# NTSB ERA16FA012: Piper PA 28-180, N57312, Lake Worth, FL, October 13, 2015 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: October 13, 2015, 17:33 local (21:33 UTC) - Place: Lake Worth, FL - Coordinates: 26.616388, -80.095001 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=26.6164&lon=-80.0950&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal; on the ground: 1 fatal - Status: Completed, report June 26, 2017 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA FSDO-19, Piper, Lycoming Engines - NTSB case key (mKey): 92169 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16FA012 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92169/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92169 - Page: https://openairdocs.org/ntsb/ERA16FA012 ## Probable cause A loss of control for reasons that could not be determined based on the available information. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Piper PA-28-180, 18 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=7102808), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) - [Health/Fitness: predisposing condition](https://openairdocs.org/ntsb-findings/02013035): Personnel issues › Physical · Pilot; cases with it: [Piper PA-28-180, 1 case](https://openairdocs.org/ntsb-findings/02013035/cases.md?model=7102808), [All aircraft, 56 cases](https://openairdocs.org/ntsb-findings/02013035/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28-180, 30 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102808), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Uncontrolled descent: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-180, 96 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102808), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot was conducting a personal cross-country flight. The pilot utilized the destination airport's common traffic advisory frequency (CTAF) to report that he was 3 miles east of the airport and that he planned to enter a midfield left downwind leg for the runway. He then reported on that he was turning a left base leg for the runway. No further communications were received from the pilot. A radar plot showed the airplane flying past the runway centerline and then making an S-turn before radar contact was lost. Postaccident examination of the airframe and engine revealed no evidence of any mechanical failures or malfunctions that would have precluded normal operation. The pilot's autopsy revealed that he had significant heart disease with enlargement and wall thickening. He also had diffuse coronary artery disease with 75 percent stenosis of the left anterior descending and right coronary arteries and 25 percent stenosis of the left main and left circumflex coronary arteries. There was also mild calcification of the mitral valve leaflets. The pilot's coronary artery disease put him at a high risk for acute ischemia, which can cause chest pain, shortness of breath, or decreased blood pressure. He was also at increased risk for an arrhythmia, which can result in loss of consciousness. None of these events would leave visible evidence at autopsy. Given the circumstances of the accident and the pilot's cardiac conditions, it is possible that he became acutely impaired or incapacitated by symptoms from his cardiac disease and that this could have resulted in the loss of aircraft control. However, given the limited available information, it could not be determined whether the loss of control was the result of incapacitation or if there was another reason that the aircraft departed controlled flight and the pilot was unable to regain control. ## Factual narrative HISTORY OF FLIGHT On October 13, 2015, about 1733 eastern daylight time, a Piper PA-28-180, N57312, impacted a residential area in Lake Worth, Florida, during approach to Palm Beach County Park-Lantana Airport (LNA), Lantana, Florida. The private pilot and one person on the ground were fatally injured. The airplane was consumed by postimpact fire and destroyed. The airplane was owned by Flyers Inc., and was being operated by a private individual as a 14 Code of Federal Regulations Part 91 personal flight. Visual meteorological conditions prevailed, and no flight plan was filed. The flight had departed Kissimmee Gateway Airport (ISM), Kissimmee, Florida, with an intended destination of LNA. Fueling records indicated that the airplane was then topped off with 20 gallons of 100-low-lead aviation gasoline before departing ISM for a flight to LNA, during which the pilot received flight-following services from air traffic control. Review of recordings of the airport's common traffic advisory frequency revealed that the pilot was 3 miles east of the airport and was going to enter the midfield left downwind leg for runway 15. The pilot then radioed that he was turning a left base leg for runway 15. No other communications were received from the pilot. Radar data provided by the Federal Aviation Administration showed a target correlated to be the accident airplane flying past the runway extended centerline and then making an S-turn before radar coverage was lost. PERSONAL INFORMATION According to FAA records, the pilot held a private pilot certificate with an airplane single-engine land rating, which was issued on May 4, 2012. He also held an FAA third-class medical certificate, issued September 23, 2015. At that time, he was 66 inches tall and weighed 180 pounds. He reported treatment for a kidney stone, a laceration repair, and hernia surgery as well as various minor ailments to the FAA. He reported the use of testosterone to treat a low testosterone level. His medical certificate was limited by a requirement to wear corrective lenses for distant vision and have glasses available for near vision. At the time of the medical examination, the pilot reported 250 hours of total flight time. AIRCRAFT INFORMATION The four-seat, low-wing, fixed-tricycle-gear airplane, serial number 28-7405042, was manufactured in 1973. It was powered by a Lycoming O-360, 180-horsepower engine and equipped with a two-bladed, fixed-pitch Sensenich propeller. A review of maintenance records revealed that the airplane's most recent annual inspection was completed on May 25, 2015. At that time, the airframe had accumulated 6,199 total flight hours and the engine had accumulated 1,320 flight hours since major overhaul. METEOROLOGICAL INFORMATION The 1753 recorded weather observation at West Palm Beach International Airport (PBI), West Palm Beach, Florida, located about 4.5 miles north of the accident site, included wind from 140° at 13 knots, visibility 10 miles, few clouds at 5,000ft, scattered clouds at 25,000 ft, temperature 28° C, dew point 21° C, and altimeter 29.91 inches of Mercury. WRECKAGE AND IMPACT INFORMATION The wreckage was examined at the accident site and again at a recovery facility. No readable cockpit instruments were recovered. Aileron control continuity was established from the control chain in the cockpit via aileron cables to their respective aileron bellcranks. The aileron cables had separated and exhibited broomstraw ends, and the bellcranks had separated from the wings. Rudder control continuity was confirmed from the rudder horn to the rudder bar. Stabilator control continuity was confirmed from the "T" bar to the balance weight. The stabilator trim system was not recovered and presumed destroyed by postimpact fire. The two-bladed propeller remained attached to the engine. One blade was bent aft, was partially melted, and contained leading edge nicks, and the outboard half of the other propeller blade was consumed by fire. The top spark plugs were removed from the engine, and the propeller was rotated by hand. Camshaft and crankshaft continuity to the rear accessory section was confirmed, and valve train continuity was confirmed to the Nos. 1 and 3 cylinders through rotation of the crankshaft. Due to impact and thermal damage, valve train continuity to the Nos. 2 and 4 cylinders was confirmed by visual inspection. MEDICAL AND PATHOLOGICAL INFORMATION The Office of the Medical Examiner, West Palm Beach, Florida, performed an autopsy on the pilot. The autopsy findings included multiple blunt force trauma and thermal injuries. The autopsy also identified heart enlargement and wall thickening and diffuse coronary artery disease with 75 percent stenosis in the left anterior descending and right coronary arteries and 25 percent stenosis of the left main and left circumflex coronary arteries. In addition, there was mild calcification of the mitral valve leaflets. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicology testing on specimens from the pilot. The toxicology tests detected greater than 10% carbon monoxide in blood (heart) and greater than 2.51 (ug/ml) cyanide in blood (heart). ## Aircraft - Registration: [N57312](https://openairdocs.org/deregistered/N57312-2016-09-19), registration cancelled 2016-09-19, S/N 28-7405042, built 1973 (OpenAirDocs) - Reported make and model: PIPER PA 28-180 - Registry model: [Piper PA-28-180](https://openairdocs.org/model/piper-pa-28-180) (registry code 7102808) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-7405042 - Year built: 1973 - Airframe hours: 6199 - Engines: LYCOMING O-360-A4A 180 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, May 25, 2015 - Departed: ISM, Kissimmee, FL - Destination: LNA, Lantana, FL - Airport: LNA, Palm Beach County Park, runway 15, 3,421 × 100 ft, asphalt - Equipment: Stall warning system ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 250 total, 250 in this make and model ## Weather - Conditions: Visual (VMC), Day - Wind: 140° at 13 knots - Visibility: 10 statute miles - Temperature: 82 °F, dew point 70 °F - Altimeter: 29.90 inHg - Observed at: PBI, 4 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 20151013017089A](https://openairdocs.org/incident/20151013017089A), Oct 13, 2015: Piper PA-28-180, Lake Worth, FL, Destroyed, 2 fatal. On October 13, 2015 aircraft n 57312 departed ism (kissimmee gateway) enroute to lna (lantana airport). At about 1733 eastern time the aircraft impacted a… ## Other investigations on N57312 (1) 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. - [NTSB FTW76FRD27](https://openairdocs.org/ntsb/FTW76FRD27), Jan 19, 1976: Piper PA-28 (N57312), Church Point, LA, substantial damage ## Docket (12 files) The files NTSB released with the investigation on June 15, 2017, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92169. 93.5 MB in all. - Medical factual report (item 1, PDF, 3 pages, 208 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4687486&FileExtension=pdf&FileName=ERA16FA012_Medical%20Factual%20Report-Rel.pdf - Weather reports and records (item 2, PDF, 1 page, 66 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=3123381&FileExtension=pdf&FileName=Metars-Rel.pdf - Fuel reciepts (item 3, PDF, 4 pages, 301 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4707562&FileExtension=pdf&FileName=Fuel%20reciepts_Redacted-Rel.pdf - Radar plot (item 4, PDF, 1 page, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=3122045&FileExtension=pdf&FileName=Full%20page%20photo-Rel.pdf - ATC radio communications (item 5, WAV, 86.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4950102&FileExtension=wav&FileName=N57312_DRB_10-13-15_2026-2159Z_trimmed-Rel.wav - Recorded CTAF communications - initial (item 6, WAV, 934 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=5163598&FileExtension=wav&FileName=0000000981_LANTANA_AIRPORT_122.7Mhz_2015-10-13_17_30_53_by_servername_asc-Rel.wav - Recorded CTAF communcations - downwind (item 7, WAV, 688 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=5164292&FileExtension=wav&FileName=0000000982_LANTANA_AIRPORT_122.7Mhz_2015-10-13_17_31_32_by_servername_asc-Rel.wav - Recorded CTAF communications - base leg (item 8, WAV, 770 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=5154567&FileExtension=wav&FileName=CTAF-Rel.wav - Statement of party representatives to NTSB investigation (item 9, PDF, 16 pages, 472 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4097604&FileExtension=pdf&FileName=party%20forms_Redacted-Rel.pdf - Investigation photographs (item 10, PDF, 4 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4707296&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 11, PDF, 1 page, 75 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=3123372&FileExtension=pdf&FileName=wreckage%20release_Redacted-Rel.pdf - Toxicological report (item 12, PDF, 1 page, 79 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=4845743&FileExtension=pdf&FileName=TOX-Rel.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.