# NTSB ERA16FA215: Piper PA31, N3591P, State College, PA, June 16, 2016 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: June 16, 2016, 08:30 local (12:30 UTC) - Place: State College, PA - Coordinates: 40.842777, -77.842498 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.8428&lon=-77.8425&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR final approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report February 22, 2018 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Lycoming Engines, Piper Aircraft Inc - NTSB case key (mKey): 93394 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA16FA215 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/93394/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=93394 - Page: https://openairdocs.org/ntsb/ERA16FA215 ## Probable cause The pilot's decision to continue an unstabilized instrument approach in instrument meteorological conditions, which resulted in controlled flight into terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-31-325, 1 case](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=7103105), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-31-325, 2 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103105), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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-31-325, 2 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7103105), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Ceiling/visibility/precip: clouds](https://openairdocs.org/ntsb-findings/03035025): Environmental issues › Conditions/weather/phenomena · Effect on operation (probable cause); cases with it: [Piper PA-31-325, 1 case](https://openairdocs.org/ntsb-findings/03035025/cases.md?model=7103105), [All aircraft, 108 cases](https://openairdocs.org/ntsb-findings/03035025/cases.md) - [Health/Fitness: predisposing condition](https://openairdocs.org/ntsb-findings/02013035): Personnel issues › Physical · Pilot; cases with it: [Piper PA-31-325, 1 case](https://openairdocs.org/ntsb-findings/02013035/cases.md?model=7103105), [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-IFR final approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Piper PA-31-325, 1 case](https://openairdocs.org/ntsb-events/120/sequence.md?model=7103105), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis The commercial pilot was completing an instrument flight rules air taxi flight on a route that he had flown numerous times for the customer on board. Radar and voice communication data revealed that the airplane was vectored to the final approach course for the precision approach and was given a radio frequency change to the destination airport control tower frequency. The tower controller issued a landing clearance, which the pilot acknowledged; there were no further communications with the pilot. Weather conditions at the airport at the time of the accident included an overcast ceiling at 300 ft with 1 mile visibility in mist. The wreckage was located in densely-wooded terrain. Postaccident examination revealed no evidence of any mechanical malfunctions or anomalies that would have precluded normal operation. The wreckage path and evidence of engine power displayed by numerous cut tree branches was consistent with a controlled, wings-level descent with power. A radar performance study revealed that, as the airplane crossed the precision final approach fix 6.7 nautical miles (nm) from the runway threshold, the airplane was 800 ft above the glideslope. At the outer marker, 5.5 nm from the runway threshold, the airplane was 500 ft above the glideslope. When radar contact was lost 3.2 nm from the threshold, the airplane was about 250 ft above the glideslope. Although the airplane remained within the lateral limits of the approach localizer, its last two recorded radar returns would have correlated with a full-downward deflection of the glideslope indicator in the cockpit, and therefore, an unstabilized approach. Further interpolation of radar data revealed that, during the last 2 minutes of the accident flight, the airplane's rate of descent increased from 400 ft per minute (fpm) to greater than 1,700 fpm, likely as a result of pilot inputs. During the final minute of the flight, the rate decreased briefly to 1,000 fpm before radar contact was lost. The company's standard operating procedures stated that, if a rate of descent greater than 1,000 fpm was encountered during an instrument approach, a missed approach should be performed. The airplane's relative position to the glideslope and its rapid changes in descent rate after crossing the outer marker suggest that the airplane never met the operator's stabilized approach criteria. Rather than executing a missed approach procedure as outlined in the company's operating procedures, the pilot chose to continue the unstabilized approach, which resulted in a descent into trees and terrain. It is unlikely that the pilot's well-controlled diabetes and effectively treated sleep apnea contributed to the circumstances of this accident. However, whether or not the pilot's multiple sclerosis contributed to this accident could not be determined. ## Factual narrative Performance Study An airplane performance study was conducted based on radar data. As the airplane crossed the precision final approach fix (PFAF), 6.7 nm from the runway threshold, the airplane was 800 ft above the glideslope. As the airplane crossed the PENUE locator outer marker (LOM), 5.5 nm from the runway threshold, the airplane was 500 ft above the glideslope. When radar contact was lost 3.2 nm from the threshold, the airplane was about 250 ft above the glideslope. At PENUE LOM and at the last radar return, the airplane's position and altitude would have correlated to a full-downward deflection of the glideslope indication in the cockpit. Interpolation of radar data revealed that, during the last 2 minutes of the accident flight, the airplane's rate of descent increased from 400 fpm to greater than 1,700 fpm. During the final minute of the flight, the rate decreased briefly to 1,000 fpm before radar contact was lost. Company Standard Operating Procedures (SOP) According to the operator's SOP, Stabilized Approach, "Flight should be stabilized by 1000 feet HAT [Height Above Touchdown] in IMC [instrument meteorological conditions]…" and further stipulated, "If an unexpected, sustained rate of descent greater than 1000 feet per minute (fpm) is encountered during the approach, a missed approach should be performed." FAA Information According to an FAA Safety Team pamphlet, "Stabilized Approach," a stabilized approach is one in which the pilot establishes and maintains a constant angle glidepath towards a predetermined point on the landing runway. According to FAA records, the airplane was manufactured in 1980. Its most recent annual inspection was completed February 19, 2016, at 15,999.6 total aircraft hours, about 44 hours before the accident. The airplane was equipped with a King KAP/KFC 200 flight control system (autopilot). According to the operating instructions for the airplane's autopilot system, the system's approach mode captures localizer course and glideslope indications when properly configured by the pilot. The system will capture from either above or below the glideslope. No system limitations were published regarding the altitude above the glideslope from which the system would not capture or the rate of descent above which the system would not capture. A certification engineer for the autopilot manufacturer stated that a descent rate of 1,000 ft per minute (fpm) was "normal" to capture the glideslope from above. The operator's director of operations said that the autopilot in the accident airplane was unlikely to capture the glideslope from above at descent rates greater than 500 fpm. It could not be determined if the autopilot was in use during the approach, or which operational modes may have been engaged. On June 16, 2016, at 0830 eastern daylight time, a Piper PA-31-325, N3591P, was destroyed when it collided with terrain while on approach to University Park Airport (UNV), State College, Pennsylvania. The airline transportpilot and the passenger were fatally injured. The airplane was owned and operated by Aeronational, Inc. Instrument meteorological conditions prevailed, and an instrument flight rules flight plan was filed for the on-demand air taxi flight, which was conducted under the provisions of Title 14 Code of Federal Regulations (CFR) Part 135. The flight departed Washington County Airport (AFJ), Washington, Pennsylvania, about 0800. According to the operator, the passenger was a regular customer who was routinely flown to UNV. The pilot was familiar with the passenger and the route and had completed the flight numerous times. Radar and voice communication information from the Federal Aviation Administration (FAA) revealed that, at 0824:35, air traffic control (ATC) provided the pilot with a heading to intercept the final approach course for the instrument landing system RWY 24 approach at UNV and cleared the airplane for the approach. At 0825:30, the pilot was advised that radar services were terminated and was instructed to contact the tower controller at UNV. At 0825, the pilot contacted the UNV tower controller and announced, "…with you on the approach." The tower controller acknowledged the call and issued a landing clearance, which the pilot acknowledged. There were no further communications with the pilot despite multiple attempts by ATC. At 0843:50, an airport operations ground vehicle operating at the approach end of runway 24 identified smoke in a wooded area about 1 mile northeast of the airport and notified control tower personnel. The source of the smoke was later identified as the accident airplane. Forensic DX, Windber, Pennsylvania, performed an autopsy on the pilot. The reported stated the cause of death was thermal injuries. The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing on specimens from the pilot, with negative results for ethanol, carbon monoxide, and all tested-for drugs. According to FAA records, in 2001 the pilot reported a diagnosis of multiple sclerosis (MS) with persistent weakness in his left leg. He received his first special-issuance medical certificate in 2002. A report from the pilot's neurologist dated February 2016 indicated that his neurologic status was unchanged through that date. At his most recent examination for an FAA medical certificate, the pilot reported new diagnoses of diabetes and obstructive sleep apnea, which were managed with diet and the use of bilevel positive airway pressure (BiPAP) treatment, respectively. At 0853, the weather recorded at UNV included an overcast ceiling at 300 ft, calm wind, and visibility 1 statute mile in mist. The temperature was 17°C and the dew point was 17°C; the altimeter setting was 29.80 inches of mercury. AIRMET Sierra for instrument meteorological conditions and mountain obscuration was in effect for the area surrounding the accident site at the time of the accident. The pilot held an airline transport pilotcertificate with ratings for airplane single-engine land, multiengine land, and instrument airplane. His most recent FAA first-class medical certificate was issued March 7, 2016, with the limitation, "Not valid for any class after 3/31/2017." The pilot reported 12,400 total hours of flight experience on the date of the examination, 350 hours of which were during the previous 6 months. Company training records indicated that the pilot had received the training required by the company's operations and training manuals. The pilot had completed the required annual ground training on January 18, 2016. His last airman competency check was completed satisfactorily on January 18, 2016, in the accident airplane. Pilot duty records indicated compliance with the flight and duty time requirements of Title 14 CFR Part 135. The pilot had just returned from 1 week of vacation, and the accident flight was his first flight since returning to duty. The accident site was about 1 nautical mile (nm) from the threshold of runway 24 and about 2 nm beyond the final radar return at an elevation of 1,200 ft mean sea level. The wreckage was examined at the accident site, and all major components were accounted for at the scene. The wreckage path was located in densely wooded terrain and extended about 450 ft on a magnetic heading of 223°. The initial impact points were in treetops about 70 ft above the ground, and tree trunks and branches displayed impact fractures and sharp, angular cuts along the length of the wreckage path. Both wings were fragmented along the path. Both engines and each main landing gear were separated and scattered along the wreckage path. The fuselage and empennage came to rest upright facing the direction of travel. The instrument panel, cockpit, and cabin area were destroyed by postcrash fire. Control continuity could not be established due to extensive impact damage; however; parts associated with the wings, flaps, and ailerons were identified. Sheet metal and cabling associated with the empennage, horizontal and vertical stabilizers, and the elevators were identified, and the cable attach points at all primary flight controls were secure. Examination of the landing gear and components associated with the flap system were consistent with a 15° flap extension and the landing gear in the down and locked position at the time of impact. The propeller systems were attached to their respective engines, and all propeller blades exhibited similar twisting, bending, leading edge gouging, and chordwise scratching. Several tree branches and trunks displayed deep, angular cuts and paint transfers consistent with propeller blade contact. The engines were each damaged by impact and postcrash fire. The left engine displayed extensive thermal damage. The magnesium oil sump and the accessories mounted to the accessory section were consumed by fire, and the damage and contamination produced by the fire precluded rotation of the engine. The single-drive, dualmagneto was consumed by fire and could not be tested. Borescope examination of the cylinders revealed normal operational deposits and wear and no preimpact anomalies. The right engine displayed extensive thermal damage. Impact damage to the No. 2 cylinder precluded rotation of the engine. The single-drive, dual magneto was damaged by fire and would not produce spark when rotated. Borescope examination of the cylinders revealed normal operational deposits and wear and no evidence of preimpact anomalies. The No. 2 cylinder was removed, and the engine was rotated by hand at the propeller. Continuity was confirmed from the powertrain through the valvetrain to the accessory section. Compression was confirmed on all cylinders using the thumb method, with the exception of the No. 2 cylinder. ## Aircraft - Registration: [N3591P](https://openairdocs.org/deregistered/N3591P-2018-10-18), registration cancelled 2018-10-18, S/N 31-8012081, built 1980 (OpenAirDocs) - Reported make and model: PIPER PA31 (325) - Registry model: [Piper PA-31-325](https://openairdocs.org/model/piper-pa-31-325) (registry code 7103105) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 31-8012081 - Year built: 1980 - Airframe hours: 16040.1 - Engines: LYCOMING TIO-540 SER 325 horsepower reciprocating; LYCOMING TIO-540 SER 325 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Part 135 - Operator: Aeronational Inc - Registered owner: Aeronational Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, February 19, 2016, 44 hours before - Departed: AFJ, Washington, PA - Destination: UNV, State College, PA - Flight plan: IFR - Airport: UNV, University Park, runway 24, 6,701 × 150 ft, asphalt - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 60; injuries: fatal; airline transport, flight instructor, commercial; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, waiver time limited special; seat: left; restraint: 3-point; toxicology performed; flight hours: 12,493 total, 718 in this make and model, 12,099 as pilot in command, 91 in the last 90 days, 19 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: calm - Visibility: 1 statute miles - Lowest ceiling: 300 ft overcast - Temperature: 63 °F, dew point 63 °F - Altimeter: 29.79 inHg - Observed at: KUNV, 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 20160616006819A](https://openairdocs.org/incident/20160616006819A), Jun 16, 2016: Piper PA-31-325, State College, PA, Destroyed, 2 fatal. The aircraft was destroyed during Collision with terrain while on approach to University Park Airport (unv), State College, Pennsylvania. The airplane departed… ## Other investigations on N3591P (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 ERA12LA557](https://openairdocs.org/ntsb/ERA12LA557), Sep 9, 2012: Piper PA-31-325 (N3591P), Washington, PA, substantial damage. Probable cause: The airplane’s encounter with a flock of geese during takeoff, which resulted in the airplane’s hard impact with the runway while the pilot maneuvered in an attempt to avoid the geese. ## Docket (14 files) The files NTSB released with the investigation on February 5, 2018, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=93394. 10.3 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459753&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - FAA Inspector's Statement Records Review (item 2, .PDF, 142 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459754&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement%20Records%20Review-Master.PDF - Memorandum for Record Autopilot (item 3, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459755&FileExtension=.PDF&FileName=Memorandum%20for%20Record%20Autopilot-Master.PDF - Approach Plate ILS RWY 24 UNV (item 4, .PDF, 276 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459756&FileExtension=.PDF&FileName=Approach%20Plate%20ILS%20RWY%2024%20UNV-Master.PDF - Maps or Charts of Accident Area (item 5, .PDF, 900 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459757&FileExtension=.PDF&FileName=Maps%20or%20Charts%20of%20Accident%20Area-Master.PDF - Aircraft Performance Radar Study (item 6, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459758&FileExtension=.PDF&FileName=Aircraft%20Performance%20Radar%20Study-Master.PDF - Operational Factors Specialist's Report (item 7, .PDF, 398 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459759&FileExtension=.PDF&FileName=Operational%20Factors%20Specialist%27s%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (Piper) (item 8, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459760&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20(Piper)-Master.PDF - Statement of Party Representatives to NTSB Investigation (Lycoming) (item 9, .PDF, 99 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459761&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20(Lycoming)-Master.PDF - Photos (item 10, .PDF, 6 photos, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459762&FileExtension=.PDF&FileName=Photos-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 11, .PDF, 121 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459763&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - NTSB Medical Review (item 12, .PDF, 503 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459764&FileExtension=.PDF&FileName=NTSB%20Medical%20Review-Master.PDF - Toxicological Report (item 13, .PDF, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40459765&FileExtension=.PDF&FileName=Toxicological%20Report-Master.PDF - Safety Alert SA 077 (item 14, .PDF, 628 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40471824&FileExtension=.PDF&FileName=Safety%20Alert%20SA%20077-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.