# NTSB SEA03FA042: Piper PA-34-220T, N9257X, Rexburg, ID, March 5, 2003 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: March 5, 2003, 16:50 local (23:50 UTC) - Place: Rexburg, ID - Coordinates: 43.848888, -111.806945 - Nearby events: https://openairdocs.org/map.md?lat=43.8489&lon=-111.8069&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report June 2, 2004 - Report: Approved by Office Director - Parties: Teledyne Continental Motors, The New Piper Aircraft, FAA-FSDO - NTSB case key (mKey): 56582 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=SEA03FA042 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/56582/pdf - Page: https://openairdocs.org/ntsb/SEA03FA042 ## Probable cause The pilot's failure to maintain aircraft control while on final approach. High and gusting winds were a factor. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, approach - vfr pattern - final approach - fatigue (conditions conducive to pilot fatigue), pilot in command - aircraft control - not maintained, pilot in command (cause) - weather condition - gusts (contributing factor) - weather condition - high wind (contributing factor) - In flight collision with terrain/water, descent - uncontrolled - terrain condition - open field ## Analysis At the end of the second leg of a long cross country flight, the pilot cancelled his IFR flight plan about seven miles south of the destination airport. The first leg of the flight was approximately three hours, 40 minutes in length with the pilot reporting unexpected high winds along the route that were slowing his progress. The flight was diverted to an alternate destination for fueling. The second leg was approximately four hours and 50 minutes in length with the pilot reporting to air traffic control toward the end of the flight that the aircraft was picking up mild rime ice on the wings and windshield. The pilot reported to the controller the need to descend due to the ice and "fuel situation." A witness at the airport reported that the pilot radioed his intentions and position over the Unicom frequency that he was entering a left downwind for runway 17. Although the position of that downwind appeared normal, the aircraft stayed on the downwind leg long enough that when it turned from base leg to final approach, it was three to four miles from the end of the runway. The aircraft was then observed to proceed inbound on final approach on a vertical approach path that was significantly lower than what other aircraft normally used when landing on this runway. When the aircraft was just over a mile from the end of the runway, at an estimated altitude of 200 feet above ground level, it suddenly rolled steeply to the right and made a descending turn into the terrain. The pilot, who had been making normal position calls, both prior to and after entering the pattern, did not indicate that he was having any problem with the aircraft. At the time the winds were reported from 210 degrees at 24 knots, with gusts to 36 knots. Post accident inspection of the airframe and engines did not reveal evidence of a mechanical failure or malfunction. ## Factual narrative HISTORY OF FLIGHT On March 5, 2003, approximately 1650 mountain standard time (MST), a Piper PA-34-220T, N9257X, impacted the terrain while on a visual flight rules final approach to Madison County Airport, Rexburg, Idaho. The commercial pilot and his three passengers received fatal injuries, and the aircraft, which was owned and operated by the pilot, was destroyed. The 14 CFR Part 91 personal pleasure flight, which departed Lamar, Colorado, about 1222, was operating in visual meteorological conditions at the time of the accident. The flight had been on an Instrument Flight Rules (IFR) flight plan, but the pilot had canceled the flight plan at 1634. On the morning of the flight, prior to his departure from Shreveport, Louisiana, the pilot contacted the FAA's Automated Flight Service Station and received a weather briefing for both legs of the trip he planned to take that day. The first portion of the briefing addressed his planned route from Shreveport to Colorado Springs, Colorado, and the second portion addressed the route from Colorado Springs to Rexburg. The pilot departed Shreveport at 0854 central standard time for the first leg of the flight, but ultimately decided to divert into Lamar, Colorado, which was 100 nautical miles closer to his point of departure. He advised the Denver Center controller that the reason for the diversion was that higher than expected winds were slowing his progress and he "didn't want to take a chance on fuel." FAA records show that the pilot was cleared for an approach at Lamar at 1120 MST, and that he canceled his IFR flight plan at 1120. Although his exact landing time was not determined, he made a telephone call to the Denver Automated Flight Service Station at 1149, ten minutes after canceling his flight plan. Upon making contact with Flight Service, the pilot confirmed that his IFR flight plan had been canceled, and then refiled the flight plan for the second leg of the trip, with a departure point of Lamar instead of Colorado Springs. During that filing, he stated that he would be departing Lamar about 1200 MST, and that the expected time en route would be three hours and thirty minutes. He also advised the briefer that he had five hours of fuel on board, based upon a true airspeed of 175 knots. Prior to departure, the aircraft fuel system was " topped off" by adding 103.8 gallons of low lead aviation fuel. Several witnesses observed the aircraft prior to the accident. One witness located on the airport, and monitoring the Unicom frequency, reported that the pilot radioed his position with the intention of entering a left downwind for runway 17. Although the position of that downwind appeared normal, the aircraft stayed on the downwind leg long enough that when it turned from base leg to final approach, it was three to four miles from the end of the runway. It was then seen to proceed inbound on final approach on a vertical approach path that was significantly lower than what other aircraft normally used when landing on this runway. When the aircraft was just over a mile from the end of the runway, at an estimated altitude of 200 feet above the ground, it suddenly rolled steeply to the right and made a descending turn into the terrain. The pilot, who had been making normal position calls, both prior to and after entering the pattern, did not indicate that he was having any problem with the aircraft. Other witnesses in the vicinity of the airport reported seeing the aircraft approach the runway "low" and with a "severe crab angle." Each of the witnesses commented on the high wind condition at the time and indicated that the plane made a right turn and descended to the ground. PERSONNEL INFORMATION At the time of the accident, the pilot held a private pilot certificate for single-engine land and sea aircraft, and a commercial certificate for multi-engine land aircraft and instrument airplane operations. A review of the pilot's flight logbook indicated a total flight time of approximately 800 hours. The first entry noted in the logbook for the accident aircraft was in November 2001. Since this time, the pilot had accumulated approximately 177 hours in this aircraft. A total of approximately 450 hours had been accumulated in multi-engine aircraft. On September 27, 2002, the pilot's flight logbook indicated entries for successfully completing the required training of 14 CFR Part 61.31(g), and it was determined that he was proficient in the operation and systems of a pressurized aircraft. The pilot also on this day, satisfactorily completed training requirements outlined in Advisory Circular 61.91H, paragraph 7a, for the Pilot Proficiency Award Program, and satisfactorily completed the Instrument Proficiency Check requirements of 14 CFR Part 61.57(d). AIRCRAFT INFORMATION Aircraft records indicated that the pilot purchased this aircraft in May 2000. A review of maintenance records indicated that the aircraft had been signed off for an annual inspection on April 1, 2002, at a total airframe time of 1039.1 hours. Approximately 163 hours had been accumulated on the aircraft since the last annual inspection. The engine logbooks indicated that both engines also had a total time since new of 1039.1 hours at the time of the annual inspection. METEOROLOGICAL INFORMATION At 1653, the surface weather observation at the Rexburg Airport was reporting a wind from 210 degrees at 24 knots, with gusts to 36 knots. The temperature was 37 degrees F and the dew point was 21 degrees F. Visibility was 10 miles with few clouds at 4,200 feet and scattered clouds at 8,000 feet. The altimeter setting was 29.56" Hg. COMMUNICATIONS Air traffic control communications and radar data provided by the Federal Aviation Administration Salt Lake City, Utah, Air Route Traffic Control Center, indicated that the flight had been cleared to proceed direct to Lorrn Intersection at 1613 and was cleared to descend. At 1616, the pilot reported to air traffic that the aircraft was picking up mild rime ice on the wings and windshield. At 1627 the controller instructed the pilot to cross Lorrn Intersection at or above 8,000 feet and that they were cleared for the GPS runway 35 approach to Rexburg. The pilot responded to the controller inquiring if there was a possibility of getting down to 9,000 feet due to the mixed ice and "fuel situation." Further communications with the pilot and controller indicated that the pilot misunderstood the controller about the altitude clearance. The controller then instructed the pilot to report Lorrn Intersection inbound on the approach. At 1629, radar data indicated that the flight was descending out of 10,300 feet and tracking in a westerly direction toward Lorrn Intersection. In the vicinity of Lorrn Intersection, at 1634 and 8,300 feet, the pilot reported to air traffic that he wanted to cancel the IFR flight plan and proceed direct to Rexburg. The controller verified the IFR cancellation and instructed the pilot to squawk VFR. There were no further communications with air traffic control after this time. Lorrn Intersection is located on the 16 degree radial from the Idaho Falls, Idaho, VOR, 14.7 Distance Measuring Equipment (DME) miles, on the 132 degree radial from the Dubois VOR, 25.7 DME miles, and 7 nautical miles southwest of Rexburg Airport. WRECKAGE AND IMPACT INFORMATION The wreckage was located in an open level field used for crops. The accident site coordinates were obtained via a hand held GPS unit. The coordinates were N 43 degrees 50.938 latitude, W 111 degrees 48.416 longitude. The elevation at the accident site via the GPS was 4,930 feet. The airport that was located approximately 140 degrees magnetic and one mile from the accident site is 4,858 feet. The ground was hard packed/frozen. Above-ground irrigation sprinklers ran in rows perpendicular to the wreckage distribution path. The aircraft collided with three ## Aircraft - Registration: [N9257X](https://openairdocs.org/deregistered/N9257X-2003-05-19), registration cancelled 2003-05-19, S/N 3447002, built 1995 (OpenAirDocs) - Reported make and model: Piper PA-34-220T - Registry model: [Piper PA-34-220T](https://openairdocs.org/model/piper-pa-34-220t) (registry code 7103420) (OpenAirDocs) - Registry engine: [Continental TSIO-360 series](https://openairdocs.org/engine/continental-tsio-360-series) (registry code 17019, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 3447002 - Airframe hours: 1200 - Engines: Continental TSIO-360-KB 220 hp reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Registered owner: Thomas Cecola - Airworthiness certificate: Standard, Normal - Last inspection: Annual, April 1, 2002, 163 hours before - Departed: LAA, Lamar, CO - Destination: RXE, Rexburg, ID - Flight plan: IFR - Airport: RXE, Madison County, runway 17, 4,200 × 75 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 45; injuries: fatal; commercial; airplane ratings: multi-engine land, single-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, valid medical--no waivers/lim.; last flight review September 27, 2002; seat: left; toxicology performed; flight hours: 800 total, 711 as pilot in command, 62 in the last 90 days, 41 in the last 30 days, 8 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 210° at 24 knots, gusting 36 - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 37 °F, dew point 21 °F - Altimeter: 29.55 inHg - Observed at: KRXE, 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 20030305002399A](https://openairdocs.org/incident/20030305002399A), Mar 5, 2003: Piper PA34220T, Rexburg, ID, Destroyed, 4 fatal. (-23) The flight was conducted in accordance with 14 CFR part 91, the purpose appears to have been a personal trip to go fishing. The aircraft last departed… 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.