# NTSB CHI92LA043: Piper PA-28-181, N8411A, Rochester, MN, December 8, 1991

- Type: NTSB accident investigation
- Classification: Accident · Minor injuries · Limited investigation · Final report
- Date: December 8, 1991, 00:41 local (06:41 UTC)
- Place: Rochester, MN
- Location: 44.0216° N, 92.4699° W: Placed by OpenAirDocs: center of Rochester, MN, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=44.0216&lon=-92.4699&mi=10
- Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping)
- Highest injury: Minor injuries
- Injuries: 2 minor
- Status: Completed, report April 23, 1993
- Report: Approved by Office Director
- NTSB case key (mKey): 15359
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI92LA043
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15359/pdf
- Page: https://openairdocs.org/ntsb/CHI92LA043

## Probable cause

IMPROPER USE OF AUTOPILOT DURING APPROACH WHICH RESULTED IN PROPER ALIGNMENT NOT MAINTAINED BY THE PILOT.  FACTORS RELATED TO THE ACCIDENT WERE TURBULENCE AND CROSSWINDS, OVER CONFIDENCE IN AIRCRAFT'S CAPABILITY AND OVERCONFIDENCE IN PERSONAL ABILITY.

## Sequence of events

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

- In flight encounter with weather, approach - faf/outer marker to threshold (ifr)
  - weather condition - turbulence (contributing factor)
  - weather condition - crosswind (contributing factor)
  - autopilot - improper use of, pilot in command (cause)
  - overconfidence in aircraft's ability, pilot in command (contributing factor)
  - proper alignment - not maintained, pilot in command (cause)
  - overconfidence in personal ability, pilot in command (contributing factor)
  - missed approach - not performed, pilot in command
- In flight collision with terrain/water, approach - faf/outer marker to threshold (ifr)

## Analysis

THE PILOT SAID WHILE FLYING A COUPLER AUTOPILOT INSTRUMENT APPROACH TO THE AIRPORT AT ROCHESTER, TURBULENCE WAS ENCOUNTERED SHORTLY AFTER PASSING THE MIDDLE MARKER. SUBSTANTIAL DEFLECTIONS OF THE OBS/GS INDICATOR WERE OBSERVED. THE ACFT COLLIDED WITH THE TERRAIN ABOUT 4000 FEET FROM THE RUNWAY. A CROSSWIND OF 17 KNOTS, 50 DEGREES TO THE RUNWAY HEADING WAS PRESENT DURING THE APPROACH.

## Aircraft

- Registration: [N8411A](https://openairdocs.org/deregistered/N8411A-1992-01-25), registration cancelled 1992-01-25, S/N 288190274 (OpenAirDocs)
- Reported make and model: PIPER PA-28-181
- Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs)
- Category: Airplane
- Serial number: 28-8190274
- Engines: LYCOMING O-360-A4M 180 horsepower reciprocating
- Damage: Substantial damage
- Flight: Personal, Part 91
- Operator: Filmore County Flying Club
- Airworthiness certificate: Standard, Normal
- Last inspection: Annual, January 2, 2000
- Departed: D42, SPRINGFIELD, MN
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot; age 45; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 325 total, 325 in this make and model, 20 in the last 90 days, 2 in the last 24 hours

## Weather

- Conditions: Instrument (IMC), Night/dark
- Wind: 180° at 17 knots
- Lowest ceiling: 100 ft
- Temperature: 36 °F, dew point 36 °F
- Observed at: RST, 1 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 19911208055149A](https://openairdocs.org/incident/19911208055149A), Dec 8, 1991: Piper PA28181, Rochester, MN, Substantial damage. Using autopilot ILS coupled approach. Turbulence on short final caused excursion off glide slope. Impacted ground.

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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