# NTSB ERA09LA124: Piper PA-28-160, N5212W, Indiana, PA, January 4, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: January 4, 2009, 18:05 local (23:05 UTC) - Place: Indiana, PA - Coordinates: 40.635276, -79.113609 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.6353&lon=-79.1136&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) - Highest injury: Fatal - Injuries: 1 fatal, 2 serious - Status: Completed, report October 21, 2010 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: Piper Aircraft, Inc, FAA/FSDO, Lycoming - NTSB case key (mKey): 73186 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA124 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73186/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73186 - Page: https://openairdocs.org/ntsb/ERA09LA124 ## Probable cause The pilot's decision to attempt VFR flight in IMC conditions, resulting in a collision with trees during a go-around. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-160, 3 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7102806), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Planning/preparation: flight planning/navigation](https://openairdocs.org/ntsb-findings/02061025): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-160, 1 case](https://openairdocs.org/ntsb-findings/02061025/cases.md?model=7102806), [All aircraft, 179 cases](https://openairdocs.org/ntsb-findings/02061025/cases.md) - [Ceiling/visibility/precip: fog](https://openairdocs.org/ntsb-findings/03035055): Environmental issues › Conditions/weather/phenomena · Contributed to outcome (probable cause); cases with it: [Piper PA-28-160, 1 case](https://openairdocs.org/ntsb-findings/03035055/cases.md?model=7102806), [All aircraft, 78 cases](https://openairdocs.org/ntsb-findings/03035055/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach: VFR encounter with IMC](https://openairdocs.org/ntsb-events/401); cases with it: [Piper PA-28-160, 1 case](https://openairdocs.org/ntsb-events/401/sequence.md?model=7102806), [All aircraft, 392 cases](https://openairdocs.org/ntsb-events/401/sequence.md) - [Approach-VFR go-around: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) (defining event); cases with it: [Piper PA-28-160, 5 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102806), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot and two passengers took off with the intent to fly around the traffic pattern. The automated weather reporting system for the field reported steadily deteriorating conditions from earlier in the day and up to the time of departure, with instrument meteorological conditions prevailing throughout the flight. The pilot was not instrument rated and the airplane was not equipped for instrument flight. The flight continued after twilight into full darkness. The pilot stated that he encountered fog that obscured his view of the runway. After five unsuccessful approaches, the pilot stated that he could see the lights on runway 28, which was mostly behind the airplane. The pilot elected to make one more go around and attempt to land on the runway; the airplane impacted trees 1,200 feet northwest of the runway. The airplane came to rest inverted. The pilot stated that he had no intentions of flying that day due to the weather. He said that he was only to going to refuel the airplane, but one of the passengers convinced him to take the airplane once in the pattern. ## Factual narrative HISTORY OF FLIGHT On January 4, 2009, at 1805 eastern standard time, a Piper, PA-28-160, N5212W, collided with trees while on a go around at the Indiana County Airport (IDI), Indiana, Pennsylvania. The pilot and one of the two passengers received serious injuries, the other passenger died from injuries four days after the accident. Instrumental meteorological conditions (IMC) prevailed and no flight plan was filed. The airplane was operated by a private individual, under the provisions of Title 14 Code of Federal Regulations Part 91, as a personal flight. The pilot stated that he had called the airport earlier in the day to inquire about the weather. After being told the weather “wasn’t too bad” he requested fuel and drove to the airport with the two passengers. They observed the poor weather conditions on their way to the field, which led to a discussion about flying another day. They arrived at the airport with the intent to simply pay for the fuel and leave. The pilot stated that one of the passengers asked if “a go in the pattern was possible.” Against his better judgment, the pilot agreed. The pilot stated that the weather “wasn’t too bad” after takeoff, but the flight later encountered fog that obscured his view of the runway. The pilot contacted line services at IDI fixed base operations via radio and repeatedly asked whether the line services personnel could see the airplane, and if it was over the runway. A line service personnel from the fixed base operator stated that he was in radio contact with the pilot during at least five attempted approaches to runway 28 at IDI. The pilot repeatedly inquired whether the line service person could see the aircraft or whether the airplane was over the runway. The line service person stated that he advised the pilot to climb, declare an emergency, and contact Cleveland Center for assistance; the repeated approaches were attempted with the airport environment obscured in heavy fog, in twilight, and after full darkness. The pilot did not heed this advice, and after at least five unsuccessful approaches, the pilot stated that he could see the lights on Runway 28, which was mostly behind the airplane. The pilot elected to make one more go around and attempt to land on the runway. At 1805, a sound of impact was heard by the line service person and radio contact was lost. PERSONNEL INFORMATION The pilot held a private pilot certificate with an airplane single engine land rating. He was issued a third class medical certificate on May 16, 2008, with the limitation that he must wear corrective lenses. The pilot’s flight logbook showed he logged a total of 113 hours at the time of the accident. AIRCRAFT INFORMATION The airplane was a Piper, PA-28-160, built in 1961 with serial number 28-248 and operated in the normal category. The airplane was powered by a Lycoming O-320-B2B, 160 horsepower engine. The airplane’s maintenance records showed the last annual inspection was performed on June 8, 2008, at a totaltime of 3,568 hours. The airplane was not equipped for instrument flight. METEOROLOGICAL INFORMATION The responding Federal Aviation Administration (FAA) inspector stated that the weather was reported by the IDI automatic weather observation system (AWOS) as steadily deteriorating throughout the time the flight was planned, initiated, and terminated. Basic visual flight rules (VFR) conditions were last reported at 1255. At 1355, the weather was reported at 800 feet overcast and 10 miles visibility with temperature of 4 degrees Celsius (C) and dew point of -1 degree C. Prior to the estimated time of departure, the weather was reported at ceiling as 200 feet overcast and visibility 1/4 mile with temperature and dew point both at 3 degrees C. At, 1801 the weather was reported at 200 feet overcast, 1/4 mile visibility, and temperature and dew point both at 5 degrees C. WRECKAGE AND IMPACT INFORMATION The wreckage debris field was located near the top of a forested area 100 feet higher than the field elevation at IDI. The airplane came to rest about 1,200 feet northwest of the threshold of runway 10 at IDI. The right wing impacted a tree about 50 feet about the terrain. The outer 1/3 of the wing was separated on impact and fell 40 feet from the majority of the wreckage. The right wing forward spar detached from the fuselage and the wing had a large, ragged hole in its lower skin. The tail of the airplane showed evidence of impacting several tree limbs and was torn from the fuselage forward of the vertical stabilizer. The left wing was also impacted by trees and the outer 1/3 of it bent at an angle about perpendicular to the fuselage. The aircraft came to rest inverted with its main fuselage, engine, forward cowling, and propeller spinner crushed. The emergency locator transmitter (ELT) did not activate. A wreckage examination was conducted by the airframe and engine manufacturer with FAA over sight. There were no discrepancies noted with the airplane, engine, and systems that would have prevented normal operational of the airplane. TEST AND RESEARCH A damage hand held global positioning system (GPS) unit was recovered from within the wreckage and sent to the National Transportation Safety Boards Vehicle Recorder Laboratory for further evaluation. The data retrieved depicts the accident flight’s route and attempts to land at the IDI airport. MEDICAL AND PATHOLOGICAL INFORMATION The cause of death for the passenger was multiple blunt force trauma as per the Cambria County Coroner’s Office in Johnstown, Pennsylvania, January 8, 2009 report. ## Aircraft - Registration: [N5212W](https://openairdocs.org/deregistered/N5212W-2017-05-22), registration cancelled 2017-05-22, S/N 28-248, built 1961 (OpenAirDocs) - Reported make and model: PIPER PA-28-160 - Registry model: [Piper PA-28-160](https://openairdocs.org/model/piper-pa-28-160) (registry code 7102806) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-248 - Airframe hours: 3569 - Engines: LYCOMING O-320 SERIES 160 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 8, 2008, 25 hours before - Departed: IDI, Indiana, PA - Destination: IDI, Indiana, PA - Airport: IDI, Indiana County Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 51; injuries: serious; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; last flight review December 1, 2007; seat: left; flight hours: 113 total, 113 in this make and model ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: calm - Visibility: 0 statute miles - Lowest ceiling: 200 ft overcast - Temperature: 41 °F, dew point 41 °F - Altimeter: 29.95 inHg - Observed at: IDI, 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 20090104005909A](https://openairdocs.org/incident/20090104005909A), Jan 4, 2009: Piper PA28160, Indiana, PA, Destroyed, 1 fatal. N5212W departed kidi at approximately 2130 UTC for a local pleasure flight. Kidi AWOS reported weather as 12 sm visibility and 400 overcast. The pilot stated… ## Docket (17 files) The files NTSB released with the investigation on July 29, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73186. 19.8 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 807 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331011&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Reports from Local Agencies: Indiana County Emergency Response Agency Record (item 2, .PDF, 159 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331013&FileExtension=.PDF&FileName=Reports%20from%20Local%20Agencies%3A%20Indiana%20County%20Emergency%20Response%20Agency%20Record-Redacted.PDF - Reports from State Agencies: Excerpt from Pennsylvania State Police Report (item 3, .PDF, 52 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331014&FileExtension=.PDF&FileName=Reports%20from%20State%20Agencies%3A%20Excerpt%20from%20Pennsylvania%20State%20Police%20Report-Redacted.PDF - Reports from Federal Agencies: Federal Aviation Administration Inspectors' Reports (item 4, .PDF, 302 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331016&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%3A%20Federal%20Aviation%20Administration%20Inspectors%27%20Reports-Redacted.PDF - Witness Statements: Statements to the Federal Aviation Administration Inspector (item 5, .PDF, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331069&FileExtension=.PDF&FileName=Witness%20Statements%3A%20Statements%20to%20the%20Federal%20Aviation%20Administration%20Inspector-Redacted.PDF - Reports from Parties to the Investigation: Excerpts from Lycoming Field Notes (item 6, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331015&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%3A%20Excerpts%20from%20Lycoming%20Field%20Notes-Redacted.PDF - Reports from Parties to the Investigation: Excerpts From Piper Wreckage Documentation. (item 7, .PDF, 17 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331065&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%3A%20Excerpts%20From%20Piper%20Wreckage%20Documentation.-Master.PDF - GPS 17 - Factual Report of Group Chairman (item 8, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40321368&FileExtension=.PDF&FileName=GPS%2017%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Other Pertinent Forms and Reports: Excerpts From the Pilot's Flight Logbook. (item 9, .PDF, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331194&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%3A%20Excerpts%20From%20the%20Pilot%27s%20Flight%20Logbook.-Master.PDF - Other Pertinent Forms and Reports: Excerpts From the Airplane's Maintenance Records. (item 10, .PDF, 8.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331240&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%3A%20Excerpts%20From%20the%20Airplane%27s%20Maintenance%20Records.-Redacted.PDF - Weather Reports and Records: For the Airport and Surrounding Areas. (item 11, .PDF, 368 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331019&FileExtension=.PDF&FileName=Weather%20Reports%20and%20Records%3A%20%20For%20%20the%20%20Airport%20and%20Surrounding%20Areas.-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 12, .PDF, 136 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331017&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 13, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331018&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 Documentation, For the Hand Held GPS. (item 14, .PDF, 243 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40335591&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15%20Documentation,%20For%20the%20Hand%20Held%20GPS.-Redacted.PDF - Photo 1) View of the Wreckage. Photo Provided by Federal Aviation Administration. (item 15, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331058&FileExtension=.PDF&FileName=Photo%201)%20View%20of%20the%20Wreckage.%20Photo%20Provided%20by%20Federal%20Aviation%20Administration.-Master.PDF - Photo 2) Front View of the Wreckage. Photo Provided by the Federal Aviation Administration. (item 16, .PDF, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331060&FileExtension=.PDF&FileName=Photo%202)%20Front%20View%20of%20the%20Wreckage.%20Photo%20Provided%20by%20the%20Federal%20Aviation%20Administration.-Master.PDF - Photo 3) View of the Wreckage. Photo Provided by the Federal Aviation Administration. (item 17, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40331061&FileExtension=.PDF&FileName=Photo%203)%20View%20of%20the%20Wreckage.%20Photo%20Provided%20by%20the%20Federal%20Aviation%20Administration.-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.