# NTSB ERA20FA014: Piper PA32, N534Z, Raleigh, NC, October 20, 2019 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: October 20, 2019, 19:21 local (23:21 UTC) - Place: Raleigh, NC - Coordinates: 35.854167, -78.757667 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=35.8542&lon=-78.7577&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: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Piper Aircraft - NTSB case key (mKey): 100457 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA20FA014 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/100457/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=100457 - Page: https://openairdocs.org/ntsb/ERA20FA014 ## Probable cause The pilot’s failure to maintain a safe glidepath during final approach to the runway, which resulted in a collision with trees and terrain. Contributing was the pilot’s lack of recent instrument flight experience. ## 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-32-301, 2 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=7103207), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-32-301, 2 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=7103207), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Experience/qualifications: recent instrument experience](https://openairdocs.org/ntsb-findings/02031050): Personnel issues › Experience/knowledge · Pilot (probable cause); cases with it: [Piper PA-32-301, 1 case](https://openairdocs.org/ntsb-findings/02031050/cases.md?model=7103207), [All aircraft, 40 cases](https://openairdocs.org/ntsb-findings/02031050/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-32-301, 3 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7103207), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) ## Analysis During a night, instrument flight rules flight in instrument meteorological conditions, the pilot checked in with approach control and was told to expect an instrument approach to a different runway than the one he had planned for. According to air traffic control communications, the pilot subsequently reported some issues interacting with his airplane’s GPS and autopilot. He had difficulty reading back instructions, missed radio calls, and did not maintain assigned altitudes and headings. The air traffic controller eventually provided him with radar vectors onto the final approach course, and when the airplane was about 9 miles away from the airport the pilot reported that he had broken out of the clouds and could see lights below. The controller cleared the pilot for a visual approach, but the pilot had difficulty visually acquiring the runway lights, and the controller increased their intensity. The controller subsequently issued two low altitude alerts to the pilot while on final approach. The pilot’s last radio transmission indicated he had the runway in sight, but radio and radar contact were lost when the airplane was on short final approach. The wreckage was found the next morning in a densely wooded and sparsely lit state park about just over a mile from the runway threshold with the wreckage facing the runway; the airplane was destroyed. Damage to the treetops indicated a controlled, gradual descent into the trees, indicative of the pilot not maintaining adequate clearance from the ground during final approach. Postaccident examination of the wreckage did not reveal evidence of a mechanical malfunction or anomaly with the airplane that would have precluded normal operation. A review of the pilot’s logbook revealed a lack of recent night and instrument experience; he had not logged the required night and instrument procedures to act as pilot-in-command for a flight carrying passengers at night and in IMC. The pilot’s issues with using his airplane’s GPS and autopilot during the accident flight were likely due to a lack of recent use in actual or simulated instrument conditions. ## Factual narrative On October 20, 2019, about 1921 eastern daylight time, a Piper PA-32-301, N534Z, was destroyed when it was involved in an accident near Raleigh, North Carolina. The private pilot and one passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations (CFR) Part 91 personal flight. The flight was destined for Raleigh-Durham International Airport (RDU), Morrisville, North Carolina. Air traffic control data provided by the Federal Aviation Administration (FAA) revealed that, at 1825, the pilot checked in with RDU north departure radar (NDR) at 5,000 ft msl and requested the area navigation (RNAV) GPS runway 5R approach to RDU. He was told to expect the RNAV GPS runway 32 approach instead. The pilot reported that he was already set up for the runway 5R approach; however, he would comply and set up for the runway 32 approach. At 1839, NDR cleared the pilot for the RNAV GPS runway 32 approach. At 1850, NDR advised the pilot to contact RDU tower, local control east (LCE). The pilot then checked in with the LCE controller and advised that he was “…on the 32 approach.” The LCE controller cleared the flight to land. At 1852, the pilot advised LCE that he needed to climb because his GPS approach just shut off. LCE instructed the pilot to maintain 3,000 ft msl and confirm his heading, and the pilot complied. The LCE controller asked the pilot twice if he was in IMC, and the pilot responded affirmatively the second time and said he was trying to climb over it. At 1854, the LCE controller advised the pilot to contact RDU approach and fly a heading of 140°. The pilot responded that he was having trouble with his heading. The controller asked the pilot to confirm his heading twice, and the pilot responded the second time that his heading was 101°, which the controller confirmed that the flight was heading 100°. The pilot then requested a climb to get above IMC and the controller cleared him to 4,000 ft msl. At 1856, the pilot reported to NDR that his “autopilot shut off.” NDR asked the pilot if he was proceeding directly to the initial approach fix NOSIC; the pilot replied, “let me figure out what’s going on here.” NDR then advised the pilot to fly heading 050° to get settled and he would provide radar vectors back to the airport. The pilot acknowledged. At 1857, the NDR controller advised the pilot that he was 400 ft above his cleared altitude; the pilot acknowledged. At 1859, NDR advised the pilot that he appeared to be flying northbound and was 500 ft high. At 1901, NDR advised the pilot to expect the initial approach fix (SINNO) for the full approach. The pilot responded that he needed to enter the input and asked the controller for the phonetics for SINNO, then 3 minutes later the NDR controller told the pilot that he missed SINNO and advised the pilot to fly a 230° heading to fly straight over NOSIC; the pilot acknowledged. At 1911, NDR asked the pilot if he had NOSIC in yet, and the pilot responded that he was headingdirectly to NOSIC. The NDR controller then cleared the pilot to fly directly to NOSIC and fly the straight in approach to runway 32. The pilot did not acknowledge. About 1 minute later, NDR cleared the pilot for the RNAV GPS runway 32 approach; the pilot acknowledged. At 1917, the NDR controller advised the pilot that he was off to the right of the approach; the pilot responded that he was turning back to it, then he “just broke out” of the clouds. The NDR controller asked the pilot if he had the runway in sight then cleared the pilot twice for a visual approach to runway 32; the pilot responded only after the third communication that he had trouble identifying the runway lights. The NDR controller then advised the pilot of a low altitude alert and to maintain 2,000 ft msl. The NDR controller then advised the pilot that the runway was 12 o’clock and 9 miles and asked if the pilot had the runway in sight; the pilot reported that he believed he saw the airport beacon. The NDR controller then advised twice that, if the pilot had the runway in sight, he was cleared for the visual approach. At 1919, the controller increased the runway lights’ intensity, and the pilot reported that he thought he saw them. At 1920, NDR advised the pilot to contact the RDU tower, and the pilot acknowledged. Then the tower controller affirmed to the NDR controller that he had the airplane in sight. The LCE controller then advised the pilot of another low altitude alert, and the pilot verified that he had the runway in sight. No further communications were received from the pilot and radar contact was lost. After numerous calls to the pilot went unanswered, airport rescue and firefighting personnel were notified, and a search was initiated for the airplane. The wreckage was located about 1000 on October 21 (the next morning). A witness landed his airplane on runway 32 shortly before the accident. He reported turning off runway 32 and watching for the accident airplane through his rear window because he was worried about the pilot. He heard some of the radio communications and thought that the pilot sounded confused and was having difficulty with the approach. He saw the airplane break out under the clouds, and the airplane’s landing light was off. He reported that the airplane was stable on the approach and just descended into the tree line. He also reported that, on the approach to runway 32, the state park area below the approach was dark with no lights. According to the Office of the Chief Medical Examiner, Raleigh, North Carolina, autopsy report, the cause of death of the pilot was multiple blunt force injuries and the manner of death was accident. Toxicology testing performed by the FAA’s Forensic Sciences Laboratory detected salicylate (aspirin) in the urine. Testing for ethanol and tested-for common drugs of abuse was negative. Testing for carboxyhemoglobin (to determine potential carbon monoxide poisoning) was not performed due to a lack of suitable specimens. The1851 local weather observation (about 30 minutes before the accident) for RDU included a ceiling of 1,000 ft above ground level broken and 10 statute miles visibility. The 1956 local weather observation (about 35 minutes after the accident) for RDU included a ceiling of 1,400 ft above ground level overcast and 10 statute miles visibility. Sunset occurred at 1831, and evening civil twilight ended at 1857. According to the pilot’s logbook entries, he did not meet the recent instrument flight experience and night takeoff and landing requirements of Title 14 CFR part 61.57 to act as pilot-in-command of an aircraft carrying passengers. His most recent instrument experience was on November 26, 2018, when he logged three instrument approaches. His most recent night experience was logged on November 3, 2018, when he recorded 0.5 hour of flight. The airplane crashed in a thickly wooded area in William B. Umstead State Park. The wreckage path was about 400 ft long and about 50 ft wide, oriented on a heading of 315º. The main wreckage was located about 1.18 miles southeast of the runway 32 threshold. All aircraft components and structures were accounted for and examined at the accident site. The initial point of impact was the top of a 100-ft-tall pine tree, and a large section of the right wing remained lodged near the top of the tree. Numerous tree branches were found along the wreckage path with smooth, angular cuts and dark paint transfer marks, consistent with a descent into the trees at a shallow descent angle. Flight control continuity was confirmed from the cockpit area to all flight control surfaces. Flap torque tube positions as found in the wreckage were consistent with the flaps-up position at impact. The engine was separated from the fuselage and its engine mount assembly was fragmented. The engine exhibited impact damage. The engine-driven fuel pump was fractured from the engine and fuel was observed within the pump during examination. The engine-driven vacuum pump’s drive coupler was intact, and during hand rotation of the drive coupler, the pump was determined to be functional. The three-blade propeller was fractured from the engine at its attaching point. The propeller spinner remained attached to its bulkheads and exhibited impact damage and torsional deformation. The propeller blades exhibited twisting and s-curved signatures, as well as chordwise scratches. The fuel selector control and valve were positioned to the “right main tank” position. Fuel was observed within the fuel filter bowl, and the screen was free of debris. Examination of the fuel selector valve revealed the selector was in its detent, and its port was open for the selected tank position. Examination of a vacuum-driven attitude indicator gyro and its internal gyro rotor and housing revealed no rotational scoring. The landing light switch in the cockpit was found in the on position; however, the panel was damaged from impact. The landing light assembly was destroyed byimpact forces. ## Aircraft - Registration: [N534Z](https://openairdocs.org/deregistered/N534Z-2020-08-02), registration cancelled 2020-08-02, S/N 3206054, built 1989 (OpenAirDocs) - Reported make and model: Piper PA32 (301) - Registry model: [Piper PA-32-301](https://openairdocs.org/model/piper-pa-32-301) (registry code 7103207) (OpenAirDocs) - Registry engine: [Lycoming IO-540 series](https://openairdocs.org/engine/lycoming-io-540-series) (registry code 41530, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 3206054 - Year built: 1989 - Airframe hours: 2172 - Engines: Lycoming IO-540-K1G5 300 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, December 14, 2018, 48 hours before - Departed: CSG, Columbus, GA - Destination: RDU, Raleigh, NC - Flight plan: IFR - Airport: RDU, Raleigh-Durham Int, runway 32, 3,570 × 100 ft, asphalt - Equipment: Auto-pilot, Electronic multifunction display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 72; injuries: fatal; private; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; restraint: 3-point; toxicology performed; flight hours: 2,956 total, 10 in the last 90 days, 4 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/dark - Wind: variable at 6 knots - Visibility: 10 statute miles - Lowest ceiling: 1,000 ft broken - Temperature: 61 °F, dew point 57 °F - Altimeter: 29.86 inHg - Observed at: KRDU, 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 20191020019319A](https://openairdocs.org/incident/20191020019319A), Oct 20, 2019: Piper PA-32-301, Raleigh, NC, Destroyed, 2 fatal. Ronald gatewood: airworthiness safety inspector [privacy data omitted] Aircraft accident inspector report Date of report: 11/05/2019 Accident aircraft: Piper… ## Docket (24 files) The files NTSB released with the investigation on November 3, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=100457. 260 MB in all. - Witness correspondence (item 1, PDF, 1 page, 357 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607327&FileExtension=pdf&FileName=1%20Witness%20Correspondence_Redacted-Rel.pdf - NTSB memorandum for record - witness statement (item 2, PDF, 2 pages, 764 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607638&FileExtension=pdf&FileName=2%20Witness%20Statement_Redacted-Rel.pdf - Excerpts - pilot log (item 3, PDF, 20 pages, 10.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607785&FileExtension=pdf&FileName=3%20Excerpts%20-%20Pilot%20Log_Redacted-Rel.pdf - Flight instructor correspondence (item 4, PDF, 2 pages, 366 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607371&FileExtension=pdf&FileName=3b%20Flight%20Instructor%20Correspondence-Rel.pdf - Excerpts - aircraft log (item 5, PDF, 7 pages, 7.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11608606&FileExtension=pdf&FileName=4%20Excerpts%20-%20Airframe%20Log_Redacted-Rel.pdf - Excerpts - engine log (item 6, PDF, 6 pages, 5.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607648&FileExtension=pdf&FileName=5%20Excerpts%20-%20Engine%20Log_Redacted-Rel.pdf - Weather data (item 7, PDF, 1 page, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607878&FileExtension=pdf&FileName=6%20Weather%20Data%20RDU_Redacted-Rel.pdf - Radar track - entire flight (item 8, PDF, 1 page, 316 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607906&FileExtension=pdf&FileName=7%20Entire%20Flight%20(2D)-Rel.pdf - Radar track - approach (2D) (item 9, PDF, 1 page, 414 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607514&FileExtension=pdf&FileName=8%20Approach%20(2D)-Rel.pdf - Radar track - approach (3D) (item 10, PDF, 1 page, 717 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11608922&FileExtension=pdf&FileName=9%20Approach%20(3D)-Rel.pdf - Opsvue radar playback (item 11, MP4, 4.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607170&FileExtension=mp4&FileName=10%20ERA20FA014%20-%20OpsVue%20Playback%20-%2010X%20Speed-Rel.mp4 - Opsvue radar data (item 12, CSV, 177 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607524&FileExtension=csv&FileName=11%20N534Z%20OpsVue%20Data-Rel.csv - FAA form 8020-6 report of aircraft accident (item 13, PDF, 11 pages, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607658&FileExtension=pdf&FileName=12%20FAA%20Form%208020-6%20Report%20of%20Aircraft%20Accident_Redacted-Rel.pdf - ATC voice communications with N534Z (item 14, WAV, 218 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11677998&FileExtension=wav&FileName=RDU%20N534Z%20LCE-4%2010-20-2019-Rel.wav - RNAV GPS runway 32 approach rdu (item 15, PDF, 1 page, 254 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607064&FileExtension=pdf&FileName=13%20RNAV%20GPS%20RWY%2032%20RDU-Rel.pdf - Rdu airport diagram (item 16, PDF, 1 page, 171 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11609000&FileExtension=pdf&FileName=14%20RDU%20Airport%20Diagram-Rel.pdf - Photo array (item 17, PDF, 11 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12879789&FileExtension=pdf&FileName=Photo%20Array-Rel.pdf - Wreckage diagram 1 (item 18, PDF, 1 page, 366 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607731&FileExtension=pdf&FileName=16%20Wreckage%20Diagram%201-Rel.pdf - Wreckage diagram 2 (item 19, PDF, 1 page, 362 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607180&FileExtension=pdf&FileName=16%20Wreckage%20Diagram%202-Rel.pdf - NTSB examination summary (item 20, PDF, 5 pages, 386 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11608031&FileExtension=pdf&FileName=17%20Examination%20Summary_Redacted-Rel.pdf - Toxicological report - pilot (item 21, PDF, 1 page, 379 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607741&FileExtension=pdf&FileName=19%20Tox%20Report%20-%20Pilot_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation (item 22, PDF, 14 pages, 3.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607888&FileExtension=pdf&FileName=22%20Party%20Form_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 23, PDF, 1 page, 433 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607960&FileExtension=pdf&FileName=23%20NTSB%20Release%20N534Z%20Signed_Redacted-Rel.pdf - Evidence control form (item 24, PDF, 1 page, 130 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=11607083&FileExtension=pdf&FileName=24%20ERA20FA014%20Evidence%20Control%20Form_Redacted-Rel.pdf From the NTSB's public API. 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