CHI06FA057

NTSB accident investigation · Piper PA-28-180 · La Vista, NE · December 29, 2005

Accident · FatalField investigationFinal report
Date
December 28, 2005, 23:57 local (Dec 29, 2005, 05:57 UTC)
Place
La Vista, NE
Injuries
3 fatal
Damage
Destroyed
Phase of flight
Takeoff
Aircraft
N9072JPiper PA-28-180
Weather
Instrument (IMC) · Night
Status
Completed · report December 28, 2006
Report
Approved by Office Director
Parties
The New Piper Aircraft, Inc., Federal Aviation Administration, Textron Lycoming
FAA report
20051228030399A
Case key
63047

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 non-instrument rated pilot not maintaining aircraft control and not maintaining altitude/clearance from terrain during takeoff into instrument meteorological conditions. Contributing factors were the low ceilings, night conditions present, and the pilot's improper decision to depart into known instrument meteorological conditions.

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 terrain/waterTakeoff
Inadequate substantiation process,insuff reviewFaa(organization)
Improper decisionPilot in commandFactor
Weather condition - low ceilingFactor
Aircraft control - not maintainedPilot in commandCause
Altitude/clearance - not maintainedPilot in commandCause
Light condition - nightFactor
Procedures/directives - not followedPilot in command
Terrain condition - ground

Analysis

The airplane, piloted by a non-instrument rated private pilot, was destroyed on impact with terrain after takeoff. A witness stated, "I spoke with the waitress on duty [Wednesday December] 28, 2005. She informed me that [the pilot] ordered 2 Crown Royal whiskey and diet Cokes between the hours of 7:30 PM and 9:30 P.M. After 9:30 he only ordered diet Coke." At 2355, recorded radar returns showed an airplane with an encoding transponder on a standard Visual Flight Rules (VFR) 1200 beacon code, about one-half nautical mile (NM) southeast of the departure airport's runway 12 at pressure altitude of 1,400 feet. The location of the first return was consistent with a departure from runway 12. The flight's radar returns indicated that the airplane was in a climbing right turn. The flight's climbing right turn crossed its departure path from runway 12. The flight climbed to a maximum pressure altitude of 2,200 feet, which was followed by a descending right turn. The last recorded return was at 2357 about one and one-half NM southeast of the departure airport at pressure altitude of 1,800 feet. That target disappeared from radar after 2357. No pre-impact anomalies were detected with the airframe or engine. A Final Forensic Toxicology Accident Report on the pilot stated: "47 (mg/dL, mg/hg) ETHANOL detected in Liver; 43 (mg/dL, mg/hg) ETHANOL detected in Muscle." Federal Aviation Administration (FAA) regulation part 91.17 Alcohol or drugs, in part, stated, "(a) No person may act or attempt to act as a crewmember of a civil aircraft - (1) Within 8 hours after the consumption of any alcoholic beverage; (2) While under the influence of alcohol; ... (b) Except in an emergency, no pilot of a civil aircraft may allow a person who appears to be intoxicated or who demonstrates by manner or physical indications that the individual is under the influence of drugs (except a medical patient under proper care) to be carried in that aircraft." The pilot had noted on his last application for airman medical certificate almost a year prior to the accident that he was experiencing anxiety due to a divorce and was using alprazolam (a prescription anti-anxiety medication) as needed, bupropion (a prescription antidepressant), and chlorpheniramine (an over-the-counter sedating antihistamine) seasonally. The FAA's Guide for Aviation Medical Examiners notes that ... "any airman who is undergoing continuous treatment with ... anxiolytics, ... moodameliorating, ... sedating antihistaminic ... drugs ... must be deferred certification unless the treatment has previously been cleared by FAA medical authority." However, the pilot was issued a medical certificate. That issuance was not in compliance with this guidance. The FAA does not appear to have detected or corrected the error.

Factual narrative

History of flight

On December 28, 2005, about 2357 central standard time, a Piper PA-28-180, N9072J, piloted by a non-instrument rated private pilot, was destroyed on impact with terrain near La Vista, Nebraska, after a takeoff from runway 12 at the Millard Airport (MLE), near Omaha, Nebraska. The personal flight was operating under 14 Code of Federal Regulations Part 91. Night instrument meteorological conditions prevailed at the time of the accident. No flight plan was on file. The pilot and two passengers were fatally injured. The flight was originating at the time of the accident and was destined for the Abilene Municipal Airport, near Abilene, Kansas.

Fueling records showed that the airplane was fuelled with 15 gallons of aviation gasoline at MLE on December 28, 2005. A taxicab driver reported that he drove the pilot and two passengers to MLE about 2330 from a dancing establishment that night.

A manager from the dancing establishment, in part, stated:

I spoke with the waitress on duty [Wednesday December] 28, 2005.

She informed me that [the pilot] ordered 2 Crown Royal whiskey

and diet Cokes between the hours of 7:30 PM and 9:30 P.M. After

9:30 he only ordered diet Coke.

The flight's radar returns were viewed at the Federal Aviation Administration's (FAA) Omaha Terminal Radar Approach Control (TRACON) facility. At 2355, the TRACON's radar antenna began recording an aircraft's radar returns with an encoding transponder on a standard Visual Flight Rules (VFR) 1200 beacon code, about one-half nautical mile (NM) southeast of MLE's runway 12 at pressure altitude of 1,400 feet. The location of the first return was consistent with a departure from runway 12. The flight's radar returns indicated that the airplane was in a climbing right turn. The flight's climbing right turn crossed its departure path from runway 12. The flight climbed to a maximum pressure altitude of 2,200 feet, which was followed by a descending right turn. The last recorded return was at 2357 about one and one-half NM southeast of MLE at pressure altitude of 1,800 feet at latitude 41 degrees 10.750 minutes North and longitude 96 degrees 5.483 minutes West. That target disappeared from radar after 2357. A radar plot is appended to the docket material associated with this case.

Personnel information

The pilot held a private pilot certificate with a single-engine land rating issued on May 2, 2005. The pilot held a third-class medical certificate with no restrictions dated January 17, 2005. On the application for that medical certificate, he reported that he had accumulated a total of 18 hours of flight time and 10 hours of flight time in the six months prior to that application. The pilot recorded that he had accumulated about 267 hours of total flight time in his logbook.

Aircraft information

N9072J was a 1966 Piper PA-28-180, Cherokee, serial number 28-3108, single-engine, low-wing airplane. Its engine was a 180-horsepower Lycoming O-360-A3A engine, serial number L-9321-36A. Its propeller was a fixed-pitch, Sensenich M76EM8S5-0-60, with serial number K21007K. The airplane contained an airworthiness certificate dated February 16, 1966 and a registration certificate dated July 23, 2001. The airplane's logbooks showed that the last annual inspection was completed on June 3, 2005. The airplane had accumulated 5,434.8 hours of total time at that inspection.

Meteorological information

At 2310, the recorded weather at MLE was: Wind 350 degrees at 3 knots; visibility 2 statute miles; present weather mist; sky condition overcast 300 feet; temperature 1 degree C; dew point 0 degrees C; altimeter 29.81 inches of mercury.

At 2330, the recorded weather at MLE was: Wind calm; visibility 1 1/2 statute miles; present weather mist; sky condition overcast 300 feet; temperature 1 degree C; dew point 0 degrees C; altimeter 29.81 inches of mercury.

At 2350Z, the recorded weather at MLE was: Wind calm; visibility 1 1/4 statute miles; present weather mist; sky condition overcast 300 feet; temperature 1 degree C; dew point 0 degrees C; altimeter 29.81 inches of mercury.

Wreckage and impact information

The wreckage was found in a field about a mile and one-half southeast of MLE on December 29, 2005 at latitude 41 degrees 10.752 minutes North and longitude 96 degrees 5.672 minutes West. The wreckage debris field was about 300 feet long and was orientated on about a 305-degree magnetic heading. The start of the path had about a five-foot ground scar that contained green media and a deformed navigation light cover. The engine and propeller were found impacted in terrain about 26 feet from the start of the wreckage path. The nose gear was found about 80 feet from the start of the path. The fuselage and empennage were found about 168 feet from the start. The furthest found piece of the wreckage was a section of the exhaust about 300 feet from the start of the path. A damaged beer can was found in the wreckage path and a crushed plastic bottle of Black Velvet whiskey was found in the pilot's inner jacket pocket.

An on-scene investigation was conducted. The control cables for the flight controls were traced. All breaks found were consistent with overload. Flight control continuity was established. Engine controls were traced and engine control continuity was established. The engine's propeller flange was rotated with a lever and crankshaft and camshaft continuity were established. The number four cylinder produced a thumb compression. A propeller blade revealed S-shaped bending and leading edge nicks. Both magnetos produced sparks at all leads. A blue liquid that smelled like aviation gasoline was found in the fuel selector valve. No pre-impact anomalies were detected with the airframe or engine.

Medical and pathological information

The following medical information was extracted by the National Transportation Safety Board's (NTSB) Medical Officer, from records maintained on the pilot by the FAA Aerospace Medical Certification Division:

11/20/00 - The pilot's first Application for 3rd Class Medical

Certificate and Student Pilot Certificate indicated "yes" in response

to "Do you currently use any medication" and indicated only "Alupent

[metaproterenol] as needed."

1/17/05 - The pilot's most recent and only other Application for

3rd Class Medical Certificate and Student Pilot Certificate indicated

"yes" in response to "Do you currently use any medication" and

indicated "Wellbutrin [bupropion]," "Alupent - as needed,"

"Alprasolam [sic] - as needed," and "Deconamine

[chlorpheniramine, pseudoephedrine] - seasonal." For each of the

first three medications, under "Previously Reported" is noted "Yes."

Under "Comments on History and Findings" is noted "HIS DOCTOR

Is following him for recent anxiety over divorce.

NO SUICIAL [sic] INTENTIONS. NO ALPRAZOLUN [sic] WHEN

FLYING." The Application noted that the pilot was issued a Medical

and Student Pilot Certificate with no restrictions.

The FAA records did not note any FAA requests for additional

information from the date of the most recent application to the date of

the accident.

An autopsy was performed on the pilot at the Douglas County Coroner's Office on December 30, 2005.

The FAA Civil Aeromedical Institute prepared a Final Forensic Toxicology Accident Report. The report stated:

47 (mg/dL, mg/hg) ETHANOL detected in Liver

43 (mg/dL, mg/hg) ETHANOL detected in Muscle

Additional information

The parties to the investigation included the FAA, Textron Lycoming, and The New Piper Aircraft, Inc.

The aircraft wreckage was released to a representative of the insurance company.

FAA regulation part 91.17 Alcohol or drugs, in part, stated:

(a) No person may act or attempt to act as a crewmember of a civil

aircraft -

(1) Within 8 hours after the consumption of any alcoholi

Aircraft

Registration
N9072J
Reported as
Piper PA-28-180
Category
Airplane
Serial number
28-3108
Airframe hours
5,434.8
Engine
Lycoming O-360-A3A, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Registered owner
Aerolease of America Inc.
Airworthiness certificate
Standard, Normal
Last inspection
Annual · June 1, 2005
Departed
MLE · La Vista, NE
Destination
K78 · Abilene, KS
Airport
MLE · Millard, runway 12, 3,801 × 75 ft, concrete

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
45
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
May 1, 2005
Seat
Left
Toxicology
Performed
Flight hours
267 total · 61 in the last 90 days · 25 in the last 30 days

Weather

Conditions
Instrument (IMC) · Night
Wind
Calm
Visibility
1.25 statute miles
Lowest ceiling
300 ft overcast
Temperature
34 °F, dew point 32 °F
Altimeter
29.80 inHg
Observed at
MLE, 2 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.

Other investigations on N9072J · 1

Matched to the same aircraft by N-number and date.