# NTSB ERA09LA033: Piper PA-32-260, N3568W, Plymouth, NC, November 1, 2008 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: November 1, 2008, 09:35 local (13:35 UTC) - Place: Plymouth, NC - Coordinates: 35.808612, -76.759162 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.8086&lon=-76.7592&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining events: [Approach: Midair collision](https://openairdocs.org/ntsb-events/250); [Approach: Midair collision](https://openairdocs.org/ntsb-events/250) - Highest injury: Minor injuries - Injuries: 2 minor - Status: Completed, report November 9, 2009 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 69381 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA033 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/69381/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=69381 - Page: https://openairdocs.org/ntsb/ERA09LA033 ## Probable cause (aircraft 1) The Piper Dakota (PA-28-236) pilot's failure to see and avoid the Piper Cherokee (PA-32-260). ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Pilot (probable cause), aircraft 1; cases with it: [Piper PA-32-260, 1 case](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=7103206), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md) - [Attention/monitoring: monitoring other aircraft](https://openairdocs.org/ntsb-findings/02021540): Personnel issues › Psychological · Pilot of other aircraft (probable cause), aircraft 2; cases with it: [Piper PA-28-236, 1 case](https://openairdocs.org/ntsb-findings/02021540/cases.md?model=7102815), [All aircraft, 231 cases](https://openairdocs.org/ntsb-findings/02021540/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: Midair collision](https://openairdocs.org/ntsb-events/250) (defining event), aircraft 1; cases with it: [Piper PA-32-260, 1 case](https://openairdocs.org/ntsb-events/250/sequence.md?model=7103206), [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) - [Approach: Midair collision](https://openairdocs.org/ntsb-events/250) (defining event), aircraft 2; cases with it: [Piper PA-28-236, 1 case](https://openairdocs.org/ntsb-events/250/sequence.md?model=7102815), [All aircraft, 196 cases](https://openairdocs.org/ntsb-events/250/sequence.md) ## Analysis (aircraft 1) The pilot of a Piper Cherokee (PA-32-260) was practicing a global-positioning-system (GPS) instrument approach in visual meteorological conditions without a safety observer onboard. Another pilot, in a Piper Dakota (PA-28-236), was also navigating inbound to the airport via GPS. Both pilots stated that they made inbound radio calls, during which they didn't hear each other, but heard a response from an airplane on the ground. The Dakota subsequently overtook the Cherokee and impacted its right side, peeling back the roof. The Dakota then descended, coming to rest inverted in trees, while the Cherokee entered a spin until a low-level recovery, followed by a descent into a river. ## Factual narrative (aircraft 1) On November 1, 2008, about 0935 eastern standard time, a Piper PA-32-260 (Cherokee Six), N3568W, and a Piper PA-28-236 (Dakota), N2139N, were substantially damaged when they collided in mid-air about 5 nautical miles north of Plymouth Municipal Airport (PMZ), Plymouth, North Carolina. The certificated private pilot onboard the Cherokee and the certificated private pilot onboard the Dakota incurred minor injuries. Neither pilot had filed a flight plan, and both airplanes were operating in visual meteorological conditions. The Cherokee had departed Plymouth on a local flight, and the Dakota had departed Warren Field (OCW), Washington, North Carolina, with Plymouth as the destination. The personal flights were conducted under the provisions of 14 Code of Federal Regulations Part 91. According to the pilot of the Cherokee, he was practicing the global positioning system (GPS) runway 21 wide area augmentation system (WAAS) approach, utilizing the autopilot. He proceeded to BERTI intersection, and subsequently, 10 miles from the airport, he announced his position on the airport common traffic advisory frequency. When he reached 7 miles, the pilot of an airplane back-taxiing to runway 21 announced his intention to depart to the southeast. The Cherokee pilot restated his position, and advised him that he should not be a factor. The Cherokee pilot subsequently descended the airplane, and maintained 1,600 feet until reaching the final approach fix, ZUHAX intersection. At that point, the autopilot intercepted the glideslope, and the airplane began to descend. The pilot of the Cherokee made another call to ensure the runway was clear, and "almost instantly," there was a loud bang on the right side of the airplane. The windshield and part of the cabin roof separated from the airplane, and the airplane entered a right spin, "going straight down." The pilot recovered from the spin about 150 feet above a river, and with trees on his right side, all he could do was pull the yoke back and land in the river. After landing, the pilot put on his life preserver, and went out on the left wing. The airplane subsequently sank, and the pilot was recovered by two fishermen. The pilot also noted that he was initially unaware that another airplane was involved, and further noted that he never heard the other pilot on the frequency or saw the other airplane. According to the pilot of the Dakota, he was inbound to Plymouth and navigating by GPS. About 7 miles from the airport, and 2,000 feet, he announced his position. Another pilot responded that he was performing an engine run-up on runway 21. The Dakota pilot then advised the pilot on the ground that his airplane wouldn't be a problem, and that he was 4 miles from the airport. Shortly thereafter, the, pilot heard a "Bamm," and the airplane began a descent. The pilot made an emergency call on the radio and applied maximum power; however, the airplane descended into a tree, spun around, and came to rest in another tree,inverted, about 8 feet off the ground. The pilot also noted that he did not initially know there was another airplane involved; he thought he had hit a bird. According to a witness on the ground, it appeared that the airplane that landed in the tree was "chasing" the other airplane. He remarked to his brother that he thought they would collide, which they did. After the collision, one airplane veered off to the left, and the other veered off to the right. A third pilot was in his airplane at Plymouth, back taxiing down runway 21. As he was doing so, he heard a pilot report his approach to the airport. After the third pilot stated his intentions, the airborne pilot advised him that the third pilot's airplane would not be a factor. After the accident, and upon further recollection, the third pilot thought he may have heard two inbound calls, but was unsure, and both were made from a distance. After departing Plymouth, the third pilot heard another pilot report that he had hit a bird. The Cherokee pilot, age 68, held a private pilot certificate with airplane single-engine land and instrument airplane ratings. The pilot reported 1,050 hours of total flight time, and his latest Federal Aviation Administration (FAA) third class medical certificate was issued in December 2007. The Dakota pilot, age 71, held a private pilot certificate with airplane single-engine land, airplane multiengine land, and instrument airplane ratings. The pilot reported 1,049 hours of total flight time, and his latest FAA third class medical certificate was issued in November 2007. Photographs of the Cherokee being recovered from the river revealed impact marks and missing cabin roof skin, beginning in the vicinity of the right side, cabin door. Weather, recorded at an airport 14 nautical miles to the northeast, at 1142, included clear skies and visibility 10 statute miles. According to Federal Aviation Regulation Part 91.109 (b), "No person may operate a civil aircraft in simulated instrument flight unless…the other control seat is occupied by a safety pilot who possesses at least a private pilot certificate with category and class ratings appropriate to the aircraft being flown." ## Aircraft 1 - Registration: [N3568W](https://openairdocs.org/deregistered/N3568W-2008-11-14), registration cancelled 2008-11-14, S/N 32-459, built 1966 (OpenAirDocs) - Reported make and model: PIPER PA-32-260 - Registry model: [Piper PA-32-260](https://openairdocs.org/model/piper-pa-32-260) (registry code 7103206) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32-459 - Airframe hours: 3142 - Engines: LYCOMING O-540 SERIES 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Thompson Billy T - Airworthiness certificate: Standard, Normal - Last inspection: Annual, January 19, 2008, 35 hours before - Departed: PMZ, Plymouth, NC - Destination: PMZ, Plymouth, NC - Airport: PMZ, Plymouth Municipal ## Aircraft 2 - Registration: [N2139N](https://openairdocs.org/deregistered/N2139N-2008-11-17), registration cancelled 2008-11-17, S/N 28-7911095, built 1979 (OpenAirDocs) - Reported make and model: PIPER PA-28-236 - Registry model: [Piper PA-28-236](https://openairdocs.org/model/piper-pa-28-236) (registry code 7102815) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7911095 - Airframe hours: 3146 - Engines: LYCOMING O-540 SERIES 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Buzby Walter M Jr - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 12, 2008, 238 hours before - Departed: OCW, Washington, NC - Destination: PMZ, Plymouth, NC - Airport: PMZ, Plymouth Municipal ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N3568W; age 68; injuries: minor; private; airplane ratings: single-engine land; medical: class 3; last flight review October 28, 2007; seat: left; flight hours: 1,050 total, 950 as pilot in command, 12 in the last 90 days, 4 in the last 30 days - Pilot, aircraft N2139N; age 71; injuries: minor; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3; last flight review March 6, 2007; seat: left; flight hours: 1,049 total, 453 in this make and model, 1,049 as pilot in command, 12 in the last 90 days, 9 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 230° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 68 °F, dew point 36 °F - Altimeter: 30.32 inHg - Observed at: EDE, 14 nm away ## Docket (10 files) The files NTSB released with the investigation on July 10, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=69381. 1.5 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (Cherokee Pilot) (item 1, .PDF, 490 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309965&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(Cherokee%20Pilot)-Redacted.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (Dakota Pilot) (item 2, .PDF, 344 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309966&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1%20(Dakota%20Pilot)-Redacted.PDF - FAA Inspector Witness Interview (item 3, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309967&FileExtension=.PDF&FileName=FAA%20Inspector%20Witness%20Interview-Redacted.PDF - FAA Inspector Pilot Interviews (item 4, .PDF, 82 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309968&FileExtension=.PDF&FileName=FAA%20Inspector%20Pilot%20Interviews-Redacted.PDF - Excerpt, Plymouth, NC, Police Department Report (item 5, .PDF, 187 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309969&FileExtension=.PDF&FileName=Excerpt,%20Plymouth,%20NC,%20Police%20Department%20Report-Master.PDF - Memorandum for Record (Pilot in a Third Airplane) (item 6, .PDF, 10 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40315205&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20(Pilot%20in%20a%20Third%20Airplane)-Master.PDF - Insurance Company Photograph - Cherokee Being Removed from River (item 7, .PDF, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309992&FileExtension=.PDF&FileName=Insurance%20Company%20Photograph%20-%20Cherokee%20Being%20Removed%20from%20River-Master.PDF - Insurance Company Photograph - Closeup of Cherokee Cabin Area (item 8, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309971&FileExtension=.PDF&FileName=Insurance%20Company%20Photograph%20-%20Closeup%20of%20Cherokee%20Cabin%20Area-Master.PDF - FAA Photograph - Dakota in a Tree (item 9, .PDF, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309972&FileExtension=.PDF&FileName=FAA%20Photograph%20-%20Dakota%20in%20a%20Tree%20-Master.PDF - Insurance Company Photograph - Dakota Propeller/Nose (item 10, .PDF, 64 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40309973&FileExtension=.PDF&FileName=Insurance%20Company%20Photograph%20-%20Dakota%20Propeller%2FNose-Master.PDF 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.