# NTSB CHI08FA135: Piper PA-28-140, N1813T, Stevens Point, WI, May 12, 2008 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 12, 2008, 17:00 local (22:00 UTC) - Place: Stevens Point, WI - Coordinates: 44.544998, -89.530281 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.5450&lon=-89.5303&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report May 6, 2009 - Report: Approved by Office Director - Parties: Federal Aviation Administration, Lycoming Engines, Piper Aircraft, Inc. - NTSB case key (mKey): 67994 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI08FA135 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/67994/pdf - Page: https://openairdocs.org/ntsb/CHI08FA135 ## Probable cause The partial loss of engine power for undetermined reasons. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Engine (reciprocating)](https://openairdocs.org/ntsb-findings/01058500): Aircraft › Aircraft power plant · Not specified (probable cause); cases with it: [Piper PA-28-140, 10 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md?model=7102802), [All aircraft, 497 cases](https://openairdocs.org/ntsb-findings/01058500/cases.md) - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Piper PA-28-140, 27 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=7102802), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of engine power (partial)](https://openairdocs.org/ntsb-events/342) (defining event); cases with it: [Piper PA-28-140, 47 cases](https://openairdocs.org/ntsb-events/342/sequence.md?model=7102802), [All aircraft, 1,858 cases](https://openairdocs.org/ntsb-events/342/sequence.md) - [Emergency descent: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120); cases with it: [Piper PA-28-140, 15 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7102802), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) - [Post-impact: Fire/smoke (post-impact)](https://openairdocs.org/ntsb-events/170); cases with it: [Piper PA-28-140, 7 cases](https://openairdocs.org/ntsb-events/170/sequence.md?model=7102802), [All aircraft, 354 cases](https://openairdocs.org/ntsb-events/170/sequence.md) ## 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](https://openairdocs.org/deregistered/N1813T-2009-01-07), registration cancelled 2009-01-07, S/N 28-7125165, built 1971 (OpenAirDocs) - Reported make and model: PIPER PA-28-140 - Registry model: [Piper PA-28-140](https://openairdocs.org/model/piper-pa-28-140) (registry code 7102802) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7125165 - Airframe hours: 3185.35 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: fatal; 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 (OpenAirDocs). - [Accident 20080512844409A](https://openairdocs.org/incident/20080512844409A), May 12, 2008: Piper PA28140, Stevens Point, WI, Destroyed, 2 fatal. (-23) On Monday, may 12, 2008, at approximately 1702 hrs local time, N1813T, a PA-28-140 owned and operated by [privacy data omitted], private pilot… 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.