# NTSB CEN22FA067: Piper PA 28-140, N3865K, Houston, TX, December 9, 2021

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Class 3 · Field · Final report
- Date: December 8, 2021, 19:57 local (Dec 9, 2021, 01:57 UTC)
- Place: Houston, TX
- Coordinates: 29.778, -95.673
- Nearby events: https://openairdocs.org/map.md?lat=29.7780&lon=-95.6730&mi=10
- Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping)
- Defining event: [Initial climb: Loss of visual reference](https://openairdocs.org/ntsb-events/402)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed
- Report: Approved by Office Director
- Investigation class: Class 3
- NTSB office: Central Region
- Parties: FAA FSDO, Lycoming, Piper Aircraft
- NTSB case key (mKey): 104379
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22FA067
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104379/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104379
- Page: https://openairdocs.org/ntsb/CEN22FA067

## Probable cause

The student pilot’s decision to depart into night instrument meteorological conditions, which resulted in spatial disorientation and a loss of airplane control.

## Findings

NTSB's coded findings; those marked are part of the probable cause.

- [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot; cases with it: [Piper PA-28-140, 6 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7102802), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md)
- [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot; cases with it: [Piper PA-28-140, 43 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102802), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md)
- [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-28-140, 103 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102802), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md)
- [Experience/qualifications: qualification/certification](https://openairdocs.org/ntsb-findings/02031010): Personnel issues › Experience/knowledge · Pilot; cases with it: [Piper PA-28-140, 6 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md?model=7102802), [All aircraft, 280 cases](https://openairdocs.org/ntsb-findings/02031010/cases.md)
- [Planning/preparation: weather planning](https://openairdocs.org/ntsb-findings/02061020): Personnel issues › Task performance · Pilot; cases with it: [Piper PA-28-140, 3 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md?model=7102802), [All aircraft, 156 cases](https://openairdocs.org/ntsb-findings/02061020/cases.md)
- [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Piper PA-28-140, 13 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7102802), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md)
- [Ceiling/visibility/precip: below VFR minima](https://openairdocs.org/ntsb-findings/03035075): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Piper PA-28-140, 3 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md?model=7102802), [All aircraft, 184 cases](https://openairdocs.org/ntsb-findings/03035075/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Initial climb: Loss of visual reference](https://openairdocs.org/ntsb-events/402) (defining event); cases with it: [Piper PA-28-140, 3 cases](https://openairdocs.org/ntsb-events/402/sequence.md?model=7102802), [All aircraft, 242 cases](https://openairdocs.org/ntsb-events/402/sequence.md)
- [Initial climb: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Piper PA-28-140, 11 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=7102802), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md)
- [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Piper PA-28-140, 44 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102802), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md)
- [Initial climb: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-140, 137 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102802), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md)

## Analysis

The student pilot and passenger departed in the pilot’s recently purchased airplane into night instrument meteorological conditions. Flight track information indicated that the airplane departed the airport and proceeded generally south-southwest. The track showed a slight descending left turn and the airplane’s groundspeed increased. The airplane then made a slightly tighter, climbing right turn before entering a tight left descending turn toward the northeast, followed immediately by a hard right descending turn back to the southwest. The airplane’s descent rate continued to increase until contact was lost about 700 ft above the ground. There were no witnesses to the accident. The airplane impacted trees and terrain about 2.5 miles southwest of the departure end of the runway. Examination of the airframe and engine did not reveal any anomalies that would have precluded normal operation. Review of weather information indicated prevailing instrument meteorological conditions (IMC) in the area of the accident site due to low ceilings and visibility restricted in mist, with ceilings near 500 ft above ground level and tops near 2,000 ft mean sea level. There was no evidence that the pilot obtained a preflight weather briefing from an access-controlled source before departure. Postaccident toxicology testing revealed that the pilot had used cannabis; low concentrations of tetrahydrocannabinol (THC) and its inactive metabolite, carboxy-delta-9-tetrahydrocannabinol (THC-COOH), were detected in his blood. Low concentrations of 11-OH-THC and THC-COOH were detected in his urine. Peak effects from using cannabis typically occur in the first couple of hours and concentrations of THC typically fall below 5 ng/mL after three hours. Since THC is stored in fatty tissues and is slowly released days and weeks after using cannabis, low concentrations can be detected long after use, especially in more chronic users. While the pilot’s pattern of cannabis use is unknown, given the low concentration of THC and THC-COOH in his blood, it is unlikely that the pilot was under the influence of THC at the time of the accident, and it is unlikely that the effects of his use of cannabis contributed to this accident. The pilot’s lack of training in instrument meteorological conditions and at night were conducive to the development of spatial disorientation, and the airplane’s flight track was consistent with the known effects of spatial disorientation. Based on the available information, it is likely that the pilot encountered instrument meteorological conditions shortly after takeoff which resulted in his spatial disorientation and a loss of airplane control.

## Factual narrative

The pilot purchased the accident airplane on November 30, 2021. The airplane first arrived at IWS on December 3rd; and was filled with about 40 gallons of 100LL Avgas on December 4th. The pilot flew the airplane for about 20 minutes on December 5th, then again for the accident flight on December 8th. The airplane maintenance logbooks were not recovered. On December 8, 2021, about 1957 central standard time, a Piper PA 28-140 airplane, N3865K, was destroyed when it was involved in an accident near Houston, Texas. The student pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Radar and Automatic Dependent Surveillance – Broadcast (ADS-B) data indicated that the airplane departed West Houston Airport (IWS) about 1955 and proceeded generally south-southwest. About 1.5 miles later, the track showed a slight descending left turn and the airplane’s groundspeed increased, after which the airplane entered a slightly tighter climbing right turn during which the groundspeed decreased. About 2.5 miles southwest of the departure end of the runway, the airplane made a tight left descending turn toward the northeast, followed immediately by a hard right descending turn back to the southwest. The airplane’s descent rate continued to increase until radar contact was lost about 700 ft above the ground. There were no witnesses to the accident. The Harris County Institute of Forensic Sciences, Houston, Texas, performed an autopsy of the pilot. The pilot’s cause of death was multiple blunt force injuries. Toxicology testing performed by the Federal Aviation Administration (FAA) Forensic Sciences Laboratory detected the primary psychoactive compound of cannabis, tetrahydrocannabinol (THC), in the pilot’s heart blood at 1.4 nanograms per milliliter (ng/mL); THC was not detected in his urine. THC’s primary metabolite, 11-hydroxy-delta-9-THC (11-OH-THC), was detected in the pilot’s urine at 11 ng/mL but not in his heart blood. THC’s inactive metabolite, carboxy-delta-9-tetrahydrocannabinol (THC-COOH), was detected in the pilot’s heart blood at 2.7 ng/mL and his urine at 26.5 ng/mL. The marijuana plant (Cannabis species) contains chemicals called cannabinoids; THC is the primary psychoactive cannabinoid compound. THC's mood-altering effects include euphoria and relaxation. In addition, marijuana causes alterations in motor behavior, time and space perception, and cognition. Significant performance impairments are usually observed for at least 1 to 2 hours following marijuana use, and residual effects have been reported up to 24 hours. THC is rapidly metabolized, but the rate of metabolism is not linear and depends on the means of ingestion (smoking, oil, and edibles), potency of the product, frequency of use, and user characteristics. The primary metabolite, 11-OH-THC, is equally psychoactive, but is rapidly metabolized to the non-psychoactive metabolite THC-COOH. THC is fat soluble; itis stored in fatty tissues and can be released back into the blood long after consumption. So, while the psychoactive effects may last a few hours, THC can be detected in the body for days or weeks. Very little THC is excreted in urine. Instead, THC-COOH can be found in urine days to weeks after the last use of the drug. Thus, both blood and urine test results do not necessarily reflect recent use and cannot always be used to prove that the user was under the influence of the drug at the time of testing. National Weather Service (NWS) Surface Analysis Charts for 1800 and 2100 depicted a stationary warm front over Texas with a high-pressure ridge extending over the area. Warm, moist, southeasterly wind advection from the Gulf of Mexico inland supported the development of low stratiform clouds and fog. The station models on the charts depicted overcast clouds and fog/mist expanding over the Texas gulf coast. They also extended northwestward and inland over the surrounding area with temperature-dew point spreads of 4°F or less. The 12-hour Low-Level Significant Weather Prognostic Chart current for 0000 indicated an extensive area of instrument flight rules (IFR) and marginal visual flight rules (MVFR) conditions expected to develop along the Texas gulf coast. The accident airport did not have a weather reporting station; however, observations from nearby airports indicated prevailing IFR conditions due to low ceilings and visibility restricted in mist. The High-Resolution Rapid Refresh (HRRR) numerical model sounding over the approximate accident site for 2000 supported a ceiling near 500 ft above ground level (agl) with tops near 2,000 ft. Satellite imagery depicted stratified clouds over the region with a radiative cloud tops temperature consistent with tops near 3,000 ft. Several pilot reports included cloud tops in the Houston area between 3,000 and 3,200 ft. There were no reports of turbulence, icing, or low-level wind shear. There was no record of the pilot receiving a preflight weather briefing from a flight service provider or through Foreflight. According to the pilot’s flight instructor, the pilot was familiar with obtaining preflight weather, interpreting METARs, TAFs, and AIRMETs, and basic weather minimums. According to the student pilot’s flight instructor, the pilot had been receiving flight training for about a year. He had about 38 hours of flight experience, all of which was in a Cessna 172. The pilot had completed all solo requirements and had 4 hours of night flight experience, toward his private pilot certificate, but had not completed all of the required training in flight solely by reference to the instruments. Before the accident, the pilot had reached out to the flight instructor twice about flight training in the accident airplane; however, the instructor never saw the airplane. He was unaware if the pilot was receiving instruction from any other flight instructors. The airplane impacted a wooded area about 2.5 milessouthwest of the departure end of the runway. The debris path was about 50 ft long on a heading of 320°. The first identified point of impact were two trees. About 10 ft past the trees was the first piece of debris; a fragment of outboard right wing that remained wrapped around and a tree. Continuing along the debris path was a narrow series of cut trees. Each one was topped slightly closer to the ground, descending toward a large impact crater in the soft dirt. Scattered around the base of these trees were various fragments of the right wing, the main landing gear, and the vertical stabilizer with rudder attached. The impact crater was about 2.5 ft deep by 5 ft long. Located inside of the crater were the propeller assembly, the starter ring gear, a spark plug fragment, and other engine fragments. Portions of engine cowling, right side door, and various instruments/radios were in the vicinity around the crater. The main wreckage came to rest just beyond the impact crater and comprised all major components of the airplane. The airplane came to rest nose-low with the tail extended upward at an angle. The engine was completely separated from the airplane and came to rest near the empennage. The firewall, instrument panel, and cabin sustained extensive damage. On-scene examination of the airframe and engine did not reveal any anomalies with the airframe or engine that would have precluded normal operation. The left wing remained attached at the wing spar and was fractured about mid span. The fuel cap remained secured; however, the fuel tank was breached and no fuel was noted. The outboard left wing leading edge exhibited extensive aft crushing. The right wing was fractured into several pieces; two larger pieces exhibited a circular tree indent along with aft crush damage. The inboard right wing came to rest near the fuselage; the fuel cap remained secured, and the fuel tank was breached. The aft fuselage sustained downward accordion crushing; the aft fuselage displayed a large circular indentation consistent with tree contact. The stabilator remained secured to its attachment points. The vertical stabilizer and rudder were fracture-separated; a large circular tree impact was noted on the side. The flight control system exhibited extensive damage, but all cables/chains remained attached at their respective surfaces and all cable fractures were consistent with overload. There were no visual indications of catastrophic engine failure. The propeller assembly was fracture separated and the crankshaft flange was bent. The No. 1 cylinder head was fractured; the push rods and upper spark plug were fracture separated. The remaining upper spark plugs were removed and consistent with normal operation. The magnetos remained attached to their mounting pads; the right magneto sustained impact damage and would not rotate. The left magneto remained intact and was removed; spark was obtained on all points. Borescope examination of the piston heads, cylinder walls,valves, and lower spark plugs were all consistent with normal operation. The engine was rotated by hand; drivetrain continuity was established, and thumb compression was obtained on all four cylinders.

## Aircraft

- Registration: [N3865K](https://openairdocs.org/deregistered/N3865K-2023-09-16), registration cancelled 2023-09-16, S/N 28-23754, built 1967 (OpenAirDocs)
- Reported make and model: Piper Aircraft PA 28-140
- Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs)
- Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-23754
- Year built: 1967
- Engines: Lycoming 0-320-E2A reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Operator: Breathtaking Navigation LLC
- Registered owner: Breathtaking Navigation LLC
- Airworthiness certificate: Standard, Normal
- Destination: LVJ, Pearland, TX
- Airport: KIWS, West Houston Airport, runway 15, 3,953 × 75 ft, asphalt
- Equipment: ADS-B

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 23; injuries: fatal; student; medical: class 3, without waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 38 total, 10 in this make and model

## Weather

- Conditions: Instrument (IMC), Night/dark
- Wind: 130° at 10 knots
- Visibility: 8 statute miles
- Lowest ceiling: 800 ft overcast
- Temperature: 66 °F, dew point 61 °F
- Altimeter: 3000.00 inHg
- Observed at: KSGR, 9 nm away
- METAR: KSGR 090153Z 13010KT 8SM OVC008 19/16 A3000 RMK AO2 SLP160 T01890156

## 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 20211208021649A](https://openairdocs.org/incident/20211208021649A), Dec 8, 2021: Piper PA-28-140, Houston, TX, Destroyed, 2 fatal. On December 8, 2021 at approximately 19:55 CST, N3865K took off from west Houston airport (iws) heading to pearland, Texas (lvj). Upon climb out the airplane…

## Docket (10 files)

The files NTSB released with the investigation on July 6, 2022, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104379. 13.1 MB in all.

- On scene observations (item 1, PDF, 23 pages, 8.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14026386&FileExtension=pdf&FileName=On%20Scene%20Notes-Rel.pdf
- Google maps (item 2, PDF, 3 pages, 590 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13168448&FileExtension=pdf&FileName=google%20earth%20images-Rel.pdf
- Record of conversation - FAA inspector regarding airport manager (item 3, PDF, 1 page, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13048489&FileExtension=pdf&FileName=ROC%20FAA-Rel.pdf
- Record of conversation - certified flight instructor (item 4, PDF, 1 page, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13048712&FileExtension=pdf&FileName=ROC%20CFI-Rel.pdf
- ADS-B data - google earth (item 5, KMZ, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13017244&FileExtension=kmz&FileName=20211209_A474A5_471481661_ADSB-Rel.kmz
- ADS-B tabular data (item 6, CSV, 233 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13016904&FileExtension=csv&FileName=20211209_A474A5_471481661_ADSB-Rel.csv
- Statement of party representatives to NTSB investigation (item 7, PDF, 2 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13996799&FileExtension=pdf&FileName=PARTY%20FORMS%20printed_Redacted-Rel.pdf
- Toxicological report (item 8, PDF, 1 page, 821 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13168150&FileExtension=pdf&FileName=Tox%20pilot_Redacted-Rel.pdf
- Record of memorandum - autopsy (item 9, PDF, 1 page, 97 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13869910&FileExtension=pdf&FileName=ROM%20auotpsy-Rel.pdf
- Medical factual (item 10, PDF, 3 pages, 224 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=13873675&FileExtension=pdf&FileName=CEN22FA067_Houston_TX_Medical_Factual_FINAL_051822-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.

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