ERA12FA163

NTSB accident investigation · Piper PA-28-180 · Thomasville, PA · January 29, 2012

Accident · FatalField investigationFinal report
Date
January 29, 2012, 12:42 local (17:42 UTC)
Place
Thomasville, PA
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N1352TPiper PA-28-180
Defining event
Approach-VFR pattern final: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report March 13, 2013
Report
Approved by Office Director
NTSB office
Eastern Region Aviation
Parties
Piper Aircraft, Inc., FAA/FSDO
FAA report
20120129011879A
Case key
82760

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

The pilot's failure to maintain airspeed during an approach in gusty crosswind conditions, which resulted in an inadvertent aerodynamic stall.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28-180: 8 casesAll aircraft: 1,681 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-28-180: 67 casesAll aircraft: 9,295 casesProbable cause
Wind: gustsEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentPiper PA-28-180: 12 casesAll aircraft: 1,199 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The private pilot was conducting a cross-country flight and landed at his destination airport, on runway 17 without incident. He taxied back to the beginning of the runway, took off, and entered a left traffic pattern for another approach to the same runway. The airplane was on final approach when it stalled and descended toward the ground. The airplane's left wing initially impacted the ground, followed by the nose. The airplane came to rest in a corn field about 1/4-mile from the approach end, and about 400 feet to the left of the extended runway centerline. Examination of the accident airplane’s global positioning system data revealed that the flight track data for the accident flight was similar to the flight track during the previous landing; however, the ground speeds during the final approach phase of the accident flight were significantly slower than during the previous landing. The airplane’s last recorded ground speed was 45 knots. According to the airplane’s performance charts, its stall speed for the landing configuration would have been 53 knots. Postaccident examination of the wreckage did not reveal any preimpact mechanical malfunctions that would have precluded normal operation. The wind reported at the airport about the time accident was from 230 degrees at 13 knots, gusting to 20 knots.

Factual narrative

HISTORY OF FLIGHT On January 29, 2012, about 1242 eastern standard time, a Piper PA-28-180, N1352T, operated by a private individual, was substantially damaged when it impacted terrain while on approach to the York Airport (THV), Thomasville, Pennsylvania. The certificated private pilot was fatally injured. Visual meteorological conditions prevailed and no flight plan had been filed for the flight that originated from Frederick Municipal Airport (FDK), Frederick, Maryland, about 1200. The personal flight was conducted under the provisions of 14 Code of Federal Regulations Part 91. The airplane was owned by a flying club and based at FDK. According to the President of the flying club, the pilot was one of nine owner-members. He believed the pilot was interested in building up cross-country flight experience and intended to pursue an instrument rating. A sectional chart, located in the cockpit of the airplane depicted a highlighted route from FDK to the Carroll County Airport (DMW), Westminster, Maryland, to THV, and back to FDK. Witnesses at THV observed the airplane on approach to runway 17, a 5,188-foot-long, 100-foot-wide, asphalt runway. They reported that the airplane looked "very low," "slow" and was rocking from side-to-side when it made a sudden left turn, pitched up, and then descended toward the ground nose-first. The airplane's left wing initially impacted the ground, followed by the nose. PERSONNEL INFORMATION The pilot, age 56, held a private pilot certificate, with a rating for airplane single-engine land. His most recent Federal Aviation Administration (FAA) third-class medical certificate was issued on March 25, 2011. At that time, he reported a total flight experience of 120 hours, which included 3 hours during the previous 6 months. His most recent biennial flight review was conducted on July 18, 2011. The pilot's logbooks were not recovered. Based on information provided by the flying club and an insurance company representative, it was estimated that at the time of the accident, the pilot had accumulated about 130 hours of total flight experience, which included about 13 hours in the same make and model as the accident airplane. According to flight logs, the pilot's most recent flight in the airplane prior to the accident was on January 8, 2011, for 1.7 hours. AIRCRAFT INFORMATION The four-seat, low-wing, fixed-gear, all-metal airplane, serial number 28-7205287, was manufactured in 1972. It was powered by a Lycoming O-360-A4A, 180-horsepower engine equipped with a Sensenich propeller. According to FAA Records, the airplane was purchased by its current owner, Condor Flying Club on April 21, 1995. A flight log for the accident flight that was found in the cockpit, listed 18 gallons of fuel in both the left and the right fuel tanks. At the time of the accident, the airplane had been operated for about 6,775 hours since new, and the engine had been operated for about 710 hours since overhaul. In addition, the airplane had beenoperated for 32 hours since its most recent annual inspection, which was performed on November 2, 2011. METEOROLOGICAL INFORMATION The reported weather at THV, elevation 495 feet mean sea level, at 1253, was: wind 230 degrees at 13 knots, gusting to 20 knots; visibility 10 statute miles; clear sky; temperature 4 degrees Celsius (C); dew point -9 degrees C; altimeter 30.16 in/hg. WRECKAGE AND IMPACT INFORMATION The airplane impacted in a corn field approximately 1/4-mile from the approach end, and about 400 feet to the left of the extended centerline of runway 17. The airplane came to rest upright on a heading of about 265 degrees. All major components of the airplane were accounted for in the immediate vicinity of the main wreckage. The left wing was separated at the wing root, at the main spar forward and aft attach points and was folded back along the side of the fuselage. The pitot/static mast was clear of any visible obstructions. The stall vane was impact damaged. The right wing remained attached to its respective main spar attach points; however, it was bent upward approximately 45 degrees. In addition, the right wing leading edge contained aft crush damage from the wingtip to the inboard root area. The rudder, vertical stabilizer and horizontal stabilator exhibited minor damage. Flight control continuity was confirmed from all flight control surfaces to the forward cockpit area. The flaps were observed at an approximate 25-degree setting. The engine was canted downward about 45 degrees. The propeller remained attached to the crankshaft flange and was partially buried in the ground. Both propeller blades contained leading edge gouges near the tip, and chordwise scratches. The crankshaft was rotated via the propeller. Continuity was observed through the accessory section and all respective cylinder rocker arms. In addition, thumb compression was attained on all cylinders. All spark plugs were removed. Their electrodes were intact and dark gray in color. Both magnetos were secure and rotated freely after removal. They subsequently produced spark on all towers when placed on magneto test bench. The gascolator was compromised; however, the screen was absent of contamination. Fuel was present in the fuel line to the carburetor and the carburetor bowl. The fuel was absent of contamination and consistent with 100-low-lead aviation gasoline. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on January 31, 2012, by Forensic Pathology Associates, Allentown, Pennsylvania. The autopsy reported listed the cause of death as injuries that were consistent "blunt impact." Toxicological testing performed on the pilot by the FAA Bioaeronautical Science Research Laboratory, Oklahoma City, Oklahoma, revealed both Amlodipine and Glipizide detected in urine and only glipizide detected in blood. Both medications, as well as the pilot's history of diabetes mellitus and hypertension were reported to the FAA during the pilot's most recentthird-class medical examination. ADDITIONAL INFORMATION Airplane Flight Manual The airplane flight manual listed the airplane's power off, wings level stall speed at a gross weight of 2,450 pounds, as 61 mph (53 knots) for 40 degrees of flaps, and 68 mph (59 knots) in a flaps retracted configuration. A Garmin 496 global positioning system (GPS) receiver was recovered from the cockpit and forwarded to the NTSB Vehicle Recorders Laboratory, Washington, DC, where it was successfully downloaded. Review of the GPS data for the accident flight revealed that the airplane departed FDK about 1200, flew past DMW about 1215, and arrived over THV at a GPS altitude of 2,450 feet about 1225. The pilot entered a left downwind for runway 17, and landed at 1232. He subsequently taxied back to the beginning of runway 17, took off at 1237, and entered a left traffic pattern for runway 17. The airplane's flight track on the accident flight was consistent with the flight track on the previous landing. At 1241:32, the airplane was about 1/2 mile from the threshold of the runway, at a GPS altitude 748 feet (253 feet above ground level [agl]) and a ground speed of 58 knots, about 9 knots slower than the previous landing. At 1241:38, the airplane was at a GPS altitude of 692 feet (197 feet agl) and a ground speed of 49 knots, about 19 knots slower than the previous landing. The airplane's last GPS target was at 1241:54, in the vicinity of the accident site at a GPS altitude of 564 feet (69 feet agl) and a ground speed of 45 knots, about 24 knots slower than the previous landing.

Aircraft

Registration
N1352T
Reported as
Piper PA-28-180
Category
Airplane
Serial number
28-7205287
Airframe hours
6,744
Engine
Lycoming O-360, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · November 2, 2011 · 32 hours before
Departed
FDK · Fredrick, MD
Destination
THV · Thomasville, PA
Airport
THV · York, runway 17, 5,188 × 100 ft, asphalt

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
56
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
July 17, 2011
Seat
Left
Toxicology
Performed
Flight hours
130 total · 13 in this make and model

Weather

Conditions
Visual (VMC) · Day
Wind
230° at 13 knots, gusting 20
Visibility
10 statute miles
Lowest ceiling
None
Temperature
39 °F, dew point 16 °F
Altimeter
30.15 inHg
Observed at
THV

Docket · 24

The files NTSB released with the investigation on January 28, 2013, on NTSB’s docket system: statements, records, photos and specialists’ reports. 49.2 MB in all.

Aircraft Bill of SaleItem 1 · .PDF · 152 KBYork Airport Weather ObservationsItem 2 · .PDF · 24 KBMemorandums For RecordItem 3 · .PDF · 578 KBGlobal Positioning System Device - Specialist's Factual ReportItem 4 · .PDF · 668 KBGlobal Positioning System Device - Specialist's Factual Report - Attachment 1Item 5 · .CSV · 15 KBFlight Log Recovered from CockpitItem 6 · .PDF · 53 KBSectional Chart Recovered Recovered from CockpitItem 7 · .PDF · 493 KBMaintenance Records (excerpts)Item 8 · .PDF · 748 KBAirplane Flight Manual (Excerpts)Item 9 · .PDF · 189 KBStatement of Party Representatives to NTSB InvestigationItem 10 · .PDF · 123 KBPilot's Flying Club ApplicationItem 11 · .PDF · 181 KBPilot Logbook ExcerptsItem 12 · .PDF · 631 KBAirplane Usage Log (exceprts)Item 13 · .PDF · 213 KBRetention / Release of Wreckage FormItem 14 · .PDF · 148 KBFAA Forensic Toxixology Accident ReportItem 15 · .PDF · 111 KBFAA Medical Certification AuthorizationItem 16 · .PDF · 212 KBPhotograph # 1 – View of airplane as it came to rest (front)Item 17 · .PDF · 7.3 MBPhotograph # 2 – View of airplane as it came to rest (left side)Item 18 · .PDF · 5.2 MBPhotograph # 3 – View of airplane as it came to rest (rear)Item 19 · .PDF · 5.9 MBPhotograph # 4 – View of right side of airplane as it came to restItem 20 · .PDF · 5.1 MBPhotograph # 5 – View of engine as it came to restItem 21 · .PDF · 6.4 MBPhotograph # 6 – Engine and propeller during recoveryItem 22 · .PDF · 5.5 MBPhotograph # 7 – Fuel drained from the carburetor and carburetor fuel lineItem 23 · .PDF · 3.5 MBPhotograph # 8 – View of carburetor during disassemblyItem 24 · .PDF · 5.7 MB

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N1352T · 1

Matched to the same aircraft by N-number and date.