# NTSB ERA09LA123: Piper PA-28-151, N43631, Powder Springs, TN, January 3, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: January 3, 2009, 12:15 local (17:15 UTC) - Place: Powder Springs, TN - Coordinates: 36.216388, -83.685836 - Nearby events: https://openairdocs.org/map.md?lat=36.2164&lon=-83.6858&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report December 20, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Textron Lycoming, Piper Aircraft Inc., FAA/FSDO - NTSB case key (mKey): 73180 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA123 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73180/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73180 - Page: https://openairdocs.org/ntsb/ERA09LA123 ## Probable cause The non-instrument rated pilot's decision to continue under visual flight rules into an area of instrument meteorological conditions, which resulted in an in-flight collision with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Ceiling/visibility/precip: low ceiling](https://openairdocs.org/ntsb-findings/03035010): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Piper PA-28-151, 1 case](https://openairdocs.org/ntsb-findings/03035010/cases.md?model=7102805), [All aircraft, 190 cases](https://openairdocs.org/ntsb-findings/03035010/cases.md) - [Ceiling/visibility/precip: low visibility](https://openairdocs.org/ntsb-findings/03035015): Environmental issues › Conditions/weather/phenomena · Effect on personnel; cases with it: [Piper PA-28-151, 2 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md?model=7102805), [All aircraft, 175 cases](https://openairdocs.org/ntsb-findings/03035015/cases.md) - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-151, 11 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102805), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-151, 2 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7102805), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [Piper PA-28-151, 4 cases](https://openairdocs.org/ntsb-events/401/sequence.md?model=7102805), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Enroute: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Piper PA-28-151, 3 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7102805), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis After departing the traffic pattern and turning toward mountainous terrain, the airplane entered instrument meteorological conditions (IMC). The pilot had some training for his instrument rating but did not yet possess one. A witness who resided near the accident location heard the airplane traveling in a northerly direction and impact terrain. He reported that, the "weather was overcast," and he could not see the tops of the mountains. He estimated that the cloud base at the time was about 100 to 200 feet below the tops of the mountains. Review of a weather briefing which was obtained by the pilot revealed that he was advised that flight under visual flight rules was not recommended due to low ceilings and visibility along the route of flight and that the pilot had declined to file a flight plan. Additionally, no evidence was discovered that indicated the pilot had attempted to receive updated weather information prior to the accident flight, or that he had contact with air traffic control. Examination of the airplane revealed no evidence of any preimpact malfunctions or failures. ## Factual narrative HISTORY OF FLIGHT On January 3, 2009, about 1215 eastern standard time, a Piper PA-28-151, N43631, was substantially damaged during impact with terrain, near Powder Springs, Tennessee. The certificated private pilot and the sole passenger were killed. Instrument meteorological conditions (IMC) prevailed for the flight that departed Gatlinburg-Pigeon Forge Airport (GKT), Sevierville, Tennessee, and was destined for Warsaw Municipal Airport (ASW), Warsaw, Indiana. No flight plan was filed for the personal flight conducted under Title 14 Code of Federal Regulations Part 91. According to a witness who was outside of his house, the "weather was overcast," and he could not see the tops of the mountains. He heard an airplane traveling in a northerly direction, and heard the engine, "cutout, two to three times" prior to hearing the airplane "crash" into trees, and the engine "stop." He advised that he distinctly heard the trees "felled." He told his wife about what he heard and then called "911." He estimated that the ceiling at the time was about 100 to 200 feet below the tops of the mountains, which equates to 1,700 to 1,800 feet above sea level (msl). PERSONNEL INFORMATION According to Federal Aviation Administration (FAA) records, the pilot held a private pilot certificate with ratings for airplane single-engine land and did not possess an instrument rating. His most recent FAA third-class medical certificate was issued on June 26, 2007 at which time he reported 116 total hours of flight experience. AIRCRAFT INFORMATION The airplane was lent to the pilot by the owner. According to FAA and maintenance records, the airplane was manufactured in 1974. The airplane's most recent annual inspection was completed on February 1, 2008. At the time of the inspection, the airplane had accrued 5,017 total hours of operation. METEOROLOGICAL INFORMATION The recorded weather at McGhee Tyson Airport (TYS), Knoxville, Tennessee, approximately 21 nautical miles southwest of the accident site, at 1153, included: wind 010 degrees at 6 knots, visibility 3 miles in mist, overcast at 1,200 feet, temperature 7 degrees C, dew point 6 degrees C and an altimeter setting of 30.07 inches of mercury. WRECKAGE AND IMPACT INFORMATION The wreckage of the accident airplane was discovered about 27 miles northwest of GKT in an area of heavy timber and mountainous terrain. Examination of the accident site by a FAA inspector revealed that the airplane had struck trees near the top of a mountain. The wings had separated from the fuselage, and the fuselage had come to rest on a magnetic heading of 328 degrees, approximately 1,932 feet msl, downhill from the initial impact point. Examination of the wreckage by the NTSB did not reveal any evidence of any preimpact malfunction of the airplane or engine and control continuity was established from the flight controls to the breaks in the cables which made up the system and exhibited tensile overload. The wings were fragmented and exhibitednumerous impact depressions. The stall vane was impact damaged, the pitot tube was unobstructed, and both the fuel screens and fuel vent were free of blockage. The left aileron had separated from its mounting location, and the right aileron was partially separated from its mounts. The vertical stabilizer and rudder were still attached to their mounting locations but displayed impact damage to the tip areas. The rudder was partially separated and the stabilizer was bent aft. The rudder sector, stop bolts and control cables were in place and secure. The rudder control cables were continuous to the rudder bar. The rudder tip and balance weight had separated and were not recovered. The horizontal stabilator hinge and stop bolts were in place and secure. The left side of the stabilator displayed impact damage to the leading edge. The tip was separated and also displayed similar impact damage. The right side was separated near the hinge and the skin was fragmented. The tip of the right side was recovered with a portion of the leading edge as well as the right side of the pitch trim tab. The balance tube was in place and the balance weight was secure. Both the upper and lower control cables were secure and continuous to the control wheel T bar assembly and the pitch trim drum inner shaft extension displayed five threads, which was consistent with a neutral trim setting. The fuselage exhibited impact damage to the front and sides of the cabin area and the aft fuselage was partially separated from the forward section. The engine was in place but the propeller was separated. The nose landing gear was impact separated from the upper portion of the strut. The gascolator was separated and found near the front of the airplane at the crash site. The electric fuel pump filter was removed and was free of debris. Examination of the cabin revealed that the cabin door had been closed and latched, the navigation lights were selected on, the panel lights were selected on, and the emergency locator transmitter was armed. Both front seats had been removed for extrication of the occupants. The left front seat belt had been cut and the right front seat belt was not fastened. Neither the left or right shoulder harness was fastened to the lap belts. The fuel selector valve was positioned in the left tank position. The flap handle and flap torque tube were in the retracted flap position. The magneto switches, as well as the master switch, had been placed in the "OFF" position by rescue personnel. Examination of the directional gyro and artificial horizon revealed that, the interior gimbaled assemblies were intact and rotated freely and the gyros exhibited light rotational scoring. The propeller was separated from the engine. The spinner was in place over the hub and displayed rotational signatures with compression wrinkling on the front side of both the blades as well as the hub bolts. Both propeller blades were twisted toward low pitch and exhibited leading edge gougingand chordwise scratching. The engine's crankshaft was rotated through the crankshaft propeller flange. Crankshaft continuity was confirmed to the accessory drive, and valve train continuity was confirmed to all cylinders. Thumb compression and suction was confirmed for all of the cylinders, and the spark plugs were intact, appeared normal, and were dark gray in color. Both the left and right magnetos produced spark from all towers when rotated by hand. Oil was present in the oil filter, on the oil suction screen, and valve springs. The interiors of all of the cylinders were examined with a lighted borescope, and no damage was noted to the piston domes or valves. The fuel pump was fractured and separated from the engine. The carburetor was also separated from the engine and fragmented. The brass floats were crushed, the float bowl was fragmented, and the fuel inlet screen was exposed. TESTS AND RESEARCH Global Positioning System (GPS) Information According to data extracted from a handheld Lowrance 600C GPS receiver that was recovered from the wreckage, after departure from runway 10 at GKT the pilot turned out on a right crosswind, then turned right again and joined the downwind paralleling the runway until clearing the traffic pattern. The airplane then turned in a northerly direction. The last data point recorded was approximately 20 nautical miles south of the accident site. Flight Service and Air Traffic Control Information Information provided by Lockheed Martin Flight Service revealed that, the pilot had received a pre-flight weather briefing for the flight from GKT to ASW and was advised that flight under visual flight rules was not recommended due to low ceilings and visibility along the route of flight. The information provided also revealed that the pilot declined to file a flight plan. Additionally, no evidence was discovered that indicated the pilot had attempted to receive updated weather information prior to the accident flight or that he had contact with air traffic control. ADDITIONAL INFORMATION According to an interview conducted with an employee at the Warsaw Flying Club, around the time of the accident, the pilot had been "working on his instrument rating." ## Aircraft - Registration: [N43631](https://openairdocs.org/deregistered/N43631-2017-06-19), registration cancelled 2017-06-19, S/N 28-7415545, built 1974 (OpenAirDocs) - Reported make and model: PIPER PA-28-151 - Registry model: [Piper PA-28-151](https://openairdocs.org/model/piper-pa-28-151) (registry code 7102805) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7415545 - Airframe hours: 5017 - Engines: Lycoming O-320-E3D 150 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Warrior Aviation LLC - Registered owner: Warrior Aviation LLC - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 1, 2008 - Departed: GKT, Sevierville, TN - Destination: ASW, Warsaw, IN - Flight plan: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, without waivers/limitations; last flight review December 10, 2008; seat: left; toxicology performed; flight hours: 116 total ## Weather - Conditions: Instrument (IMC), Day - Wind: 10° at 6 knots - Visibility: 3 statute miles - Lowest ceiling: 1,200 ft overcast - Temperature: 45 °F, dew point 43 °F - Altimeter: 30.06 inHg - Observed at: TYS, 21 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 20090103000299A](https://openairdocs.org/incident/20090103000299A), Jan 3, 2009: Piper PA28151, Powder Springs, TN, Destroyed, 2 fatal. Aircraft departed sevierville, TN airport (gkt) on a planned trip to warsaw, in (asw). Pilot clipped the treetops and crashed into clinch mountain. Approximate… ## Docket (10 files) The files NTSB released with the investigation on September 17, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73180. 4.6 MB in all. - Witness Statements (item 1, .PDF, 632 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335291&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Weather Reports and Records (item 2, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335290&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records-Redacted.PDF - Chronological Summary of Flight and Transcription of Voice Recording (item 3, .PDF, 155 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335282&FileExtension=.PDF&FileName=Chronological%20Summary%20of%20Flight%20and%20Transcription%20of%20Voice%20Recording-Redacted.PDF - Fueling Information (item 4, .PDF, 15 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335283&FileExtension=.PDF&FileName=Fueling%20Information-Redacted.PDF - GPS - Specialist's Factual Report (item 5, .PDF, 344 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40336263&FileExtension=.PDF&FileName=GPS%20-%20Specialist%27s%20Factual%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 6, .PDF, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335284&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335292&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report (item 8, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335289&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Photograph of Main Wreckage (FAA) (item 9, .PDF, 604 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335514&FileExtension=.PDF&FileName=Photograph%20of%20Main%20Wreckage%20(FAA)-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 10, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40337078&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.