# NTSB CEN22FA131: Piper PA-32-260, N3952W, Fostoria, OH, February 23, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: February 22, 2022, 22:41 local (Feb 23, 2022, 03:41 UTC) - Place: Fostoria, OH - Coordinates: 41.14139, -83.377247 - Nearby events: https://openairdocs.org/map.md?lat=41.1414&lon=-83.3772&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: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Central Region - Parties: Lycoming Engines, Piper Aircraft, FAA - NTSB case key (mKey): 104683 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN22FA131 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104683/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104683 - Page: https://openairdocs.org/ntsb/CEN22FA131 ## Probable cause The pilot’s loss of airplane control in night instrument meteorological conditions during the procedure turn of an instrument approach due to spatial disorientation, which resulted in a collision with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-32-260, 2 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7103206), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Performance/control parameters: heading/course](https://openairdocs.org/ntsb-findings/01062047): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-32-260, 1 case](https://openairdocs.org/ntsb-findings/01062047/cases.md?model=7103206), [All aircraft, 82 cases](https://openairdocs.org/ntsb-findings/01062047/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-32-260, 18 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103206), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-32-260, 2 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7103206), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) - [Ceiling/visibility/precip: clouds](https://openairdocs.org/ntsb-findings/03035025): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Piper PA-32-260, 2 cases](https://openairdocs.org/ntsb-findings/03035025/cases.md?model=7103206), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/03035025/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: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-32-260, 10 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7103206), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Approach-IFR initial approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120); cases with it: [Piper PA-32-260, 4 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7103206), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) - [Approach-IFR initial approach: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-32-260, 3 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7103206), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) ## Analysis The pilot was conducting a night cross-country flight in instrument meteorological conditions. After passing the initial approach fix (IAF) for the RNAV (GPS) instrument approach at the destination airport, the airplane made about a 30° left turn, consistent with a teardrop entry into the procedure turn. The track data showed the airplane aligned with the outbound side of the holding pattern for about a mile before turning left again. As the airplane flew north of the published hold in its final minute of flight its altitude decreased from about 3,000 ft to about 2,600 ft before climbing back to about 3,000 ft and about 4 nautical miles (nm) from the initial approach fix (IAF), the airplane turned right, and descended rapidly in a spiral. The airplane traveled through heavily forested terrain and was highly fragmented. A witness who was inside a residence described hearing an airplane at a low altitude near the house. The witness described the noise as a loud or high pitch engine followed by silence. Another nearby witness saw the lights of the airplane but did not hear anything because they were in a car with the radio on. The witness stated the airplane was between 300 and 500 ft above ground level (agl). When they lost sight of the airplane as it descended behind houses, they estimated the altitude between 150 and 250 ft agl. A postaccident examination of the airframe and engine revealed no preaccident mechanical malfunctions or failures that would have precluded normal operation. The pilot’s toxicology results revealed that sedating antihistamines diphenhydramine and doxylamine were present in tissue samples. It is possible that the combined effects of those drugs might have increased the pilot’s susceptibility to spatial disorientation. However, the diphenhydramine and doxylamine results in tissue cannot be used to establish whether the drugs contributed to spatial disorientation or were otherwise impairing the pilot at the time of the accident. Based upon the wreckage fragmentation, which was consistent with a high-speed impact, the constant descending turn and IMC, it is likely that the accident pilot experienced spatial disorientation and lost airplane control. ## Factual narrative Spatial Disorientation The Federal Aviation Administration’s (FAA) Airplane Flying Handbook (FAA H 8083 3B) described some hazards associated with flying when the ground or horizon are obscured. The handbook states, in part, the following: The vestibular sense (motion sensing by the inner ear) in particular can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated, leading the pilot to believe the attitude of the airplane has changed when, in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation. On February 22, 2022, about 2241 eastern standard time, a Piper PA32 airplane, N3952W, was destroyed when it was involved in an accident near Fostoria, Ohio. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 business flight. The flight was conducted as an instrument flight rules (IFR) flight from Effingham County Memorial Airport (1H2), Effingham, Illinois to Findlay Airport (FDY), Findlay, Ohio. The filed IFR flight plan stipulated a cruise altitude of 9,000 ft mean sea level (msl), an estimated time en route of 1 hour 28 minutes with 4 hours of fuel on board. A review of archived Federal Aviation Administration (FAA) automatic dependent surveillance broadcast data revealed that the airplane departed 1H2 about 1956 central standard time, climbed to about 7,000 ft msl and proceeded on a relatively direct track toward DOYET, the initial approach fix for the RNAV/GPS runway 25 instrument approach, as shown in figure 1. Figure 1: Published Instrument Approach Procedure After passing DOYET, the airplane made about a 30° left turn, consistent with a teardrop entry into the procedure turn. The airplane aligned with the outbound side of the holding pattern for about a mile before turning left again. As the airplane flew north of the published holding pattern in its final minute of flight its altitude decreased from about 3,000 ft to about 2,600 ft before climbing back to about 3,000 ft About 4 nm from the IAF, the airplane turned right, and descended rapidly in a spiral and impacted terrain on a heading of 340° (see figure 2). Figure 2: Instrument Approach with Flight Track Overlay A review of commercially available communications data revealed that the last confirmed communication between the accident airplane and air traffic control (ATC) took place when ATC instructed the pilot to cross DOYET at or above 3,000 ft and cleared them for the RNAV runway 25 approach, to which the pilot read back the clearance and altitude restriction. Shortly thereafter, ATC attempted to contact the pilot and subsequently issued a low altitude alert, but no reply or acknowledgement was received. A witness inside their residencedescribed hearing an airplane low near their house. They described the noise as a loud engine or high rpm engine followed by silence. Another nearby witness saw the lights of the airplane but did not hear anything because they were in a car with the radio on. They said that at first sight, the airplane was estimated between 300 and 500 ft above ground level (agl). When they lost sight of the airplane as it descended behind houses, they estimated the altitude between 150 and 250 ft agl. The FAA Forensic Sciences laboratory performed toxicological testing of postmortem specimens from the pilot. Diphenhydramine was detected in liver and muscle and Doxylamine was detected in muscle; the liver specimen was unsuitable for reporting a doxylamine result. Dextromethorphan was detected in liver and muscle, and the dextromethorphan metabolite dextrorphan was detected in liver (not in muscle). Diphenhydramine is a sedating antihistamine medication available over the counter in multiple cold and allergy products and sleep aids. Doxylamine is another sedating antihistamine medication that is available over the counter as a sleep aid and as an ingredient in various cold and allergy products. Sedating antihistamines can cause cognitive and psychomotor slowing and drowsiness, and products containing sedating antihistamines often carry warnings that they may impair performance of tasks like driving and operating heavy machinery., , , , The FAA states that pilots should not fly within 60 hours of using diphenhydramine or doxylamine, to allow time for the drugs to be cleared from circulation. Dextromethorphan is a cough suppressant medication that is available over the counter in a variety of cold and allergy products. Dextrorphan is the main active metabolite of dextromethorphan. Dextromethorphan and dextrorphan are not typically impairing at levels associated with medicinal dextromethorphan use. The FAA states that pilots who use dextromethorphan should observe a waiting period for the drug to be cleared from circulation before flying. The airplane impacted a field in a relatively flat attitude and continued on a 340° track into a forest, where it collided with multiple trees and became highly fragmented. Flight control continuity could not be established due to the highly fragmented nature of the wreckage, but all lengths of control cables were accounted for at the accident location. All major pieces of the airplane were observed at the accident location. A postaccident examination of the engine revealed no mechanical malfunctions or anomalies that would have precluded normal operation. ## Aircraft - Registration: [N3952W](https://openairdocs.org/deregistered/N3952W-2023-12-01), registration cancelled 2023-12-01, S/N 32-936 (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: 32-936 - Engines: LYCOMING 0-540-E4B5 250 horsepower reciprocating - Damage: Destroyed - Flight: Business, Part 91 - Airworthiness certificate: Standard, Normal - Departed: 1H2, Effingham, IL - Destination: FDY, Findlay, OH - Flight plan: IFR - Equipment: Stall warning system, Auto-pilot, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 59; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; toxicology performed; flight hours: 1,137.2 total, 630.8 in this make and model - Pilot; age 51; injuries: fatal; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane, helicopter; medical: class 1, without waivers/limitations; flight hours: 6,500 total ## Weather - Conditions: Instrument (IMC), Night - Wind: 270° at 27 knots, gusting 33 - Visibility: 8 statute miles - Lowest ceiling: 600 ft broken - Temperature: 41 °F, dew point 37 °F - Altimeter: 29.94 inHg - Observed at: KFDY, 15 nm away - METAR: SPECI KFDY 230339Z AUTO 27027G33KT 8SM BKN006 OVC011 05/03 A2994 RMK AO2 PK WND 27033/0338 PRESRR T00500028= ## 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 20220222007139A](https://openairdocs.org/incident/20220222007139A), Feb 22, 2022: Piper PA-32-260, Fostoria, OH, Destroyed, 2 fatal. N3952W departed effingham airport Indiana (1H2) to findlay airport (fdy). Pilot requested vectors to the RNAV runway 25 approach at fdy. Aircraft was having a… ## Docket (15 files) The files NTSB released with the investigation on June 28, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104683. 34.7 MB in all. - On-scene examination (item 1, PDF, 3 pages, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15328382&FileExtension=pdf&FileName=Airframe%20Examination%20Summary-Rel.pdf - Engine examination (item 2, PDF, 2 pages, 74 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15327735&FileExtension=pdf&FileName=Engine%20Examination%20Memo-Rel.pdf - Meteorology (item 3, PDF, 22 pages, 3.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15075762&FileExtension=pdf&FileName=CEN22FA131%20-%20Fortoria,%20OH-Rel.pdf - Meteorology attachment 1 - preflight briefing (item 4, PDF, 30 pages, 7.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15075673&FileExtension=pdf&FileName=Attachment%201%20-%20ForeFlight%20Weather%20Briefing%20CEN22FA131-Rel.pdf - Electronic devices - specialist's factual report (item 5, PDF, 10 pages, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15078107&FileExtension=pdf&FileName=CEN22FA131%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.pdf - Attachment 1 to electronic devices - specialist's factual report (item 6, CSV, 4.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15078111&FileExtension=csv&FileName=CEN22FA131%20Attachment%201%20to%20Electronic%20Devices%20-%20Specialist%27s%20Factual%20Report-Rel.csv - Witness statements (item 7, PDF, 2 pages, 138 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15716473&FileExtension=pdf&FileName=Witness%20Statements_Redacted-Rel.pdf - Air traffic control memo (item 8, PDF, 1 page, 62 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15716711&FileExtension=pdf&FileName=ATC%20Memo-Rel.pdf - Photos (item 9, PDF, 1 page, 712 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15328620&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - ADS-B data (item 10, XLSX, 15.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15327821&FileExtension=xlsx&FileName=20220223_A4980F_477040768_ADSB-Rel.xlsx - ADS-B plot (item 11, KMZ, 366 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15328246&FileExtension=kmz&FileName=20220223_A4980F_477040768-Rel.kmz - Medical factual report (item 12, PDF, 8 pages, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15329910&FileExtension=pdf&FileName=CEN22FA131_MedicalFactualReport-Rel.pdf - Toxicological reports (item 13, PDF, 2 pages, 322 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15348646&FileExtension=pdf&FileName=Toxicology%20Reports_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 14, PDF, 11 pages, 538 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15357429&FileExtension=pdf&FileName=Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 15, PDF, 1 page, 150 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15330597&FileExtension=pdf&FileName=N3952W%20NTSB%20Wreckage%20Release%20Form%20Signed%2004%2011%2023_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.