# NTSB CHI92FA027: Piper PA-24-180, N5935P, Coffeyville, KS, November 14, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: November 14, 1991, 10:20 local (16:20 UTC)
- Place: Coffeyville, KS
- Location: 37.0327° N, 95.6516° W: Placed by OpenAirDocs: center of Coffeyville, KS, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=37.0327&lon=-95.6516&mi=10
- Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 2 fatal
- Status: Completed, report April 23, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 15271
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI92FA027
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15271/pdf
- Page: https://openairdocs.org/ntsb/CHI92FA027

## 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

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Loss of engine power, maneuvering
  - weather condition - low ceiling (contributing factor)
  - weather condition - gusts (contributing factor)
  - planning/decision - poor, pilot in command (contributing factor)
  - fluid,fuel - starvation
  - fuel tank selector position - disregarded, pilot in command (contributing factor)
  - inattentive, pilot in command (contributing factor)
  - emergency procedure - attempted, pilot in command
- Loss of control - in flight, descent - emergency
  - weather condition - tailwind (contributing factor)
  - airspeed(vs) - not maintained, pilot in command (cause)
  - stall - inadvertent, pilot in command
- In flight collision with terrain/water, descent - 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](https://openairdocs.org/aircraft/N5935P), registered now, S/N 24-1025, built 1959 (OpenAirDocs)
- Reported make and model: PIPER PA-24-180
- Registry model: [Piper PA-24](https://openairdocs.org/model/piper-pa-24) (registry code 7102402) (OpenAirDocs)
- Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs)
- Category: Airplane
- Serial number: 24-1025
- Airframe hours: 5329
- Engines: 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

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 65; 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 (OpenAirDocs).

- [Accident 19911114051479A](https://openairdocs.org/incident/19911114051479A), Nov 14, 1991: Piper PA24180, Coffeyville, KS, Destroyed, 2 fatal. Crashed in open field attempting to stay below low clouds.

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.

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