# NTSB ERA22LA191: Piper PA-32-260, N3618W, Grantsville, MD, April 16, 2022 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Class 3 · Limited · Final report - Date: April 16, 2022, 19:52 local (23:52 UTC) - Place: Grantsville, MD - Coordinates: 39.706574, -79.080896 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=39.7066&lon=-79.0809&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Structural icing](https://openairdocs.org/ntsb-events/210) - Highest injury: Minor injuries - Injuries: 3 minor - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO, Piper Aircraft, Lycoming Engines - NTSB case key (mKey): 104952 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA22LA191 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104952/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104952 - Page: https://openairdocs.org/ntsb/ERA22LA191 ## Probable cause The pilot’s decision to continue the flight into an area of moderate to heavy icing conditions, which resulted in a degradation of airplane performance and subsequent loss of control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-32-260, 10 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md?model=7103206), [All aircraft, 3,098 cases](https://openairdocs.org/ntsb-findings/02041520/cases.md) - [Temp/humidity/pressure: conducive to structural icing](https://openairdocs.org/ntsb-findings/03031025): Environmental issues › Conditions/weather/phenomena · Decision related to condition (probable cause); cases with it: [Piper PA-32-260, 2 cases](https://openairdocs.org/ntsb-findings/03031025/cases.md?model=7103206), [All aircraft, 103 cases](https://openairdocs.org/ntsb-findings/03031025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Structural icing](https://openairdocs.org/ntsb-events/210) (defining event); cases with it: [Piper PA-32-260, 2 cases](https://openairdocs.org/ntsb-events/210/sequence.md?model=7103206), [All aircraft, 102 cases](https://openairdocs.org/ntsb-events/210/sequence.md) - [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Piper PA-32-260, 10 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7103206), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis During cruise flight above 10,000 ft mean sea level (msl) in instrument meteorological conditions (IMC), the pilot noted the airplane’s airspeed slowing and the autopilot pitching the airplane up in order to maintain altitude. After he disconnected the autopilot, the pilot had difficulty maintaining pitch control. The pilot suspected that the airplane was accumulating ice but did not see any on the wings or windscreen. A performance study using automatic dependent surveillance-broadcast (ADS-B) data indicated that the airplane descended and slowed until there was a sudden loss of lift near the airplane’s stall speed, which was consistent with an aerodynamic stall. The pilot lowered the nose, and the airplane gained airspeed while continuing to descend. About 3 minutes 30 seconds later, the airplane experienced a second sudden loss of lift at a much lower lift coefficient and higher airspeed. This second loss of lift was consistent with an accumulation of ice on the wing, which increased drag and reduced the amount of lift the wing could produce before a stall. The airplane recovered briefly before drag again began to increase. Drag continued to gradually increase until the flight descended below ADS-B coverage. According to the pilot, the airplane descended out of the clouds into heavy rain. The pilot performed a forced landing to a road. During the landing the airplane impacted trees and terrain, resulting in substantial damage to the fuselage, wings, and empennage. Based on surface weather observations, upper air sounding data, and satellite weather imagery, clouds were likely present in the accident area from 3,300 ft msl (about 400 ft above ground level) through 13,000 ft msl. In areas with precipitation, which the flight encountered, clouds likely persisted from 13,000 ft msl to near the surface. Moderate or greater icing conditions were indicated from near 6,000 ft msl through 9,500 ft msl, but icing conditions likely persisted through 13,000 ft msl near the cloud tops. Further, supercooled liquid droplets (SLD) conditions were likely present in the icing encountered by the flight. The flight was likely in IMC below 13,000 ft msl with moderate or greater icing conditions and SLD. The pilot’s reports that the airplane was underperforming, unable to climb, and that the autopilot was increasing pitch to maintain altitude were consistent with ice accumulation degrading handling. The second loss of lift event occurred at a high lift coefficient, high angle of attack, and at an airspeed lower than the airplane’s stall speed. The ice accumulation on the airplane likely made it difficult for the pilot to control airspeed and attitude, which resulted in a loss of control. Based on the ForeFlight weather briefing information that the pilot received, he should have been aware of the potential for icing conditions on the accident flight. His decision to continue the flight in an airplane not equipped for flight into known into icing conditionsresulted in the accident. ## Factual narrative On April 16, 2022, about 1952 eastern daylight time, a Piper PA-32-260, N3618W, was substantially damaged when it was involved in an accident near Grantsville, Maryland. The pilot and two passengers received minor injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. According to the pilot, he performed a preflight inspection with no anomalies noted, received a weather briefing, and departed Wabash Municipal Airport (IWH), Wabash, Indiana, destined for Martin State Airport (MTN) in Baltimore, Maryland, on an instrument flight rules clearance. About 2 hours into the flight, the airplane was about 11,000 ft mean sea level (msl) approaching clouds, and the pilot increased engine power and turned the pitot heat on. The airplane was “underperforming and unable to climb over the clouds.” After entering the clouds, he noticed the airspeed decreasing and the autopilot increasing the pitch of the airplane to maintain altitude. The pilot disengaged the autopilot, decreased the pitch attitude of the airplane, and noted that it was “difficult to maintain pitch control.” He examined the wings and windscreen for any signs of ice but saw none. The pilot notified air traffic control of his difficulty controlling the airplane, and they declared an emergency for him. The airplane descended out of the clouds into heavy rain. The pilot elected to perform a forced landing to a road. During the landing the airplane impacted trees and terrain, resulting in substantial damage to the fuselage, wings, and empennage. Postaccident examination of the airframe confirmed flight control continuity from the cockpit flight controls to the flight control surfaces through multiple cuts made by recovery personnel and tensile overload fractures. Engine crankshaft and valvetrain continuity were confirmed when the propeller was rotated by hand, and compression was observed on all cylinders. The cylinders were examined with a lighted borescope, and no anomalies were noted. There was no evidence found of pre-impact anomalies that would have precluded normal operation. According to the Airplane Flight Manual and an engineering drawing, the airplane was required to have a placard on the left side of the cockpit that states, “THIS AIRCRAFT APPROVED FOR NIGHT IFR NON-ICING FLIGHT WHEN EQUIPPED IN ACCORDANCE WITH FAR 91 OR FAR 135.” The placard was not located in the cockpit after the accident. Composite weather images for radar scans initiated at 1935:50, 1940:09, 1944:28, and 1948:46, respectively, indicated light to moderate precipitation along the airplane’s flight path (figure 1). The upper air sounding indicated that the freezing level was located at 5,100 ft msl, and cloud conditions were expected up to 13,000 ft msl. Figure 1 - Weather radar image for scan initiated at 1948:46 with the weather encounter location marked with a red circle. The flight track is depicted as a magenta line with black arrows pointing in the direction oftravel. The National Weather Service’s Current Icing Product (CIP) and Forecast Icing Product (FIP) are intended to supplement AIRMETs and SIGMETs. The FIPs for 9,000 ft msl, 10,000 ft msl, and 11,000 ft msl indicated a 40 to 85% probability of icing from 9,000 ft msl to 11,000 ft msl over the area corresponding to the weather encounter. The FIPs indicated that the icing intensity would range from “light” to “heavy.” An AIRMET for icing conditions valid from 1700 through 2000 indicated moderate icing between the freezing level and 17,000 ft msl. A performance study was conducted using automatic dependent surveillance-broadcast (ADS-B) data to determine specific airplane performance characteristics. The study showed that during level flight above 10,000 ft msl, there were increases in drag that were also present during the final descent of the airplane. The study indicated that, at 1945, the pitch was increasing and the airspeed was decreasing, which was consistent with the pilot’s report that the autopilot was increasing the pitch to maintain altitude. Just after 1946:30, the pitch decreased, corresponding to when the pilot disconnected the autopilot and decreased the pitch attitude. The airplane began to descend 15 seconds later, and there was a marked increase in drag. At 1947, the airplane began a turn to the right; pitch again increased; but the descent continued while lift and drag increased. At that time, drag was four times higher than any other time in the flight. The airplane’s calculated airspeed slowed to near 54 knots, which was below the power off, gross weight, no flaps stall speed of 57 knots. At 1948, the angle of attack, pitch, lift, and drag all decreased suddenly; this loss of lift was consistent with an aerodynamic stall. The airplane then recovered and gained airspeed while continuing to descend. At 1951, the drag quickly increased but without an increase in lift, and the airplane began a turn to the right. At 1951:30, the lift dropped sharply without having increased during the increase in drag. This sudden loss of lift occurred at a much lower lift coefficient and angle of attack than the previous event at 1948 and at an airspeed above 100 knots, well above the airplane’s stall speed. The airplane recovered briefly before the drag began to increase again. The airplane was still slowing when the ADS-B data ended as the airplane descended below 150 ft above the terrain. The accident site was located about 2,500 ft beyond the last data point. Generally, ice accumulation on an airplane’s wings increases drag and reduces the amount of lift the wing can produce. Ice accumulation on the fuselage of an airplane also increases drag. Additionally, ice accumulation on propeller blades reduces the amount of thrust that can be produced. The pilot did not request weather information from Leidos Flight Service; however, he did request and receive a ForeFlight weather briefing at 1713 with a proposed departure time of 1725. The pilotreported that there was moderate icing forecast for the time of the flight. ## Aircraft - Registration: [N3618W](https://openairdocs.org/deregistered/N3618W-2022-09-30), registration cancelled 2022-09-30, S/N 32-519, built 1966 (OpenAirDocs) - Reported make and model: PIPER PA-32-260 - Registry model: [Piper PA-32-260](https://openairdocs.org/model/piper-pa-32-260) (registry code 7103206) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 32-519 - Year built: 1966 - Airframe hours: 3279.9 - Engines: Lycoming O-540-E4B5 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 7, 2021 - Departed: IWH, Wanash, IN - Destination: MTN, Baltimore, MD - Flight plan: IFR - Equipment: Electronic primary flight display, Stall warning system, ADS-B, Auto-pilot, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: minor; private, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review February 12, 2022; seat: left; restraint: 5-point; flight hours: 955 total, 48 in this make and model, 793 as pilot in command, 36 in the last 90 days, 18 in the last 30 days, 5 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Dusk - Wind: 290° at 13 knots, gusting 20 - Visibility: 3 statute miles - Lowest ceiling: 300 ft overcast - Temperature: 43 °F, dew point 43 °F - Altimeter: 29.92 inHg - Observed at: 2G4, 12 nm away - METAR: METAR K2G4 162355Z AUTO 29013G20KT 3SM OVC003 06/06 A2992 RMK AO1= ## 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 20220416013879A](https://openairdocs.org/incident/20220416013879A), Apr 16, 2022: Piper PA-32-260, Grantsville, MD, Destroyed. Aircraft was cruising at 9000 MSL. It began pitching up when on autopilot altitude hold and the pilot, observing that the engine RPM had not changed, concluded… ## Docket (14 files) The files NTSB released with the investigation on October 5, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104952. 68.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 11 pages, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14824941&FileExtension=pdf&FileName=LA191%206120_Redacted-Rel.pdf - Wreckage examination summary (item 2, PDF, 14 pages, 2.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14949028&FileExtension=pdf&FileName=Wreckage%20Examination%20Summary%20LA191-Rel.pdf - Engine data monitor factual report (item 3, PDF, 5 pages, 581 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14927548&FileExtension=pdf&FileName=ERA22LA191%20JPI%20Factual%20Report-Rel.pdf - Memorandum for record - placard in cockpit (item 4, PDF, 3 pages, 290 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14948239&FileExtension=pdf&FileName=Memo%20of%20missing%20placard%20LA191-Rel.pdf - Engine data monitor factual report - attachment 1 (item 5, CSV, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14927012&FileExtension=csv&FileName=ERA22LA191%20-%20Engine%20Data%20Monitor%20Factual%20Report%20-%20Attachment%201%20-Rel.csv - Weather factual report (item 6, PDF, 37 pages, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14270805&FileExtension=pdf&FileName=ERA22LA191_weatherfactualSuffernfinal-Rel.pdf - Weather attachment 1 (item 7, GIF, 20.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14270116&FileExtension=gif&FileName=attachment1_animation_wxradar_2322to2357utc-Rel.gif - Weather attachment 2 (item 8, PDF, 5 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14270530&FileExtension=pdf&FileName=attachment2_GFAimagedata-Rel.pdf - Weather attachment 3 (item 9, ZIP, 11.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14270126&FileExtension=zip&FileName=attachment3_ERA22LA191_icing-Rel.zip - Weather attachment 4 (item 10, PDF, 9 pages, 127 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14270884&FileExtension=pdf&FileName=attachment4_foreflightera22la191_Redacted-Rel.pdf - ADS-B data (item 11, CSV, 19.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14815403&FileExtension=csv&FileName=20220416_A41388_481383370_ADSB-Rel.csv - Aircraft performance study (item 12, PDF, 8 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14921281&FileExtension=pdf&FileName=ERA22LA191_PerformanceStudy-Rel.pdf - ATC transcript summary (item 13, PDF, 8 pages, 587 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14929075&FileExtension=pdf&FileName=ATC%20Summary-Rel.pdf - Statement of party representatives to NTSB investigation (item 14, PDF, 10 pages, 364 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14948516&FileExtension=pdf&FileName=LA191%20Party%20Forms%20Signed_Redacted-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.