# NTSB CEN21FA263: Piper PA-32-260, N3258W, Madisonville, TX, June 14, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: June 13, 2021, 23:55 local (Jun 14, 2021, 04:55 UTC) - Place: Madisonville, TX · 1,000 feet prior to runway 36. - Coordinates: 30.908162, -95.952974 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=30.9082&lon=-95.9530&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) - Highest injury: Fatal - Injuries: 1 fatal, 5 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Piper Aircraft, Federal Aviation Administration; Houston FSDO, Lycoming Engines - NTSB case key (mKey): 103250 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN21FA263 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/103250/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=103250 - Page: https://openairdocs.org/ntsb/CEN21FA263 ## Probable cause The pilot’s failure to maintain a proper glidepath during final approach for landing, which resulted in impact with trees and terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-32-260, 3 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=7103206), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-32-260, 9 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7103206), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) (defining event); cases with it: [Piper PA-32-260, 30 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7103206), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot departed on a night cross-country flight. While on approach to the destination airport, the airplane impacted trees and terrain and came to rest about 550 ft from the runway threshold. Postaccident examination of the airplane revealed no anomalies that would have preclude normal airplane operation. The switches for the airplane’s landing light and rotating beacon were both found in the OFF position. Autopsy revealed that the pilot had 85% stenosis of one of his coronary arteries, which placed him at an increased risk for a sudden cardiac event; however, there was no evidence to suggest that occurred and based on the circumstances of this accident, it is unlikely that the pilot’s cardiovascular condition was a factor in the accident. Toxicological testing identified the antidepressant sertraline and its metabolite desmethysertraline in the pilot’s heart blood and urine. While the levels detected were above therapeutic levels, this medication can undergo postmortem redistribution. Sertraline is one of the four medications the Federal Aviation Administration will consider for treatment of depression. Special issuance is usually issued after 6 months of treatment when the applicant is clinically stable. It is unknown how long the pilot was taking sertraline and whether he was taking it for depression or some other condition. However, after a few weeks of use, sertraline does not impact psychomotor performance. Given the circumstances of this accident, it is unlikely that effects from the pilot’s use of sertraline were factors in the accident. ## Factual narrative The airplane’s maintenance logs were not located. A mechanic who completed the most recent annual inspection stated that he completed an “extensive” annual inspection of the airplane in July or August 2020. On June 13, 2021, about 2355 central daylight time, a Piper PA-32-260 airplane, N3258W, was substantially damaged when it was involved in an accident near Madisonville, Texas. The private pilot was fatally injured, and five passengers received serious injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to automatic dependent surveillance-broadcast data, the accident flight departed from Port Isabel-Cameron Country Airport, Port Isabel, Texas, about 2121 and proceeded to Madisonville Municipal Airport (51R), Madisonville, Texas. The airplane impacted 50-ft-tall trees about 680 ft south of the approach end of runway 36 at 51R. The airplane came to rest about 550 ft south of the approach end of the runway. At the time of his most recent Federal Aviation Administration (FAA) medical examination, the pilot reported taking no medications and no medical conditions. According to the autopsy, the pilot died as a result of blunt force injuries and the manner of death was accident. Other than an approximate 85% narrowing of his left anterior descending coronary artery, no other significant natural disease was identified. Toxicological testing by the FAA Forensic Sciences Laboratory identified the antidepressant sertraline at 1,006 nanograms per milliliter (ng/mL) and its metabolite, desmethysertraline, in the pilot’s heart blood at 1,533 ng/mL; both were also detected in his urine. The non-impairing medications salicylic acid and atorvastatin were also detected. A pilot logbook was found in the wreckage, and its two most recent entries were dated October 10, 2018, and November 8, with no year specified. The pilot’s recency of experience and the date of his most recent flight review could not be determined. The airplane sustained substantial damage to the fuselage and wings due to impact with trees and terrain. The propeller displayed S-bending consistent with the engine producing power at the time of impact. The trees along the wreckage path exhibited slash marks consistent with propeller strikes. The wing flaps were fully extended. Flight control continuity was confirmed. There were no mechanical anomalies that would have precluded normal operation. The airplane’s rotating beacon and landing light switches were in the OFF position. The landing light filament did not exhibit stretching. ## Aircraft - Registration: [N3258W](https://openairdocs.org/aircraft/N3258W), registered now, S/N 32-81, built 1965 (OpenAirDocs) - Reported make and model: PIPER PA-32-260 - Registry model: [Piper PA-32-260](https://openairdocs.org/model/piper-pa-32-260) (registry code 7103206) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32-81 - Year built: 1965 - Engines: Lycoming O-540-E4B5 260 hp reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, July 1, 2020 - Departed: PIL, Port Isabel, TX - Destination: Same as departure - Airport: 51R, Madisonville Muni, runway 36, 3,202 × 50 ft, asphalt - Equipment: ADS-B, Auto-pilot, Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 68; injuries: fatal; private; airplane ratings: multi-engine land, single-engine land; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 664 total, 582 as pilot in command ## Weather - Conditions: Visual (VMC), Night - Wind: calm - Lowest ceiling: none - Temperature: 81 °F, dew point 81 °F - Altimeter: 29.95 inHg - Observed at: UTS, 21 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 20210613007429A](https://openairdocs.org/incident/20210613007429A), Jun 13, 2021: Piper PA-32-260, Madisonville, TX, Destroyed, 1 fatal. N3258W flight with 01 pilot and 05 passengers onboard originating from port isabel-cameron county airport (pil), port isabel, TX, crashed short of runway 36,… ## Other investigations on N3258W (1) 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. - [NTSB CHI03LA258](https://openairdocs.org/ntsb/CHI03LA258), Aug 10, 2003: Piper PA-32-260 (N3258W), Litchfield, IL, substantial damage. Probable cause: An animal wandered onto the runway and collided with the airplane. A factor was the night light condition. ## Docket (9 files) The files NTSB released with the investigation on July 7, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=103250. 19.7 MB in all. - Google earth radar plot (item 1, KMZ, 526 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13677762&FileExtension=kmz&FileName=20210614_A38468_456734791-Rel.kmz - Adsb data (item 2, CSV, 14.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13677133&FileExtension=csv&FileName=20210614_A38468_456734791_ADSB-Rel.csv - Record of examination (item 3, PDF, 2 pages, 169 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13678675&FileExtension=pdf&FileName=RECORD%20OF%20EXAMINATION%20-Rel.pdf - Pilot logbook excerpt (item 4, PDF, 2 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13678473&FileExtension=pdf&FileName=Logbook%20Master-Rel.pdf - Record of conversation - mechanic (item 5, PDF, 1 page, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13706064&FileExtension=pdf&FileName=RECORD%20OF%20CONVERSATION%20Larry%20Franz_Redacted-Rel.pdf - Medical factual (item 6, PDF, 2 pages, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13573038&FileExtension=pdf&FileName=CEN21FA263_Madisonville_TX_Medical_Factual_FINAL_032922-Rel.pdf - FAA toxicological report (item 7, PDF, 1 page, 175 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13678206&FileExtension=pdf&FileName=Tox%20Master_Redacted-Rel.pdf - Photo log (item 8, PDF, 2 pages, 892 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13678124&FileExtension=pdf&FileName=Photo%20Log-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 2 pages, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13680962&FileExtension=pdf&FileName=Party%20Statements%20MASTER_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.