# NTSB CHI95FA061: Piper PA-46-350P, N133MA, Rochester, MN, December 22, 1994 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: December 22, 1994, 11:52 local (17:52 UTC) - Place: Rochester, MN - Coordinates: 44.009906, -92.470771 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.0099&lon=-92.4708&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 3 fatal - Status: Completed, report August 4, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 9722 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI95FA061 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/9722/pdf - Page: https://openairdocs.org/ntsb/CHI95FA061 ## Probable cause FAILURE OF THE PILOT TO MAINTAIN CONTROL OF THE AIRPLANE, WHILE CLIMBING IN INSTRUMENT METEOROLOGICAL CONDITIONS (IMC) AFTER TAKEOFF. FACTORS RELATED TO THE ACCIDENT WERE: FOG, LOW CEILING, THE PILOT'S LACK OF RECENT INSTRUMENT EXPERIENCE, AND THE EXCESSIVE GROSS WEIGHT OF THE AIRPLANE. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, climb - to cruise - weather condition - fog (contributing factor) - weather condition - low ceiling (contributing factor) - aircraft weight and balance - exceeded, pilot in command (contributing factor) - aircraft control - not maintained, pilot in command (cause) - lack of recent instrument time, pilot in command (contributing factor) - Airframe/component/system failure/malfunction, descent - uncontrolled - design stress limits of aircraft - exceeded, pilot in command (cause) - wing - overload - wing - separation - In flight collision with terrain/water, descent - uncontrolled ## Analysis THE AIRPLANE DEPARTED ON RUNWAY 31 IN INSTRUMENT METEOROLOGICAL CONDITIONS (IMC) AND TURNED RIGHT TO A HEADING OF 090 DEGREES. RADAR CONTACT (ARTS TAG) WAS ACQUIRED ABOUT 1 TO 2 MILES NORTH OF THE AIRPORT. REPORTEDLY, THE ARTS TAG WOULD TYPICALLY BE ACQUIRED AS THE AIRPLANE CLIMBED THROUGH AN ALTITUDE OF ABOUT 700 FEET AGL. SUBSEQUENTLY, THE AIRPLANE CRASHED ABOUT 2 MILES NORTH OF THE AIRPORT. A WITNESS REPORTED HEARING A LOUD ENGINE NOISE BEFORE THE PLANE CRASHED. THE WRECKAGE PATH WAS ORIENTED ALONG A WESTERLY HEADING AND OVER AN AREA OF ABOUT 380 FEET. THERE WAS EVIDENCE OF AN IN-FLIGHT BREAKUP. AN OUTBOARD PORTION OF THE RIGHT WING WAS FOUND ABOUT 150 FEET FROM THE MAIN IMPACT CRATER. AN EXAMINATION REVEALED THE RIGHT WING HAD FAILED NEAR THE PRODUCTION SEAM. THE RIGHT SPAR EXHIBITED FEATURES 'TYPICAL OF AN UPWARD BENDING OVERSTRESS SEPARATION.' EXAMINATION REVEALED NO OTHER EVIDENCE OF PREIMPACT AIRCRAFT OR ENGINE MALFUNCTION. THE AIRPLANE'S GROSS WEIGHT WAS ESTIMATED TO BE ABOUT 4696 POUNDS; ITS MAX LIMIT WAS 4300 POUNDS. THE PILOT'S LOGBOOK INDICATED THAT HE HAD FLOWN ONLY 2 INSTRUMENT APPROACHES IN THE PREVIOUS 14 MONTHS. ## Factual narrative HISTORY OF FLIGHT On December 22, 1994, at 1152 central standard time, a Piper PA46-350P airplane, N133MA, was destroyed when it impacted the terrain shortly after departure from the Rochester Municipal Airport, Rochester, Minnesota. The private pilot and two passengers sustained fatal injuries. The personal flight originated about 1148 and was conducted under 14 CFR Part 91. An IFR flight plan was filed to Guntersville, Alabama, and instrument meteorological conditions prevailed. The local controller in the Rochester Airport Air Traffic Control Tower cleared N133MA to take-off on runway 31. He issued a right turn to a heading of 090 when the airplane was approximately 1/4 mile past the departure end of the runway. He observed the airplane in the right turn. He last observed the airplane on the DBRITE scopeabout two miles north of the airport on "what appeared to be an east-south-east track." The radar controller reported that he observed a radar target depart runway 31 and turn east. The automated radar terminal systems (ARTS) tag was acquired approximately one to two miles north of the airport. He was unable to establish radio contact and the ARTS tag dropped into "coast" status. The tower manager reported in a telephone interview that he believed the ARTS tag would typically be acquired as the airplane climbed through an altitude of approximately 700 feet AGL. The ARTS II radar installed at the Rochester Airport does not include a recording capability. A quality assurance representative at the Minneapolis Air Route Traffic Control Center (ARTCC) reported that the airplane was not recorded by the ARTCC radar. He said an airplane would have to climb to a few thousand feet AGL before it could be interrogated. Several people heard the airplane prior to the impact, however, no eye witnesses were located. A private pilot, who was hunting north of the airport, described the engine noise, immediately prior to the impact, as very loud as when "an aircraft lands and reverses its prop." During a telephone interview, the pilot of a Piper Cheyenne who departed on runway 31 immediately after the accident airplane, said he observed N133MA prior to departure but noted nothing abnormal. He reported the weather was about 200 feet overcast and the tops of the clouds were about 3,500 feet as he climbed through them. He said he experienced "nothing abnormal" and it was fairly calm with a slight left crosswind, no windshear, no turbulence, and no significant icing. PERSONNEL INFORMATION The pilot's logbook listed two instrument approaches and 5.2 hours of actual instrument flight in the previous 14 months. WRECKAGE AND IMPACT INFORMATION The NTSB on scene investigation began December 22, 1994, about 1700 central standard time. The wreckage was located about two miles north of the Rochester Municipal Airport, near 5435 31st Avenue SW. The wreckage path was on a heading of 260 degrees. The first items in the wreckage path were fragments of the right flap. The right wing, outboard of the production seam, was 137 feet west and 72 feet south of the flap fragments. The main impact crater was 309 feet from the flap fragments at N43-56.43 W92-30.34. An impression of the left wing, in the soil, extended south from the crater. A four foot impression of the inboard portion of the right wing extended to the north. The fuselage and pieces of the left wing were 27 feet past the crater. The inboard right wing and fragments of the left wing were strewn for 76 feet past the crater. The fuselage was located on a heading of 250 degrees. The forward cabin area was destroyed with severe compression damage and accordion buckling along both sides. The left wing, which was located with the main wreckage, was fractured at station 116. The inboard section of the spar showed slight upward bending. The leading edge skin was separated outboard of station 116. The right wing was fractured between stations 117 and 120. Sections of the fractured spar from the right wing were retained for subsequent examination. Examination of flight control continuity revealed no evidence of preimpact mechanical malfunction. The six and one half threads were exposed on the forward portion of the elevator trim jack screw. The aft fuselage, immediately forward of the empennage, was bent upward approximately 90 degrees. The horizontal stabilizer forward spar attach points were intact. The lower skin of the horizontal stabilizer exhibited slight downward buckling. The right tip of the horizontal stabilizer was bent upward and the left tip was bent downward. The engine was located beneath the cabin area in an inverted, aft facing position. Examination of the engine revealed no evidence of preimpact malfunction. One propeller blade remained attached to the hub and was wrapped around the top of the engine. The other was recovered from within the main crater. Both blades exhibited torsional bending, leading edge gouges and chordwise scratches. One vacuum pump was destroyed. The rotor and vanes were not located. In the other vacuum pump, the vanes were intact and remained in place in the rotor. The primary and standby attitude indicators and both turn and bank indicators exhibited rotational scoring on the drums of the gyros. The Kohlsman window in the primary altimeter was set to 30.21 and the altimeter indicated 1,220 feet. 220 pounds of luggage and personal effects were collected from in and around the cabin area. 100 pounds of antique lamps and servicing equipment were recovered from the forward baggage compartment. An antique brass cash register, wedged behind seat 2B, household items, and books recovered from the aft cabin area weighed a total of 139 pounds. A line boy at the Rochester Airport reported he had "topped off" the airplane with fuel when it arrived there on December 11. He said the airplane remained in the back of a hangar until it departed on the day of the accident. MEDICAL AND PATHOLOGICAL INFORMATION Autopsy of the pilot was performed by the Olmsted County Coroner, 2300 Government Center, 151 Fourth Street S. E., Rochester, Minnesota 55904-3710. Toxicological testing was negative for all tests conducted. TESTS AND RESEARCH The airplane annunciator panel, autopilot annunciator panel, and fractured section from the right wing spar were recovered and examined by a National Resource Specialist at the NTSB laboratory in Washington, D. C. All bulb filaments exhibited little or no stretching. The spar section exhibited features "typical of an upward bending overstress separation." The autopilot servos and mounts, altitude alerter, primary attitude indicator, yaw computer, primary directional gyro, yaw rate gyro, and communications radios were examined at Allied Signal, Inc., Olathe, Kansas, under the supervision of an FAA Aviation Safety Inspector. The primary attitude gyro exhibited rotational scoring on the drum. All servo clutches were operative and no evidence of preimpact malfunction was reported. Weight and balance data was acquired from the original aircraft record dated February 22, 1993. The aircraft logbook reflected the addition of a flight phone since that date. The maximum weight for takeoff specified in the pilot operating handbook is 4,300 pounds. The forward center of gravity limit, at the maximum gross weight is 143.3 inches. Weight Arm Moment Basic Operating Weight 3067.1 134.7 413268 Pilot 170 135.5 23035 Passengers 1B 120* 135.5 16260 2A 178 177 31506 Baggage 220 198* 43560 139 198* 27522 100 88.6 8860 Zero Fuel Weight 3994.1 141.2 564011 Fue ## Aircraft - Registration: [N133MA](https://openairdocs.org/deregistered/N133MA-1997-02-11), registration cancelled 1997-02-11, S/N 4622133 (OpenAirDocs) - Reported make and model: PIPER PA-46-350P - Registry model: [Piper PA 46-350P](https://openairdocs.org/model/piper-pa-46-350p) (registry code 7104620) (OpenAirDocs) - Category: Airplane - Serial number: 4622133 - Airframe hours: 106 - Engines: LYCOMING TIO-540-AE2A 350 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Ryders Replica Fighter Museum - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 20, 1994, 26 hours before - Destination: 8A1, GUNTERSVILLE, AL - Flight plan: IFR - Airport: RST, Rochester Municiple, runway 31, 7,533 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; private; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 2,500 total, 96 in this make and model, 10 in the last 90 days, 4 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 300° at 14 knots - Visibility: 1 statute miles - Lowest ceiling: 400 ft overcast - Temperature: 34 °F - Altimeter: 30.00 inHg - Observed at: RST ## 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 19941222046539A](https://openairdocs.org/incident/19941222046539A), Dec 22, 1994: Piper PA46350P, Rochester, MN, Destroyed, 3 fatal. Took off with a turn after takeoff into low overcast. Disappeared from radar. Low altitude breakup. Wing detached. 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. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.