# NTSB IAD05LA137: Piper PA-24-260, N9311P, Tiffin, OH, September 18, 2005 - Type: NTSB accident investigation - Classification: Accident · Fatal · Limited investigation · Final report - Date: September 18, 2005, 10:45 local (14:45 UTC) - Place: Tiffin, OH - Coordinates: 41.089721, -83.207496 - Nearby events: https://openairdocs.org/map.md?lat=41.0897&lon=-83.2075&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report October 31, 2006 - Report: Approved by Office Director - Parties: Lycoming Engines, FAA, New Piper - NTSB case key (mKey): 62504 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=IAD05LA137 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/62504/pdf - Page: https://openairdocs.org/ntsb/IAD05LA137 ## Probable cause The pilot's decision to takeoff in weather below the published takeoff minimums, which resulted in spatial disorientation and the airplane's collision with trees and terrain. Factors in the accident were the instrument meteorological conditions, and the pilot's inadequate weather evaluation. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight encounter with weather, takeoff - weather condition - fog (contributing factor) - weather evaluation - inadequate, pilot in command (contributing factor) - procedures/directives - not complied with, pilot in command (cause) - weather condition - low ceiling - Loss of control - in flight, takeoff - initial climb - aircraft control - not obtained/maintained, pilot in command - spatial disorientation, pilot in command - use of inappropriate medication/drug, pilot in command - In flight collision with terrain/water, descent - uncontrolled - object - tree(s) ## Analysis When the pilot arrived at the airport, the weather included an estimated ceiling "about treetop level," and the visibility was about 1/2 mile due to fog. The pilot carried on a conversation with the airport manager for about an hour, then drove over to his hangar to "wash the windshield of his airplane." Witnesses then heard the airplane depart, but could not see it due to fog and the low ceiling. One witness said, "I just heard him takeoff. I was surprised that anyone would takeoff in those weather conditions." The published takeoff minimums for the airport were ceiling 300 feet, with 1 mile visibility. The airplane impacted trees and terrain about 1 minute after takeoff, and pieces of angularly cut wood were found along the 400-foot wreckage path. Examination of the wreckage revealed no evidence of any pre-impact failures or malfunctions. Interviews and FAA records showed that the pilot was instrument rated, but did not obtain a weather briefing or file a flight plan prior to departure. Toxicological testing of the pilot revealed the presence of prescription stimulants and antidepressants. The extent to which these drugs may have affected the pilot could not be determined. ## Factual narrative On September 18, 2005, at 1045 eastern daylight time, a Piper PA-24-260, N9311P, was substantially damaged when it impacted terrain after departure from runway 24, at Seneca County Airport (16G), Tiffin, Ohio. The certificated private pilot was fatally injured. Instrument meteorological conditions prevailed, and no flight plan was filed for the local personal flight conducted under 14 CFR Part 91. In a telephone interview, the airport manager said that the pilot arrived at the airport around 0930, and carried on a conversation with her in the office for about an hour. The pilot appeared to be in good health and in a relaxed mood. During that hour, he did not use the telephone or the computer to check the weather, or to call for a weather briefing. The pilot eventually stated that he was "going to wash the windshield of his airplane," then left the office, and drove over to his hangar. The airport manager left the office right after the pilot, and drove a short distance to her home. She did not see or hear the airplane depart. When she arrived at her home, she was notified of the accident by telephone. The airport employee, who took over the duties in the office for the manager, heard the airplane, but could not see it depart. He said, "I just heard him take off. I was surprised that anyone would take off in those weather conditions." The witness continued to listened to the airplane during the takeoff roll, and walked outside about 30 seconds later. At that time, he could not hear the airplane. After another 30 seconds, he again heard the airplane, "and it sounded like he was circling back to the airport. There was a brief moment when he pulled the power back, and then back to full power, and then about 10 to 15 seconds later, the sound of a 'crunch'." On September 19, 2005, the airplane was examined at the site by a Federal Aviation Administration (FAA) aviation safety inspector, and all major components were accounted for at the scene. The initial point of impact was in trees about 75 feet above ground level, about 1 mile south of the airport. The wreckage path was about 400 feet long, and was oriented about 250 degrees magnetic. The left wing, and the right wing outboard of the flap, the empennage, and the tail section separated from the airplane and were scattered along the wreckage path. All of the fuel tanks were breached, and a strong odor of fuel was present at the scene. Pieces of angularly-cut wood were found along the wreckage path. The cockpit and cabin area came to rest in a cornfield, with the engine still attached by cables and some sheet metal. Control cable continuity was established from the cockpit area out to the point of cable bellcrank separation from their respective flight control surfaces. All cables were intact from the cockpit to the bellcranks. Examination of the flaps and the flap-actuator jackscrews revealed measurements consistent with a full-down, 32-degree flap setting. The main landing gear was up, and locked in the well. The nose landing gear was damaged by impact in the nose section of the airplane. The landing gear electric motor was removed from the airframe, and field-tested with a 12-volt automotive battery. The motor ran in both directions, with no anomalies noted. The wreckage was then transferred to the airport for further examination. On September 20, 2005, the engine was examined at Seneca County Airport. The engine was rotated by hand, and continuity was established through the powertrain and valvetrain to the accessory section. Compression was confirmed using the "thumb" method. The magnetos were rotated by hand, and spark was produced at all towers. Fuel was present in the engine-driven fuel pump and the flow divider. The fuel screen was clear and absent of debris. The airplane was manufactured in 1969, and the most recent annual inspection was completed on September 2, 2004, at 4,449.3 total aircraft hours. The airplane's most recent maintenance, an oil change, was performed on January 27, 2005, at 4,509 total aircraft hours. The pilot held a private pilot certificate with a rating for airplane single engine land, and instrument airplane. His most recent third class medical certificate was issued February 19, 2004. The pilot reported 760 hours of total flight experience on that date. At 1032, the weather reported at Findlay Airport (FDY), Findlay, Ohio, 21 nautical miles west of Tiffin, included winds from 210 degrees at 5 knots. There was an overcast ceiling at 800 feet with 3 miles of visibility in fog. The airport manager estimated that, at the time of the accident, the ceiling was 100 feet, and the visibility was about 1/2 mile due to fog. The airport employee estimated that, at the time of the accident, the ceiling was "at about treetop level," and the visibility was about 1/2 mile due to fog. Examination of FAA records revealed that the pilot did not contact flight service for a weather briefing prior to departure, nor did he file a flight plan. The published takeoff minimums for the Seneca County airport were ceiling 300 feet, with 1 mile visibility. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing which revealed the presence of the following drugs in the pilot's tissues (no appropriate blood sample was available for testing): Phentermine, a prescription stimulant typically used as a diet aid. Fluoxetine, a prescription antidepressant often known by the trade name Prozac. Metoprolol, a prescription medication often used to control blood pressure. The local toxicology testing performed in conjunction with the autopsy detected metoprolol and phentermine (but not fluoxetine) in the blood. The local toxicology testing noted an extremely high blood level of phentermine, but the blood was noted to be contaminated by gastric contents. The pilot reported the use of only a combination prescription blood pressure medication containing hydrochlorothiazide and lisinopril on his most recent application for a medical certificate. ## Aircraft - Registration: [N9311P](https://openairdocs.org/deregistered/N9311P-2006-12-05), registration cancelled 2006-12-05, S/N 24-4807, built 1969 (OpenAirDocs) - Reported make and model: Piper PA-24-260 - Registry model: [Piper PA-24-260](https://openairdocs.org/model/piper-pa-24-260) (registry code 7102406) (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: 24-4807 - Airframe hours: 4449 - Engines: Lycoming TIO-540 260 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Stambaugh Packaging Co - Airworthiness certificate: Standard, Normal - Last inspection: Annual, September 1, 2004 - Departed: 16G, TIFFIN, OH - Destination: 16G, Tiffin, OH - Airport: 16G, Seneca County, runway 24, 4,000 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 760 total ## Weather - Conditions: Instrument (IMC), Day - Wind: 210° at 5 knots - Visibility: 3 statute miles - Lowest ceiling: 800 ft overcast - Temperature: 64 °F, dew point 63 °F - Altimeter: 30.12 inHg - Observed at: FDY, 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 20050918023919A](https://openairdocs.org/incident/20050918023919A), Sep 18, 2005: Piper PA24260, Tiffin, OH, Destroyed, 1 fatal. (-23) At approximately 1045 on 9/18/05 aircraft departed 16G, destination unknown. Airport weather at time of departure was foggy with limited visibility.… 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.