CHI00FA288

NTSB accident investigation · Piper PA-22-108 · Custer, SD · September 8, 2000

Accident · FatalField investigationFinal report
Date
September 8, 2000, 08:20 local (14:20 UTC)
Place
Custer, SD
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N4730ZPiper PA-22-108
Weather
Visual (VMC) · Day
Status
Completed · report January 2, 2002
Report
Approved by Office Director
FAA report
20000908037119A
Case key
50249

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot not maintaining clearance from the tree. Factors relating to this accident were the pilot's inadequate preflight planning and preparation, the high density altitude, the inadequate rate of climb, the pilot's improper in-flight decision to fly into rising terrain, the rising terrain, the blind canyon, and the tree.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with objectManeuvering
Clearance - not maintainedPilot in commandCause
Preflight planning/preparation - inadequatePilot in commandFactor
Weather condition - high density altitudeFactor
Proper climb rate - inadequateFactor
In-flight planning/decision - improperPilot in commandFactor
Terrain condition - risingFactor
Terrain condition - blind/box canyonFactor
Object - tree(s)Factor
In flight collision with terrain/waterDescent - uncontrolled

Analysis

A witness watched the airplane take off on runway 33 (4,000 feet by 50 feet, dry asphalt) at the Custer State Park Airport (3V0). "About halfway down the runway, he got airborne. He then pushed the nose over, as if he was trying to pick up more airspeed." The witness said he keyed his microphone and asked the pilot, "You got trouble there?" The pilot responded, "No, just a little trouble climbing." The witness called the pilot again and said, "Turn into the wind, if you think it will help you out." The witness said that the pilot's response back was something like, "I got my hands full right now. Don't call me back." The witness said he watched the airplane until it went around the edge of a ridge beyond the end of the runway, where he lost sight of it. "A few minutes later, I saw smoke coming over the ridge." Several witnesses at a campground in the park saw the airplane flying westbound through the canyon along the state park road. One witness said the airplane was below the tops of the mountains and trees making up the canyon walls. Another witness saw the airplane bank hard to the left. "While banking the turn, his right wing was way up and his left wing tipped ... close to [the] ground." The witness said the next thing he realized, the airplane had crashed. An examination of the airplane wreckage revealed no anomalies. The temperature and altimeter for the Custer County Municipal Airport, (field elevation 5,602 feet), 11 miles southwest of the accident site, were 60 degrees F and 29.95 inches of Mercury, respectively. 3V0 rests in a valley at a field elevation of 3,980 feet. The terrain rises off the end of runway 33 into a 4,400-foot ridge, 1.4 miles north of the airport. A second 4,800-foot ridge, forming the north side of a canyon, begins 4 miles north of the airport. The canyon runs east to west and is characterized by steep walls and sharp turns. A fire fighter pilot at 3V0 said the winds were out of the west at 20 knots. The fire fighter pilot said that runway 33 slopes uphill, and that the winds coming off the hills to the west present difficulties to airplanes that don't have the power to climb. "We takeoff on 33 and settle over the valley there. If you keep going, you get into rising terrain and then into the canyon. If you can't climb there, it's done." The results of FAA toxicology testing of specimens received from the pilot showed the presence of 0.85 (ug/ml) cyanide in the blood. Normal blood cyanide concentrations are less than 0.15 ug/ml, while lethal concentrations are greater than 3 ug/ml. Entering the "Climb Speeds and Rates vs. Standard Altitude" chart in the airplane's Owner's Handbook with a density altitude of 7,001 feet, provides a rate of climb of approximately 315 feet per minute.

Factual narrative

History of flight

On September 8, 2000, at 0820 mountain daylight time, a Piper PA-22-108, N4730Z, operated by a private pilot, was destroyed when after takeoff from the Custer State Park Airport, Custer, South Dakota, it struck a tree, and subsequently impacted into the wall of a canyon. A post-crash fire ensued. Visual meteorological conditions prevailed at the time of the accident. The personal flight was being operated under the provisions of Title 14 Code of Federal Regulations Part 91. There was no flight plan on file. The pilot and pilot-rated passenger on board were fatally injured in the accident. The local flight originated at Custer, South Dakota at 0810.

A witness said that N4730Z was one of two airplanes that were going to fly by Mount Rushmore, so that the witness could have his airplane photographed against the backdrop of the mountain. The witness said that both airplane's taxied out to the end of runway 33 (4,000 feet by 50 feet, dry asphalt), and performed their preflight checks and engine run-ups. The witness said the winds at the airport were pretty much a crosswind, but seemed to favor runway 33. The witness said that N4730Z departed first. "About halfway down the runway, he got airborne. He then pushed the nose over, as if he was trying to pick up more airspeed." The witness said he keyed his microphone and asked the pilot of N4730Z, "You got trouble there?" The pilot responded, "No, just a little trouble climbing." The witness called the pilot again and said, "Turn into the wind, if you think it will help you out." The witness said that the pilot's response back was something like, "I got my hands full right now. Don't call me back." The witness said he watched the airplane until it went around the edge of a ridge beyond the end of the runway, and he lost sight of it. "A few minutes later, I saw smoke coming over the ridge."

A fire fighter pilot on the Custer State Park Airport said he watched N4730Z takeoff over the departure end of runway 33. "They were about 150 feet above the ground when he went by. He didn't gain any altitude at all. He went straight ahead and to the west." The fire fighter pilot said that the airplane wasn't climbing, and was not gaining altitude while flying into up-sloping terrain. He said the airplane passed over a ridge located about one mile off the end of runway 33. After he passed the ridge, the fire fighter pilot said he dropped out of sight. A short time after that, black smoke could be seen coming over a ridge to the northwest.

Several witnesses at a campground near the accident site saw the airplane flying along U. S. Highway 16A, heading west through the canyon. One witness said the airplane was below the tops of the mountains and trees making up the canyon walls. Another witness saw the airplane bank hard to the left. "While banking the turn, his right wing was way up and his left wing tipped ... close to [the] ground." The witness said the next thing he realized, the airplane had crashed. The witness said that the airplane's engine sounded normal.

Personnel information

The pilot held a private pilot certificate with single-engine land, instrument airplane ratings.

According to his pilot logbook, as of August 20, 2000, the pilot had recorded a total of 721.7 flying hours, 663.3 hours of which were in single-engine airplanes. The pilot's logbook showed that he had last flown N4730Z on August 20, 2000, logging 2.5 hours of flight time.

The pilot's logbook also showed that he successfully completed a biennial flight review on August 12, 2000.

The pilot held a current third class medical certificate, dated July 17, 2000. The limitations block on the certificate showed the pilot "Must wear corrective lenses."

The pilot-rated passenger held a private pilot certificate with a single-engine land rating.

According to Federal Aviation Administration aeromedical records, the pilot-rated passenger reported having 920 total civilian flying hours on July 30, 1997.

The pilot-rated passenger held a third class medical certificate, dated July 30, 1999. The limitations block on the certificate showed the pilot-rated passenger "Must wear corrective lenses for near and distant vision."

Aircraft information

The airplane was owned and operated by the pilot, and used for pleasure.

The airplane underwent an annual inspection on November 1, 1999. At the time of the annual inspection, the airframe time was 2,596.0 hours.

Meteorological information

At 0753, the Routine Aviation Weather Report (METAR) at the Custer County Municipal Airport, Custer, South Dakota (field elevation 5,602 feet), 11 nautical miles from the accident site on a 245 degree magnetic heading, reported clear skies, 10 miles visibility, winds 250 degrees at 7 knots, temperature 60 degrees F, dew point 21 degrees F, and altimeter 29.95 inches of Mercury (Hg).

A fire fighter pilot at the Custer State Park Airport said that at the time N4730Z took off, the winds were out of the west, and estimated at 20 knots.

Airport information

The Custer State Park Airport (3V0) is located at the east edge of the park along Wildlife Loop Road. The field elevation is 3,980 feet. The airport operates runways 15-33. The airport exists primarily for staging aerial fire fighting operations. The park keeps two agricultural-model airplanes, loaded with water, on alert, in the event that a forest fire breaks out. Private airplanes are allowed to operate out of Custer State Park Airport with prior permission.

The airport sits in a valley. The terrain rises west of the airport. The terrain also rises off the departure ends of both runways, but especially off the end of runway 33. A 4,400-foot ridge sits approximately 1.4 miles north of the airport. A second ridge, beginning 4 miles north of the airport, forms the north walls of a canyon that proceeds northwest and then west through the park. U. S. Highway 16A runs westward along the canyon floor. The highway and the canyon walls are characterized by sharp 45 and 90 degree turns. A topographical chart of the area shows 4,200 to 4,800 foot contour lines along the second ridge.

Fire fighter pilots who stage out of the Custer State Park Airport said that they usually take off to the south on runway 15, because the terrain falls off and there is more room to climb. When they use runway 33, they turn to the northeast to east, away from the rising terrain. One pilot said that the runway [33] slopes uphill, and the winds coming off the hills to the west present difficulties to airplanes that don't have the power to climb. "We takeoff on 33 and settle over the valley there. If you keep going, you get into rising terrain and then into the canyon. If you can't climb there, it's done."

Wreckage and impact information

The Safety Board on scene investigation began on September 9, 2000, at 1030.

The accident site was located in a canyon, along a 1,600 foot long, north-to-south stretch of U. S. Highway 16A, a two-lane, paved road, which begins at the east entrance to Custer State Park, and winds through the park, west to the town of Custer, South Dakota. The accident site began 5 miles west of the park's east entrance station, and 1/8 mile southwest of the park's Grace Coolidge Campground. The approximate elevation of the accident site was 4,475 feet mean sea level.

An 85-foot tall, 32 inch diameter pine tree defined the beginning of the accident site. It was located at the north end of a north-south running section of U. S. Highway 16A, approximately 15 feet northwest of the highway's edge. Several branches from the top of the tree were broken off. A 4-foot branch section was found 15 feet south of the tree's base. Several pine boughs were found on the west edge of the highway, approximately 90 feet south of the pine tree.

The airplane's main wreckage was located 270 feet south-south

Aircraft

Registration
N4730Z
Reported as
Piper PA-22-108
Category
Airplane
Serial number
22-8276
Airframe hours
2,596
Engine
Lycoming O-235-C1B, 115 horsepower, reciprocating
Damage
Destroyed
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Larry P. Peltry
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 1, 1999
Departed
3V0
Airport
3V0 · Custer State Park Airport, runway 33, 4,000 × 50 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
51
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
721 total · 607 as pilot in command · 10 in the last 90 days · 7 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
250° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
140 °F, dew point 70 °F
Altimeter
29.00 inHg
Observed at
CUT, 11 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.