CHI92FA027

NTSB accident investigation · Piper PA-24-180 · Coffeyville, KS · November 14, 1991

Accident · FatalField investigationFinal report
Date
November 14, 1991, 10:20 local (16:20 UTC)
Place
Coffeyville, KS
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N5935PPiper PA-24-180
Weather
Instrument (IMC) · Day
Status
Completed · report April 23, 1993
Report
Approved by Office Director
FAA report
19911114051479A
Case key
15271

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's failure to maintain sufficient airspeed (above stall speed) during the emergency procedure. Related factors are the pilot's poor planning/decision, inattentiveness, and the weather (low ceiling, gusty tailwinds).

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 engine powerManeuvering
Weather condition - low ceilingFactor
Weather condition - gustsFactor
Planning/decision - poorPilot in commandFactor
Fluid,fuel - starvation
Fuel tank selector position - disregardedPilot in commandFactor
InattentivePilot in commandFactor
Emergency procedure - attemptedPilot in command
Loss of control - in flightDescent - emergency
Weather condition - tailwindFactor
Airspeed(vs) - not maintainedPilot in commandCause
Stall - inadvertentPilot in command
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - open field

Analysis

The pilot took off with full fuel tanks and flew for about 2 hours 15 minutes before the accident occurred. The airplane was observed near the accident site, flying erratically beneath a 300 to 400 foot ceiling in strong, gusty wind conditions. Witnesses reported the engine seemed to be cutting in and out. The airplane was northbound with a 25 to 40 knot tailwind when it was observed to pitch up abruptly, rotate left, and nose down into the ground. Post-accident examination of airframe, powerplant and systems revealed no evidence of pre-impact failure/difficulty. The left fuel tank was nearly full of fuel. The right fuel tank was compromised at impact, however there was no evidence of fuel spillage at the accident site. The landing gear was extended, fuel boost pump was on, and the fuel selector was jammed in an intermediate position. Fuel consumption calculations (using 75%) indicated as much as half the available fuel may have been burned.

Aircraft

Registration
N5935P
Reported as
Piper PA-24-180
Category
Airplane
Serial number
24-1025
Airframe hours
5,329
Engine
Lycoming O-360-A1A, 180 horsepower, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Operator
Gamache, Joseph C
Registered owner
Gamache, Joseph C
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 1, 1991 · 15 hours before
Departed
4M4 · Clinton, AR
Destination
K50 · Derby, KS

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
65
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
764 total · 469 in this make and model · 17 in the last 90 days · 7 in the last 30 days · 4 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
200° at 25 knots, gusting 40
Visibility
2 statute miles
Lowest ceiling
400 ft broken
Temperature
55 °F, dew point 1 °F

FAA reports on this event · 1

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