CHI91FA259

NTSB accident investigation · Piper PA-24-250 · Guide Rock, NE · August 12, 1991

Accident · FatalField investigationFinal report
Date
August 12, 1991, 12:41 local (17:41 UTC)
Place
Guide Rock, NE
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N5145PPiper PA-24-250
Weather
Visual (VMC) · Day
Status
Completed · report April 8, 1993
Report
Approved by Office Director
FAA report
19910812033709A
Case key
14915

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

Spatial disorientation, and exceeding the design limits of the aircraft. Factors related to the accident are inadequate preflight planning, VFR flight into IMC, flight weather avoidance assistance not followed, excessive altitude, physical impairment (anoxia/hypoxia), and lack of total instrument time.

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.

Loss of control - in flightManeuvering
Oxygen system - not installed
Preflight planning/preparation - inadequatePilot in commandFactor
Physical impairment(anoxia/hypoxia)Pilot in commandFactor
Lack of total instrument timePilot in commandFactor
In flight weather avoidance assistance - not followedPilot in commandFactor
Spatial disorientationPilot in commandCause
Vfr flight into imc - encounteredPilot in commandFactor
Altitude - excessivePilot in commandFactor
Airframe/component/system failure/malfunctionDescent - uncontrolled
Wing - failure,total
Design stress limits of aircraft - exceededPilot in commandCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - crop

Analysis

The pilot who was not instrument rated was trying to remain VFR on top when he encountered IMC at 17,500 feet. Aircraft entered an uncontrolled descent after the pilot tried to maneuver to remain in VMC. The right wing separated from the aircraft during descent. The pilot was above 14,000 feet for one hour. The aircraft was not oxygen equipped, and no evidence of portable oxygen was found. There was no record of a prelfight weather briefing. The pilot got an inflight weather briefing 1.5 hours before the crash in which VFR was not recommended, and a route of flight to avoid the weather was suggested. A second inflight weather briefing was obstained 20 minutes beore the crash in which a route of flight to avoid the weather was again suggested. Pilot continued until he was IMC.

Aircraft

Registration
N5145P
Reported as
Piper PA-24-250
Category
Airplane
Serial number
24-161
Airframe hours
2,441
Engine
Lycoming O-540-A1C5, 250 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Thomas K. Phelps
Registered owner
Thomas K. Phelps
Airworthiness certificate
Standard, Normal
Last inspection
Annual · March 20, 1991 · 20 hours before
Departed
SPF · Spearfish, SD
Destination
FYV · Fayetteville, AR

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
57
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
817 total · 172 in this make and model · 756 as pilot in command · 18 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
190° at 4 knots
Visibility
5 statute miles
Lowest ceiling
4,000 ft overcast
Temperature
64 °F, dew point 63 °F
Altimeter
30.00 inHg
Observed at
HSI, 30 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 N5145P · 1

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