ERA21LA122

NTSB accident investigation · Piper PA46 · Leicester, MA · February 2, 2021

Accident · Serious injuriesClass 3 · LimitedFinal report
Date
February 2, 2021, 16:55 local (21:55 UTC)
Place
Leicester, MA
Injuries
2 serious, 1 minor
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N221STPiper PA46
Defining event
Approach-IFR initial approach: Structural icing
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Eastern Region Aviation
Parties
Lycoming Engines, Piper Aircraft, FAA/FSDO
FAA report
20210202002569A
Case key
102592

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 the minimum airspeed for flight in icing conditions, which resulted in a loss of elevator control during approach due to ice accumulation.

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.

Temp/humidity/pressure: conducive to structural icingEnvironmental issues › Conditions/weather/phenomena · Compliance w/ procedurePiper PA 46-350P: 5 casesAll aircraft: 103 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA 46-350P: 15 casesAll aircraft: 1,681 casesProbable cause

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 pilot reported that, while descending through clouds and beginning the instrument approach, some ice accumulated on the wings and he actuated the deice boots twice. The pilot saw the deice boots functioning normally on the wings and could not see the tail; however, the elevator began to shake, and he lost elevator control. The pilot applied forward pressure on the yoke and had to trim nose-down to avoid a stall. There were no cockpit caution indications and the pilot had disengaged the autopilot before descent. The airplane descended through the clouds and impacted a tree before coming to rest upright in a grass area. Postaccident examination of the wreckage, including component testing of the deice system, did not reveal any preimpact mechanical malfunctions. The flap jackscrew position suggested that the flaps were likely in transit between 0° and 10° flap extension at the time of impact. Review of radar data revealed that, during the 2 minutes before the accident, the airplane’s groundspeed averaged about 82 knots; or an approximate average airspeed of 94 knots when accounting for the winds aloft. Current weather observations and forecast weather products indicated that the airplane was likely operating in an area where moderate and potentially greater structural icing conditions prevailed, and where there was the potential for the presence of supercooled liquid droplets. Review of the pilot operating handbook for the airplane revealed that the minimum speed for flight in icing conditions was 130 knots indicated airspeed. It is likely that the pilot’s failure to maintain an appropriate speed for flight in icing conditions resulted in insufficient airflow over the ice contaminated elevator and the subsequent loss of elevator control.

Factual narrative

On February 2, 2021, about 1655 eastern standard time, a Piper PA-46-350P, N221ST, was substantially damaged when it was involved in an accident near Leicester, Massachusetts. The commercial pilot sustained minor injuries and the two passengers were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot stated that he received weather briefings via flight service and ForeFlight. The flight service specialist advised the pilot that there would be some icing in clouds, with cloud tops near 6,000 ft mean sea level msl (msl). Additionally, an AIRMET was in effect for moderate icing from the freezing level up to 18,000 ft msl. The pilot further stated that his previous flight that day, from Worcester, Massachusetts, to Martha’s Vineyard, Massachusetts, was uneventful. He added that the actual conditions were better than forecast with no ice observed during that flight and the accident flight, until descent for the RNAV (GPS) RWY11 approach to Worcester. Light freezing rain was reported in the area of the accident site around the time of the accident, and the forecast icing potential indicated a 60% probability of supercooled liquid droplets (SLD) over the accident site, at the time of the accident, at 4,000 ft msl. The current icing potential indicated a 90% to 100% probability of SLD at 1,000 to 4,000 ft msl at the accident site, at 1700. The pilot reported that, while descending through clouds and beginning the approach, a little ice built up on the wings and he actuated the deice boots twice. The pilot observed the deice boots functioning normally on the wings and could not see the tail. He reported that the elevator “began to shake and became ineffective” and that he “felt like the airplane was approaching a stall.” The pilot applied forward pressure on the yoke and had to trim elevator nose down to get the airplane to descend and avoid a stall, and he reported that any effort to pull back on the yoke exacerbated the situation. He further stated that no caution annunciators illuminated, and that he had disengaged the autopilot before descent. The airplane descended through the clouds and the pilot flew toward trees to avoid a house. The airplane subsequently contacted a tree and came to rest upright in the front yard of a residence about 3 miles from the runway threshold. Examination of the wreckage did not reveal evidence of any preimpact mechanical malfunctions. Flight control continuity was confirmed from the cockpit to all control surfaces. The flap lever was observed at the 10° flap extension position. Examination of the flap jackscrew revealed about five exposed threads, which corresponded to a flap position between 0° and 10°. Component testing of the deice system did not reveal any anomalies. Review of air traffic control audio and radar data revealed that the pilot contacted the tower controller at 1653 and reported a position of 1 mile from the RILOC intersection (about6.5-mile final approach). The controller acknowledged the report and cleared the pilot to land. From that time until the flight upset about 2 minutes later, the airplane’s groundspeed averaged about 82 knots, or an airspeed of 94 knots based on a winds aloft forecast of 060° at 17 knots, at 3,000 ft msl. Review of a pilot operating handbook (POH) for the airplane make and model revealed a minimum speed for flight in icing conditions as 130 knots indicated airspeed. The POH further stated, “The ice protection system was not designed or tested for flight in freezing rain, freezing drizzle or supercooled liquid water and ice crystals, or conditions defined as severe. Flight in these conditions is prohibited and must be avoided.”

Aircraft

Registration
N221ST
Reported as
Piper PA46 (350P)
Category
Airplane
Serial number
4636651
Built
2014
Airframe hours
946
Engine
Lycoming TIO-540, 350 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Forza Management Co
Registered owner
Forza Management Co
Airworthiness certificate
Standard, Normal
Last inspection
Annual · September 2, 2021 · 114 hours before
Departed
MVY · Vineyard Haven, MA
Destination
ORH · Worcester, MA
Flight plan
IFR
Airport
ORH · Worcester Regional Airport, runway 11, 7,001 × 150 ft, asphalt
Equipment
Stall warning system, Onboard weather, ADS-B

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
63
Injuries
Minor
Certificate
Commercial
Airplane ratings
Single-engine land, Single-engine sea, Multi-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
February 17, 2020
Seat
Left
Restraint
3-point
Flight hours
3,000 total · 630 in this make and model · 2,875 as pilot in command · 67 in the last 90 days · 28 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Day
Wind
20° at 13 knots, gusting 21
Visibility
5 statute miles
Lowest ceiling
1,100 ft overcast
Temperature
30 °F, dew point 27 °F
Altimeter
29.32 inHg
Icing
Rime
Observed at
ORH, 3 nm away

Docket · 25

The files NTSB released with the investigation on October 17, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 623 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1Item 1 · PDF · 12 pages · 874 KBInterview summariesItem 2 · PDF · 3 pages · 136 KBExcerpts from pilot operating handbookItem 3 · PDF · 3 pages · 1.2 MBWeather factual reportItem 4 · PDF · 39 pages · 4.8 MBWeather attachment 1Item 5 · PDF · 1 page · 131 KBWeather attachment 2Item 6 · GIF · 24.5 MBWeather attachment 3Item 7 · PDF · 5 pages · 2.5 MBWeather attachment 4Item 8 · PDF · 2 pages · 246 KBWeather attachment 5Item 9 · PDF · 61 pages · 407 KBWeather attachment 6Item 10 · WAV · 7.0 MBWeather attachment 7Item 11 · ZIP · 4.2 MBWeather attachment 8Item 12 · PDF · 3 pages · 119 KBWeather attachment 9Item 13 · ZIP · 46.6 MBAir traffic control specialist reportItem 14 · PDF · 6 pages · 1.5 MBAir traffic control attachment 1 - orh ATC audio recordingItem 15 · WAV · 7.9 MBAir traffic control attachment 2 - orh ATIS recordingItem 16 · WAV · 105 MBAir traffic control - attachment 3 aircraft accident packageItem 17 · PDF · 30 pages · 8.5 MBAir traffic control attachment 4 - radar dataItem 18 · PPB · 391 MBAir traffic control attachment 5 mandatory occurrence report (Y90)Item 19 · PDF · 4 pages · 712 KBAdditional radar plotItem 20 · PDF · 1 page · 750 KBMap of wreckage in relation to runway 11Item 21 · PDF · 1 page · 13.4 MBPhoto arrayItem 22 · PDF · 5 pages · 1.2 MBCorrespondence from FAA - vacuum pump testItem 23 · PDF · 1 page · 105 KBStatement of party representatives to NTSB investigationItem 24 · PDF · 10 pages · 464 KBEvidence control formsItem 25 · PDF · 2 pages · 189 KB

FAA reports on this event · 1

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