# NTSB CHI92FA028: Piper PA28-236, N412GK, Valley Center, KS, November 15, 1991

- Type: NTSB accident investigation
- Classification: Accident · Fatal · Field investigation · Final report
- Date: November 14, 1991, 22:33 local (Nov 15, 1991, 04:33 UTC)
- Place: Valley Center, KS
- Coordinates: 37.830585, -97.37046 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=37.8306&lon=-97.3705&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Fatal
- Injuries: 1 fatal
- Status: Completed, report April 23, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 15272
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI92FA028
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15272/pdf
- Page: https://openairdocs.org/ntsb/CHI92FA028

## Probable cause

THE PILOT'S SPATIAL DISORIENTATION, HIS LOSS OF AIRCRAFT CONTROL, AND HIS EXCEEDING THE AIRCRAFT'S DESIGN LIMITS. FACTORS IN THE ACCIDENT WERE THE PILOT'S DISREGARD FOR DIRECTIVES AND PROCEDURES, AND HIS CONTINUED FLIGHT INTO KNOWN ADVERSE WEATHER.

## Sequence of events

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

- Loss of control - in flight, approach - iaf to faf/outer marker (ifr)
  - procedures/directives - disregarded, pilot in command (contributing factor)
  - light condition - dark night
  - flight into known adverse weather - continued, pilot in command (contributing factor)
  - aircraft control - not maintained, pilot in command (cause)
  - spatial disorientation, pilot in command (cause)
- Airframe/component/system failure/malfunction, descent - uncontrolled
  - pull-up - abrupt, pilot in command
  - design stress limits of aircraft - exceeded, pilot in command (cause)

## Analysis

A PRIVATE PILOT WITHOUT INSTRUMENT RATING OBTAINED A WEATHER BRIEF AND FILED IFR FOR A 4-HOUR NIGHT FLIGHT TO A REFUELING STOP. HIS DESTINATION WAS REPORTING IFR AND FORECASTING MARGINAL CONDITIONS ON ARRIVAL, WITH AN OUTLOOK FOR IFR. WEATHER REMAINED IFR THROUGH ARRIVAL, AND HE COMMENCED AN ILS APPROACH TO THE FIELD. WHILE ATTEMPTING TO INTERCEPT COURSE, THE PILOT INITIATED A RIGHT TURN WHICH CONTINUED AWAY FROM THE FIELD AND WAS ACCOMPANIED BY A RAPID DESCENT OUT OF RADAR CONTACT. THE AIRPLANE BROKE UP IN FLIGHT AS RESULT OF HIGH POSITIVE ACCELERATION.

## Aircraft

- Registration: [N412GK](https://openairdocs.org/deregistered/N412GK-1992-04-10), registration cancelled 1992-04-10, S/N 287911047 (OpenAirDocs)
- Reported make and model: PIPER PA28-236
- Registry model: [Piper PA-28-236](https://openairdocs.org/model/piper-pa-28-236) (registry code 7102815) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-7911047
- Airframe hours: 1924
- Engines: LYCOMING O-540-J345D 235 horsepower reciprocating
- Damage: Destroyed
- Flight: Personal, Part 91
- Operator: Heck, Thomas J III
- Registered owner: Heck, Thomas J III
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, February 26, 1991, 91 hours before
- Departed: ABQ, ALBUQUERQUE, NM
- Destination: ICT, WICHITA, KS
- Flight plan: IFR
- Airport: ICT, Wichita Mid-Continent, runway 19, 10,300 × 150 ft

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 42; private; airplane ratings: single-engine land; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 415 total, 245 in this make and model, 37 in the last 90 days, 28 in the last 30 days, 8 in the last 24 hours

## Weather

- Conditions: Instrument (IMC), Night/dark
- Wind: 200° at 12 knots
- Visibility: 7 statute miles
- Lowest ceiling: 800 ft broken
- Temperature: 61 °F, dew point 57 °F
- Altimeter: 29.00 inHg
- Observed at: ICT, 10 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 (OpenAirDocs).

- [Accident 19911114051469A](https://openairdocs.org/incident/19911114051469A), Nov 14, 1991: Piper PA28236, Wichita, KS, Destroyed, 1 fatal. Lost control during attempted ILS approach. Broke up in flight.

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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