CHI99FA342

NTSB accident investigation · Piper PA-38-112 · Warrensburg, IL · September 17, 1999

Accident · FatalField investigationFinal report
Date
September 17, 1999, 12:48 local (17:48 UTC)
Place
Warrensburg, IL
Injuries
2 fatal
Damage
Destroyed
Phase of flight
Maneuvering
Aircraft
N9575TPiper PA-38-112
Weather
Visual (VMC) · Day
Status
Completed · report January 2, 2002
Report
Approved by Office Director
FAA report
19990917030559A
Case key
47406

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

Aircraft control not being maintained by the private pilot candidate and the inadequate supervision by the FAA Designated Examiner. Factors relating to the accident were the inadvertent spin, the unsuccessful remedial action attempted by the flightcrew, and the flightcrew's decision to operate the airplane over the certified maximum gross weight.

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 control - in flightManeuvering
Aircraft weight and balance - exceededFlightcrewFactor
Procedures/directives - not followedFlightcrewFactor
Aircraft control - not maintainedPilot in commandCause
Supervision - inadequateDesignated examinerCause
Stall/spin - inadvertentPilot in commandFactor
In flight collision with terrain/waterDescent - uncontrolled
Remedial action - attemptedFlightcrewFactor
Remedial action - not successfulFlightcrewFactor

Analysis

During a Federal Aviation Administration (FAA) private pilot checkride the aircraft was destroyed when it impacted the terrain. FAA radar data indicated that the aircraft was maneuvering prior to the uncontrolled descent. A witness to the accident described the accident airplane in a nose-low, counter-clockwise rotating dive prior to impacting the terrain. Post-accident examination of the airframe and flight control systems revealed no anomalies that could be associated with a preexisting condition. The aircraft's weight was calculated to be approximately 96.5 lbs over the certified maximum gross weight at the beginning of the flight. The PA-38-112 Pilot Operating Handbook (POH) states that, "IT IS THE RESPONSIBILITY OF THE PILOT AND AIRCRAFT OWNER TO INSURE THAT THE AIRPLANE IS LOADED PROPERLY."

Factual narrative

History of flight

On September 17, 1999, at 1248 central daylight time, a Piper PA-38-112, N9575T, operated by Decatur Aviation Inc., Decatur, Illinois, was destroyed during impact with the terrain following an in-flight loss of control, near Warrensburg, Illinois. Visual meteorological conditions prevailed at the time of the accident. The Federal Aviation Administration (FAA) private pilot checkride was operating under the provisions of 14 CFR Part 91 and was not on a flight plan. The private pilot candidate and FAA Designated Examiner were fatally injured. The local flight originated from the Decatur Airport, Decatur, Illinois, at 1217.

A witness to the accident was working in an agricultural field approximately 1/4 statute mile from the accident site. The witness reported that, "I saw the last 200 foot of the plane crash. I think [the] plane was spinning counter clockwise dropping like a rock from the sky. It crashed nose first in the field just east of where I was sitting."

The witness reported that approximately two minutes prior to the accident he, "Saw large whirl wind in S.E. [southeast] corner of our corn field. Approx[imate] size 100' tall by 40-50 ft wide with thousands of corn stalks leaves swirling in it." The witness reported that the whirlwind's size was described by one of his fellow workers, located approximately 3-statute miles from the accident site, as a "small tornado".

The witness' written statement is appended to this factual report.

Aircraft radar track data for the period before and after the reported accident time was obtained from FAA Air Traffic Control. The obtained data indicated there was a single aircraft, which was transmitting a visual flight rules (VFR) 1200 transponder beacon code, maneuvering near the accident location around the time of the accident. According to the data, the aircraft's Mode-C transponder altitude encoding function was transmitting erroneous information, and accurate altitude data was not obtained.

A plot of the aircraft radar track data was generated, and is appended to this factual report along with a copy of the source data.

Personnel information

According to FAA records, the private pilot candidate was the holder of a private pilot certificate with a glider rating, which was issued on September 13, 1997. FAA records show the pilot's last medical examination date was March 3, 1999, and the pilot was issued a third-class medical certificate with the limitation, "MUST WEAR CORRECTIVE LENSES."

The private pilot candidate reported on FAA Form 8710-1 "Airman Certificate and/or Rating Application", dated September 16, 1999, that his total flight time was 132 hours. The private pilot candidate listed his total time in the accident make and model as 71 hours and his total time in single engine land airplane as 71 hours. The private pilot candidate stated that 37 of the 71 hours were as pilot-in-command (PIC). The private pilot candidate reported that he had 61 hours of flight time in a glider, of which 39 hours were as PIC.

According to the private pilot candidate's flight logbook, he had flown 45.7 hours the last 90 days and 12.1 hours in the last 30 days, all of which were in the accident make and model of airplane. The pilot had flown 2.1 hours during the previous 24 hours and all 2.1 hours were flown in the accident make and model of airplane.

According to the flight logbook, the private pilot candidate had an endorsement for the private pilot practical exam, dated September 17, 1999. According to the logbook, spin entry, spins, and spin recovery techniques were not demonstrated to, or executed by, the private pilot candidate in an airplane. According to Federal Aviation Regulations (FAR) 61.105 Aeronautical Knowledge, private pilot candidates are required to have satisfactory aeronautical knowledge of, "stall awareness, spin entry, spins, and spin recovery techniques for airplane and glider category ratings." The private pilot candidate took the required aeronautical knowledge test on August 3, 1999, and received a passing score. According to FAR 61.107 Flight Proficiency, a private pilot candidate does not need to have logged any flight training in spin entry, spins, and spin recovery techniques in order to be eligible for a private pilot certificate.

According to FAA records, the FAA Designated Examiner was the holder of a commercial pilot certificate with ratings for airplane single-engine land, airplane multi-engine land, and instrument airplane operations. The examiner also held a certified flight instructor certificate with ratings for single-engine land, multi-engine land, and instrument airplane operations. According to FAA records, designated examiner authority was granted to the examiner on March 16, 1999, by the Springfield Flight Standards District Office, Springfield, Illinois. FAA records show the pilot's last medical examination date was October 12, 1998, and the pilot was issued a second-class medical certificate with the limitation, "MUST WEAR CORRECTIVE LENSES FOR NEAR AND DISTANT VISION".

The FAA Designated Examiner reported on FAA Form 8710-1 "Airman Certificate and/or Rating Application", dated March 16, 1999, that his total flight time was in excess of 29,250 hours. According to NTSB Form 6120.1/2, completed by a representative of Decatur Aviation Inc., the examiner had accumulated more than 2,000 hours in the accident make and model of airplane as pilot-in-command. The examiner was reported to have flown more than 18,000 hours in single-engine land airplanes and 14,000 hours in multi-engine airplanes. The examiner had flown 31.5 hours in the last 90 days, of which 6.3 were in the accident make and model of airplane. The examiner had flown 17.2 hours in the last 30 days, of which 3.4 were in the accident make and model of airplane. According to company flight logs and NTSB Form 6120.1/2, the examiner did not fly within 24 hours of the accident.

Aircraft information

The aircraft was a Piper PA-38-112, Tomahawk, serial number 38-78A0135. The Tomahawk is a single-engine, low wing monoplane of all metal construction equipped with a fixed landing gear, and can accommodate a pilot and a passenger in a side-by-side seating arrangement. The Tomahawk has a T-tail empennage configuration with a fixed horizontal stabilizer mounted on top of the vertical fin.

The FAA issued the airplane a Standard Airworthiness Certificate on April 25, 1978, and the airplane was certificated for both normal and utility categories. The airplane had accumulated a total-time of 6019.25 hours at the time of the accident. The last annual inspection was completed on July 16, 1999, and had accumulated 13.35 hours since the inspection. According to the aircraft maintenance logbooks, all applicable FAA Airworthiness Directives were complied with at the completion of the last annual inspection.

The FAA issued Airworthiness Directive (AD) 78-22-01 "Rudder or Elevator Binding" for the Piper PA-38-112 Tomahawk aircraft on October 30, 1978. The purpose of AD 78-22-01 was, "To prevent possible binding of the rudder or elevator in flight... ." A one-time compliance with the AD could be accomplished by completing all portions of Piper Service Bulletin 607A. According to the maintenance logbook, AD 78-22-01 was fully complied with on December 22, 1978. Copies of AD 78-22-01, Piper Service Bulletin 607A, and the maintenance logbook entry are attached to this factual report.

Piper Service Bulletin 876, entitled "Additional Flow Strip Installation", was issued on April 12, 1979. The purpose for issuance of Piper Service Bulletin 876 was reported as, "The installation of two (2) additional flow strips to the leading edges of the wings has been found to improve operational characteristics during stall maneuvers. This Service Release announces the availability of a Flow Strip Installation Kit." A copy of Piper Service Bulletin 876

Aircraft

Registration
N9575T
Reported as
Piper PA-38-112
Category
Airplane
Serial number
38-78A0135
Airframe hours
6,019
Engine
Lycoming O-235-L2C, 112 horsepower, reciprocating
Damage
Destroyed
Flight
Part 91
Registered owner
Decatur Aviation Inc.
Airworthiness certificate
Standard, Normal; Standard, Utility
Last inspection
Annual · July 16, 1999 · 13 hours before
Departed
DEC · Decatur, IL

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
61
Certificate
Private
Medical
Class 3, Valid Medical--w/ waivers/lim
Seat
Left
Toxicology
Performed
Flight hours
132 total · 71 in this make and model · 76 as pilot in command · 45 in the last 90 days · 12 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
Variable at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
154 °F, dew point 115 °F
Altimeter
30.00 inHg
Observed at
DEC, 14 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.