# NTSB GAA16LA128: Piper PA24, N6691P, Sturgis, SD, February 12, 2016 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: February 12, 2016, 12:15 local (19:15 UTC) - Place: Sturgis, SD - Coordinates: 44.424167, -103.385002 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.4242&lon=-103.3850&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-IFR missed approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report October 6, 2016 - Report: Approved by Office Director - NTSB office: General Aviation Accidents - Parties: FAA Rapid City FSDO - NTSB case key (mKey): 92726 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=GAA16LA128 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92726/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92726 - Page: https://openairdocs.org/ntsb/GAA16LA128 ## Probable cause The pilot's failure to execute the published missed approach procedure in a timely manner, which resulted in collision with a light pole and subsequent impact with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-24-250, 3 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7102404), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-24-250, 1 case](https://openairdocs.org/ntsb-findings/02063032/cases.md?model=7102404), [All aircraft, 191 cases](https://openairdocs.org/ntsb-findings/02063032/cases.md) - [Object/animal/substance: pole](https://openairdocs.org/ntsb-findings/03022010): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-24-250, 1 case](https://openairdocs.org/ntsb-findings/03022010/cases.md?model=7102404), [All aircraft, 142 cases](https://openairdocs.org/ntsb-findings/03022010/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-IFR missed approach: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-24-250, 4 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102404), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Approach-IFR missed approach: Course deviation](https://openairdocs.org/ntsb-events/281); cases with it: [Piper PA-24-250, 1 case](https://openairdocs.org/ntsb-events/281/sequence.md?model=7102404), [All aircraft, 52 cases](https://openairdocs.org/ntsb-events/281/sequence.md) - [Approach-IFR missed approach: Controlled flight into terr/obj (CFIT)](https://openairdocs.org/ntsb-events/120) (defining event); cases with it: [Piper PA-24-250, 2 cases](https://openairdocs.org/ntsb-events/120/sequence.md?model=7102404), [All aircraft, 1,074 cases](https://openairdocs.org/ntsb-events/120/sequence.md) - [Approach-IFR missed approach: Loss of control in flight](https://openairdocs.org/ntsb-events/240); cases with it: [Piper PA-24-250, 22 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102404), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Approach-IFR missed approach: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-24-250, 55 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102404), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot reported that he was conducting an instrument approach in instrument meteorological conditions. Upon reaching the decision altitude, the front seat passenger reported the runway was in front of the airplane. The pilot looked up from the instruments, but could not see the runway out the windscreen or the side window. Referring back to the flight instruments, the pilot noted that the airplane was level, but he was unable to determine the airplane's altitude and did not know where the airplane was in relation to the runway. The pilot then applied full engine power and began to climb the airplane; however, the airplane's right wing impacted a light pole. The airplane immediately pitched nose-down and descended into terrain. The pilot reported there were no mechanical malfunctions or anomalies with the airplane that would have precluded normal operation, and that the accident could have been prevented if he had immediately executed a missed approach at the decision altitude. ## Factual narrative On February 12, 2016 about 1215 mountain standard time, a Piper PA-24-250 airplane, N6691P, impacted a light pole and terrain while executing a missed approach at the Sturgis Municipal Airport (49B) in Sturgis, South Dakota. The commercial pilot sustained minor injuries and the passenger sustained serious injuries. The airplane was registered to and operated by the pilot as a day, Instrument Flight Rules (IFR) personal flight under the provisions of 14 Code of Federal Regulations Part 91. Instrument Meteorological Conditions (IMC) prevailed at the time of the accident at the airport and an IFR flight plan was filed. The flight originated from the Jamestown Regional Airport (JMS) in Jamestown, North Dakota. The pilot reported that he was conducting the RNAV (GPS) RWY 29 instrument approach procedure. During the descent to the Decision Altitude (DA), he said that the autopilot system was engaged and that he encountered light ice at 4700 feet mean sea level. He reported that he kept the needles centered to the DA of 3530 feet, and the passenger in the front right seat stated that "the runway was in front of us." The pilot reported he looked up from the instruments, he did not see the runway, and the passenger stated that "we were above the runway." The pilot said that he looked out the side window and did not see the runway, and while returning his view to the instruments he noted that his airspeed was stable at 120 knots and the wings were level. The pilot reported that he referred to the altimeter but was unable to determine his altitude and told the passenger that he did not know where he was. The passenger stated that the "runway was to the left," and the pilot stated he went full throttle and began to climb. He reported at the moment of applying throttle and beginning to climb, the right wing impacted a light pole located on the airport. He said that the airplane immediately pitched down, and he held the ailerons neutral and used "severe" rudder movements to keep the wings as level as possible. He said there was a "severe" left bank tendency. Just prior to impact, he "yelled to brace and we both crossed our arms in front of our faces and pulled our feet back from the rudders." The airplane then impacted terrain, coming to rest in a ditch about 950 feet to the north of the departure end of the runway. The airplane sustained substantial damage to both wings and the fuselage. The pilot verified that there were no preimpact mechanical failures or malfunctions with the airframe or engine that would have precluded normal operation. As a safety recommendation, the pilot reported that "when the runway was not visible to the pilot in command at decision altitude, an immediate missed approach should have been executed." He also reported that "excessive head movement should be avoided at all times during the transition from instrument meteorological conditions to visual meteorological conditions." METEOROLOGICAL INFORMATION The closest weather reportingstation to the accident site was Ellsworth Air Force Base (RCA), about 21 nautical miles to the southeast, which reported at the time of the accident that the wind was 7 knots from 140 degrees, visibility was 1 statue mile, and a 200 foot overcast ceiling. The weather station also reported the presence of light drizzle and moderate mist. The pilot reported that the weather conditions at the accident site were a variable wind condition, visibility of 0.25 statue mile, and a 500 foot overcast ceiling. He also reported that fog was present along with light ice. A photograph taken by the Federal Aviation Administration (FAA) aviation safety inspector at the accident site showed ice accumulation on the leading edge of the airplane's horizontal stabilizer in addition to fog present at the accident site. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was located about 950 feet north of the departure end of runway 29. The initial impact point was a 50 foot light pole located in the north corner of a ramp located on the airport, about 1,180 feet behind the airplane's wreckage to the southeast. The bottom of the fuselage exhibited damage consistent with impacting terrain. The airplane's right wing leading edge had an impact mark about mid-span, which was consistent with impact marks found on the light pole. The impact marks on the light pole were about 39 feet above the ground. The airplane's left wing, about 6 feet inboard from the wing tip was partially separated, which was consistent with the pilot's statement about both wings striking fence posts. The light pole was located in the north corner of a ramp, about 765 feet northeast of the departure end of the runway. An image is located in the public docket to illustrate the location of the light pole in relation to the runway. SURVIVAL FACTORS The pilot reported that both he and his passenger had 3-point restraint systems available in the airplane and that they both utilized a lap belt only. The pilot reported that he and his passenger sustained head lacerations and that the passenger sustained serious injuries to her neck. The FAA has published Advisory Circular (AC) 21-34 Shoulder Harness – Safety Belt Installations (1993). This AC discusses the benefits of utilizing a shoulder harness and states in part: Accident experience has provided substantial evidence that use of a shoulder harness in conjunction with a safety belt can reduce serious injuries to the head, neck, and upper torso of aircraft occupants and has the potential to reduce fatalities of occupants involved in an otherwise survivable accident. ADDITIONAL INFORMATION Instrument Approach Procedure Minimums The FAA has published FAA-H-8083-15B Instrument Flying Handbook (2012). This handbook discusses instrument approach procedure minimums and states in part: Pilots may not operate an aircraft at any airport below the authorized minimum descent altitude (MDA) or continue an approach below the authorized decision altitude (DA)/decisionheight (DH) unless: 1. The aircraft is continuously in a position from which a descent to a landing on the intended runway can be made at a normal descent rate using normal maneuvers; 2. The flight visibility is not less than that prescribed for the approach procedure being used; and 3. At least one of the following visual references for the intended runway is visible and identifiable to the pilot: Approach light system, threshold, threshold markings, threshold lights, runway end identifier lights, visual approach slope indicator, touchdown zone or touchdown zone markings, touchdown zone lights, runway or runway markings, and runway lights. Missed Approaches FAA-H-8083-15B Instrument Flying Handbook also discusses missed approaches and states in part: A missed approach point is formulated for each published instrument approach and allows the pilot to return to the airway structure while remaining clear of obstacles. Pilots should immediately execute the missed approach point: 1. Whenever the requirements for operating below DA/DH or MDA are not met when the aircraft is below MDA, or upon arrival at the MAP and at any time after that until touchdown; 2. Whenever an identifiable part of the airport is not visible to the pilot during a circling maneuver at or above MDA; or 3. When so directed by air traffic control. ## Aircraft - Registration: [N6691P](https://openairdocs.org/deregistered/N6691P-2018-09-13), registration cancelled 2018-09-13, S/N 24-1815, built 1960 (OpenAirDocs) - Reported make and model: PIPER PA24 (250) - Registry model: [Piper PA-24-250](https://openairdocs.org/model/piper-pa-24-250) (registry code 7102404) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 24-1815 - Year built: 1960 - Airframe hours: 3977 - Engines: Lycoming O-540 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 15, 2015 - Departed: JMS, JAMESTOWN, ND - Destination: 49B, Sturgis, SD - Flight plan: IFR - Airport: 49B, Sturgis Muni, runway 29, 5,100 × 75 ft, concrete - Equipment: Stall warning system, Handheld GPS, Auto-pilot, Electronic flight bag or handheld device ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 46; injuries: minor; flight instructor, private, commercial; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 2, without waivers/limitations; last flight review August 7, 2014; seat: left; restraint: lap only; flight hours: 1,266 total, 871 in this make and model, 1,162 as pilot in command, 79 in the last 90 days, 40 in the last 30 days, 8 in the last 24 hours - Pilot-rated passenger; injuries: serious; student; medical: unknown, unknown; seat: right; restraint: lap only; flight hours: 13 total, 13 in this make and model ## Weather - Conditions: Instrument (IMC), Day - Wind: 140° at 7 knots - Visibility: 1 statute miles - Lowest ceiling: 200 ft overcast - Temperature: 27 °F, dew point 27 °F - Altimeter: 30.37 inHg - Icing: Unknown - Observed at: KRCA, 21 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 20160212001629A](https://openairdocs.org/incident/20160212001629A), Feb 12, 2016: Piper PA-24-250, Sturgis, SD, Substantial damage. On February 12, 2016 at 12:20 pm a Piper PA24-250-commanche, [privacy data omitted] was involved in an accident while navigating a missed approach, during a… ## Other investigations on N6691P (2) 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 FTW81DRA06](https://openairdocs.org/ntsb/FTW81DRA06), Nov 7, 1980: Piper PA-24 (N6691P), Iola, TX, substantial damage - [NTSB LAX77DUK07](https://openairdocs.org/ntsb/LAX77DUK07), Sep 21, 1977: Piper PA-24 (N6691P), Globe, AZ, substantial damage ## Docket (6 files) The files NTSB released with the investigation on July 21, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92726. 5.1 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442515&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Accident Photographs (item 2, .PDF, 8 photos, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442516&FileExtension=.PDF&FileName=Accident%20Photographs-Master.PDF - FAA Inspector's Statement (item 3, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442517&FileExtension=.PDF&FileName=FAA%20Inspector%27s%20Statement-Master.PDF - Pilot's Statement 1 (item 4, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442518&FileExtension=.PDF&FileName=Pilot%27s%20Statement%201-Master.PDF - Pilot's Statement 2 (item 5, .PDF, 343 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442519&FileExtension=.PDF&FileName=Pilot%27s%20Statement%202-Master.PDF - Passenger's Statement (item 6, .PDF, 277 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40442520&FileExtension=.PDF&FileName=Passenger%27s%20Statement-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.