CHI08FA135

NTSB accident investigation · Piper PA-28-140 · Stevens Point, WI · May 12, 2008

Accident · FatalField investigationFinal report
Date
May 12, 2008, 17:00 local (22:00 UTC)
Place
Stevens Point, WI
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N1813TPiper PA-28-140
Defining event
Initial climb: Loss of engine power (partial)
Weather
Visual (VMC) · Day
Status
Completed · report May 6, 2009
Report
Approved by Office Director
Parties
Federal Aviation Administration, Lycoming Engines, Piper Aircraft, Inc.
FAA report
20080512844409A
Case key
67994

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 partial loss of engine power for undetermined reasons.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Engine (reciprocating)Aircraft › Aircraft power plant · Not specifiedPiper PA-28-140: 10 casesAll aircraft: 497 casesProbable cause
Not determinedNot determined › Not determined · Unknown/Not determinedPiper PA-28-140: 27 casesAll aircraft: 2,247 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane was taking off and experienced a loss of engine power during the initial climb. Witnesses on the ground observed smoke off of the end of the runway from the postimpact fire. An examination of the accident scene showed a ground scar containing green glass pieces from the right navigation light and pieces of the right wing tip. A nearby ground depression was consistent with the shape of the engine cowling. An examination of the propeller showed damage signatures consistent with the engine at low power. No preimpact anomalies were revealed with the airplane during the investigation.

Factual narrative

History of flight

On May 12, 2008, about 1700 central daylight time, a Piper PA-28-140, N1813T, owned and piloted by a private pilot, sustained substantial damage when it impacted terrain south of runway 12 (3,635 feet by 75 feet, dry, asphalt) at the Stevens Point Municipal Airport (STE), near Stevens Point, Wisconsin. A post-impact fire occurred. The personal flight was operating under 14 CFR Part 91 and no flight plan was on file. Visual meteorological conditions prevailed at the time of the accident. The pilot and passenger were fatally injured. The flight was originating from STE at the time of the accident and was destined for the J. Douglas Bake Memorial Airport (OCQ), near Oconto, Wisconsin.

A refueling receipt showed that the airplane was serviced with 27.4 gallons of "auto" fuel at OCQ on May 12, 2008, prior to its departure to STE.

A witness at the fixed base operator (FBO) at STE recalled that the pilot and passenger checked the weather computer prior to their departure from STE. Another witness flying on downwind for runway 12 said that he heard a pilot announce on the common traffic advisory frequency a takeoff from runway 12. He heard no further transmissions as he turned base on approach to runway 12. He saw smoke off the departure end of runway 12 and advised the FBO of a possible airplane down. He flew over the area and observed the accident airplane. The airplane's center section was "engulfed in fire." The pilot radioed the FBO and confirmed that it was a "downed" airplane.

Review of a video record from a ramp camera at STE showed an airplane was departing runway 12 about 1659. About 1700, a plume of smoke is observed in the recording.

Personnel information

The 56 year old pilot held a Federal Aviation Administration (FAA) private pilot certificate with a single-engine land airplane rating. A review of a copy of the pilot's logbook indicated that his most recent flight review was completed on July 27, 2007. The last recorded entry was dated April 20, 2008, and the logbook showed that the pilot had accumulated 278.2 hours of total flight time.

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

11/1/04 - An application for 3rd class Airman Medical Certificate

indicates "Yes" for "Do you currently use any medication" and

notes the use only of atorvastatin. The application notes "Yes" to

"Diabetes" and "No" to all other items under "Medical History."

Under "Comments on History and Findings" is noted, in part, "...

Recent diagnosis of Type II diabetes, recently started on Actos

[pioglitazone] and glyburide. Random sugar today 250 mg%. ..."

Total pilot time is noted as 67 hours with 2 hours in the previous 6

months. Also noted is "No Certificate Issued - Deferred for

Additional Evaluation."

11/3/04 - Personal physician's note indicates, in part, that the pilot

"...works as a truck driver and is also pursuing a pilot's license and

he saw [another doctor] for a DOT exam 2 days ago, who called me

indicating he was off his meds and his nonfasting glucose was 500. ...

he has been pulled off the road for now."

12/7/04 - A letter from the Manager of the Aerospace Medical

Certification Division notes, in part, "We have received FAA Form

8500-8, Application for Airman Medical Certification, dated

November 1, 2004. For further consideration regarding your diabetes

mellitus requiring oral hypoglycemic medication for control, please

submit ... A current status report from your treating physician

regarding your diabetes mellitus in accordance with the enclosed

specification sheet. Upon receipt of this information, we will notify

you regarding your eligibility for medical certification."

1/14/05 - A letter from the Manager of the Aerospace Medical

Certification Division notes, in part, "A careful review of your

application and physical examination performed on November 1,

2004, discloses that you do not meet the medical standards ... By

virtue of your failure to provide requested information as outlined

in our letter dated December 7, 2004 ... we have no alternative

except to deny your application for Aerospace Medical Certification."

1/9/06 - Personal physician's note indicates, in part, that the pilot "...

has a history of poor compliance. Note when last seen in June his

hemoglobin A1c was elevated and I increased his glyburide ... and

he was told to return for a recheck in 3 months which he did not do.

He states his Accu-Checks typically range 180 to 210. He states that

when he gets a low reading in the 120s his feet will sting or tingle. ...

He gets no regular exercise ... has apparently been unable to fly

because of his poorly diet controlled diabetes ...Have tried again to

emphasize the necessity of good diabetic control ... emphasized the

fact that his diabetes has never been well controlled. ..."

2/15/06 - An internal FAA electronic memo from the Manager of

the Aerospace Medical Certification Division (AMCD) notes, in part,

"I see that the airman's treating physician mentions history of poor

control but based on the hemoglobin A1c levels given to AMCD he

can be issued a time-limited certificate and a 6 year Authorization."

2/23/06 - An Authorization for Special Issuance of a Medical

Certification from the Manager of the Aerospace Medical Certification

Division notes, in part, "I have reviewed the information submitted

by you in support of your request for an airman medical certificate.

The medical information reveals a history of diabetes mellitus

requiring oral hypoglycemic medication. You are ineligible for

medical certification .... I have determined, however, that you may

be granted an Authorization for special issuance of a third-class

airman medical certificate ... Enclosed is your medical certificate

with the restriction 'Not valid for any class after November 30, 2006.'

You must promptly report any adverse changes in your medical

condition to the AMCD at the above address. ... Because of your

history of diabetes mellitus, operation of aircraft is prohibited at any

time new symptoms or adverse changes occur or if you experience

side-effects from, or require a change in medication."

3/19/07 - A letter from the pilot's personal physician notes, in part,

that the pilot "... was last seen by me on March 5, 2007. He continues

to take glyburide 5 mg tablets one twice a day, Actos 45 mg every

day, Byetta [exenatide] 10 micrograms twice a day. Reviewing his

Accu-Check readings the 14 and 28 day average is 129. He has had

no significant hypoglycemic episodes and has been instructed on how

to deal with these should they occur, always have some type of sugar

available. His hemoglobin A1c was 7.0 which is considerably

improved from his previous Hemoglobin A1c of 10.2 on December

4, 2006. There is no evidence of any cardiovascular, neurologic, renal,

or ophthalmologic complications. I note that his most recent diabetic

eye examination was on February 24, 2006 ... and there was no

background retinopathy noted at that time. ..."

3/30/07 - The pilot's most recent application for 3rd class Airman

Medical Certificate indicates "Yes" for "Do you currently use any

medication" and notes the use of pioglitazone, atorvastatin, exenatide,

and glyburide. The application notes "Yes" to "Diabetes,"

"Admission to hospital," and "Other illness, disability, or surgery."

Under "Comments on History and Findings" is noted, in part, "...

shoulder surgery ... good control of Type II diabetes ..." Height is

noted as 70 inches and weight as 223 pounds. Total pilot time is

noted as 231 hours with 17 hours in the previous 6 months.

Aircraft

Registration
N1813T
Reported as
Piper PA-28-140
Category
Airplane
Serial number
28-7125165
Airframe hours
3,185.35
Engine
Lycoming O-320-E2D, 150 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Registered owner
Dean McGinn
Airworthiness certificate
Standard, Normal
Last inspection
Annual · May 1, 2007
Departed
STE · Stevens Point, WI
Destination
OCQ · Oconto, WI
Airport
STE · Stevens Point Muni, runway 12, 3,635 × 75 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
56
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
July 1, 2007
Seat
Left
Toxicology
Performed
Flight hours
278 total · 278 in this make and model · 242 as pilot in command · 16 in the last 90 days · 16 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
180° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
63 °F, dew point 32 °F
Altimeter
29.90 inHg
Observed at
STE

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.