# NTSB CEN23LA255: Piper PA-25-235, N7419Z, Westhope, ND, June 22, 2023 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 4 · Limited · Final report - Date: June 22, 2023, 12:15 local (17:15 UTC) - Place: Westhope, ND - Coordinates: 48.909464, -101.02071 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=48.9095&lon=-101.0207&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: Serious injuries - Injuries: 1 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Central Region - Parties: Federal Aviation Administraiton, Fargo FSDO - NTSB case key (mKey): 192426 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN23LA255 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192426/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192426 - Page: https://openairdocs.org/ntsb/CEN23LA255 ## Probable cause The pilot’s failure to maintain aircraft control that resulted in an impact with terrain after takeoff. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Maintenance/inspections](https://openairdocs.org/ntsb-findings/01010500): Aircraft › Aircraft handling/service · Incorrect service/maintenance; cases with it: [Piper PA-25-235, 1 case](https://openairdocs.org/ntsb-findings/01010500/cases.md?model=7102504), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/01010500/cases.md) - [Maintenance/inspections: scheduled maint checks](https://openairdocs.org/ntsb-findings/01010520): Aircraft › Aircraft handling/service · Not serviced/maintained; cases with it: [Piper PA-25-235, 1 case](https://openairdocs.org/ntsb-findings/01010520/cases.md?model=7102504), [All aircraft, 76 cases](https://openairdocs.org/ntsb-findings/01010520/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-25-235, 18 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102504), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Prior to flight: Aircraft maintenance event](https://openairdocs.org/ntsb-events/040); cases with it: [Piper PA-25-235, 1 case](https://openairdocs.org/ntsb-events/040/sequence.md?model=7102504), [All aircraft, 484 cases](https://openairdocs.org/ntsb-events/040/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-25-235, 11 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102504), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-25-235, 28 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102504), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot, who did not hold an airframe and powerplant (A&P) certificate, stated that after he installed the overhauled engine onto the agricultural airplane, he planned on flying the airplane during the accident flight to break the engine in prior to having it inspected and signed off by an A&P mechanic with inspection authorization. There was no record of a current annual inspection of the airplane prior to the flight. The pilot loaded the airplane with 20 gallons of water to test the spray system since he planned on flying for about an hour. During climb after takeoff, the pilot lost control, and the airplane descended and impacted terrain resulting in substantial damage to both wings and fuselage. The pilot stated there was no mechanical malfunction/failure of the airplane that would have precluded normal operation. ## Aircraft - Registration: [N7419Z](https://openairdocs.org/deregistered/N7419Z-2024-02-15), registration cancelled 2024-02-15, S/N 25-3390, built 1965 (OpenAirDocs) - Reported make and model: PIPER PA-25-235 - Registry model: [Piper PA-25-235](https://openairdocs.org/model/piper-pa-25-235) (registry code 7102504) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 25-3390 - Year built: 1965 - Airframe hours: 7249 - Engines: Lycoming O-540-B2B5 reciprocating - Damage: Substantial damage - Flight: Flight test, Part 91 - Operator: Pilot - Registered owner: Pilot - Airworthiness certificate: Special, Restricted (Special) - Last inspection: Annual, May 21, 2020 - Destination: Same as departure - Airport: D64, Westhope Municipal Airport, runway 32, 3,000 × 60 ft - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: serious; private; airplane ratings: single-engine land; medical: class 2, without waivers/limitations; last flight review June 30, 2021; seat: center; flight hours: 400 total ## Weather - Conditions: Visual (VMC), Day - Wind: 100° at 2 knots - Visibility: 10 statute miles - Lowest ceiling: 2,300 ft overcast - Temperature: 64 °F, dew point 54 °F - Altimeter: 30.11 inHg - Observed at: MIB, 32 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 20230622007879A](https://openairdocs.org/incident/20230622007879A), Jun 22, 2023: Piper PA-25-235, Westhope, ND, Destroyed. Pilot was test flying aircraft after engine installation. Aircraft also had 20 gallon load of water. Shortly after takeoff, during climbout, aircraft stalled,… ## Docket (4 files) The files NTSB released with the investigation on October 5, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192426. 181 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15861621&FileExtension=pdf&FileName=6120%20Master_Redacted-Rel.pdf - FAA inspector statement (item 2, PDF, 1 page, 47 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15860360&FileExtension=pdf&FileName=Tofteland%20Inspector%20Statement%202023-06-26-Rel.pdf - Maintenance records excerpt (item 3, PDF, 3 pages, 178 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15859987&FileExtension=pdf&FileName=Maintenance%20Log%20Master_Redacted-Rel.pdf - Photo log (item 4, PDF, 2 pages, 957 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15862684&FileExtension=pdf&FileName=Photo%20Log%20Master%20Redacted-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.