the underly depression, which may have significant effects on judgement, executive functioning, and reaction time. Amphetamine may be used to treat attention deficit issues but does not treat the increased impulsivity associated with attention deficit disorders. The pilot’s estimated total flight time was based on information that he provided during his most recent Federal Aviation Administration medical examination on January 9, 2020. The pilot’s logbooks were not available during the investigation. The fuselage exhibited severe tearing crumpling and crushing of the cabin and forward fuselage sections. The instrument panel and firewall were crushed by impact forces. The fuel system exhibited severe impact damages but did not reveal any pre-impact anomalies or restrictions. Flight control continuity was confirmed from the cockpit to all flight control surfaces. The two-bladed propeller hub was attached to its flange. Both blades exhibited scoring on their respective leading edges, consistent with some rotation at impact. Several small trees showed cuts consistent with propeller blade contact. The postaccident examination of the aircraft and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. ## Aircraft - Registration: [N6461J](https://openairdocs.org/deregistered/N6461J-2022-09-03), registration cancelled 2022-09-03, S/N 28-4884, built 1968 (OpenAirDocs) - Reported make and model: PIPER PA28 (180) - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-4884 - Year built: 1968 - Airframe hours: 5437 - Engines: Lycoming O-360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, November 6, 2019, 65 hours before - Departed: 2LO, Pineville, LA - Destination: 2LO, Pineville, LA - Airport: 2LO, Pineville Municipal Airport, runway 36, 3,000 × 75 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 37; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: unknown, unknown; seat: left; restraint: 3-point; flight hours: 175 total, 65 in this make and model, 1 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 7 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 86 °F, dew point 61 °F - Altimeter: 30.11 inHg - Observed at: AEX, 8 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 20200531004379A](https://openairdocs.org/incident/20200531004379A), May 31, 2020: Piper PA-28-180, Pineville, LA, Destroyed, 2 fatal. On may 31, 2020, about 1330 central daylight time, a Piper PA28-180, N6461J, was destroyed when it was involved in an accident near Pineville, Louisiana. The… ## Docket (7 files) The files NTSB released with the investigation on June 29, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=101343. 15.1 MB in all. - Witness statements CEN20LA199 (item 1, PDF, 2 pages, 10.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14001472&FileExtension=pdf&FileName=Witness%20Statements%20CEN20LA199_Redacted-Rel.pdf - Witness statement CEN20LA199 (item 2, PDF, 1 page, 77 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14004333&FileExtension=pdf&FileName=Witness%20Statement%20CEN20LA199_Redacted-Rel.pdf - Memorandum for the record airframe examinations findings CEN20LA199 (item 3, PDF, 2 pages, 478 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14001721&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Airframe%20Examinations%20Findings%20CEN20LA199_Redacted-Rel.pdf - Memorandum for the record engine examination findings CEN20LA199 (item 4, PDF, 1 page, 137 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14001599&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Engine%20Examination%20Findings%20CEN20LA199_Redacted-Rel.pdf - Memorandum for the record weight and balance estimate CEN20LA199 (item 5, PDF, 1 page, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14001806&FileExtension=pdf&FileName=Memorandum%20for%20the%20Record%20Weight%20and%20Balance%20Estimate%20CEN20LA199_Redacted-Rel.pdf - Photo array CEN20LA199 (item 6, PDF, 3 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14001731&FileExtension=pdf&FileName=Photo%20Array%20CEN20LA199-Rel.pdf - Toxicology report CEN20LA199 (item 7, PDF, 1 page, 385 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14002946&FileExtension=pdf&FileName=Toxicology%20Report%20CEN20LA199_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.