# NTSB WPR09FA379: Piper PA-22-150, N6905B, Saint Charles, ID, August 7, 2009 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: August 7, 2009, 11:45 local (17:45 UTC) - Place: Saint Charles, ID - Coordinates: 42.110832, -111.38861 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.1108&lon=-111.3886&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report April 22, 2010 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Piper Aircraft Incorporated, Federal Aviation Administration - NTSB case key (mKey): 74420 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR09FA379 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74420/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74420 - Page: https://openairdocs.org/ntsb/WPR09FA379 ## Probable cause The pilot’s failure to maintain terrain clearance while maneuvering. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: altitude](https://openairdocs.org/ntsb-findings/01062012): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-22-150, 3 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7102210), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Effect on operation; cases with it: [Piper PA-22-150, 2 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=7102210), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md) - [Use of equip/info](https://openairdocs.org/ntsb-findings/02063000): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-22-150, 1 case](https://openairdocs.org/ntsb-findings/02063000/cases.md?model=7102210), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02063000/cases.md) - [Temp/humidity/pressure: high density altitude](https://openairdocs.org/ntsb-findings/03031020): Environmental issues › Conditions/weather/phenomena · Effect on equipment; cases with it: [Piper PA-22-150, 1 case](https://openairdocs.org/ntsb-findings/03031020/cases.md?model=7102210), [All aircraft, 278 cases](https://openairdocs.org/ntsb-findings/03031020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470) (defining event); cases with it: [Piper PA-22-150, 41 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102210), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The private pilot was on a visual flight rules personal cross-country flight during day visual meteorological conditions near mountainous terrain. Witnesses along the route of flight reported observing the airplane overfly their position at a low altitude on a course towards the accident site. There were no known witnesses to the accident sequence. The accident site was in an open area surrounded by rising terrain in three of the four quadrants. Examination of the wreckage revealed that impact damage signatures on the wings were consistent with right wing low impact with terrain. The fuselage, wings, and most of the empennage were consumed by a post-impact fire. No evidence of any pre impact mechanical anomalies was discovered with the engine or airframe. Using reported weather conditions near the accident site and the accident site elevation, the density altitude was calculated to be about 10,706 feet mean sea level. Toxicology testing on the pilot was positive for an unspecified amount of Famotidine within the blood and urine. Famotidine is an acid-reducing medication, used to treat heartburn or ulcer disease and is available through prescription or over the counter. Famotidine is commonly known by the trade name Pepcid. ## Factual narrative HISTORY OF FLIGHT On August 7, 2009, about 1145 mountain daylight time, a Piper PA22-150, N6905B, was destroyed when it impacted the ground while maneuvering near mountainous terrain near Saint Charles, Idaho. The airplane was registered to and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The private pilot and his passenger were killed. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The cross-country flight originated from the Ogden-Hinckley Airport (OGD), Ogden, Utah, at 1102 with an intended destination of Alpine, Wyoming. There were no known witnesses to the accident sequence; however, there were two witnesses in the area of the accident that observed an airplane similar to the accident airplane flying in a northerly direction. One witness, located at a recreational camping area about six miles south of the accident site, reported that the airplane flew overhead at an altitude of about 500 to 1,000 feet above ground level (agl). Using the witnesses reported location, it was estimated the witness was at an elevation of about 7,220 feet mean sea level (msl). Another witness, located about 2.5 miles south of the accident site, reported that he was traveling north in a vehicle when he noticed an airplane traveling north about 300 feet above the tree line. Using the witnesses reported location, it was estimated that the witness was at an elevation of about 7,710 feet msl. About 30 minutes later, a group of people operating all terrain vehicles stopped the second witness and informed him that an airplane had crashed in the area. Both witnesses did not report observing any abnormal flight patterns or smoke trailing from the airplane. PERSONNEL INFORMATION The pilot, age 57, held a private pilot certificate with an airplane single-engine land rating, which was issued on January 10, 2004. A third-class airman medical certificate was issued on May 12, 2009, with the limitation "must wear corrective lenses for near and distance vision.” The pilot reported on his most recent medical certificate application a total flight time of 503 hours. The pilot's logbook was not located during the investigation. AIRCRAFT INFORMATION The four-seat, high-wing, fixed-gear airplane, serial number (S/N) 22-4179, was manufactured in 1956. It was powered by a Lycoming O-320 150-horse power engine, and equipped with a Sensenich fixed-pitch propeller. The airplane was also equipped with two 18-gallon fuel tanks. The airplane's maximum certificated gross weight was 2,000 pounds. Review of copies of maintenance logbook records showed an annual inspection was completed on March 27, 2009, at a recorded tachometer reading and airframe total time of 2,578.13 hours. The engine underwent a 100-hour inspection on March 19, 2009, at a tachometer reading of 2,578.13 hours and 398.25 hours since major overhaul. The most recent airframe logbook entry stated that on August 6, 2009, at atachometer reading and airframe total time of 2,605.0 hours, eight rubber engine mounts were replaced at all four engine mount locations. The tachometer was observed at the accident site; however, damage precluded determining the current reading. According to a family member of the pilot, prior to the accident flight, the pilot had removed the rear seat to allow for additional baggage. They reported that the pilot had placed two sleeping bags, one emergency kit, and one tent within the airplane. The family member of the pilot estimated the total weight to be about 30 pounds. The family member further reported that the pilot had refueled the airplane prior to the accident flight with automotive fuel via fuel canisters at his hangar. The Safety Board investigator-in-charge (IIC) examined the pilot’s hangar and observed six five-gallon fuel containers. One of the fuel containers was full of a liquid consistent with automotive fuel. Trace amounts of liquid consistent with automotive fuel was also observed within one of the remaining five fuel containers. The liquid was tested using water finding paste with negative results. No debris was observed within any of the fuel containers. METEOROLOGICAL INFORMATION A review of recorded weather data from the automated weather observation station at the Logan-Cache Airport, Logan, Utah, located 25 miles southwest of the accident site, at an of elevation 4,457 feet, revealed that at 1151, conditions were wind from 360 degrees at 5 knots, visibility 10 statute miles, sky clear, temperature 19 degrees Celsius, dew point 6 degrees Celsius, and an altimeter setting of 29.97 inches of Mercury. Using the reported weather conditions and the accident site elevation of 8,321 feet, the density altitude was calculated to be about 10,706 feet. The pressure altitude was calculated to be about 8,276 feet. WRECKAGE AND IMPACT INFORMATION The wreckage was located in an open field with numerous large rocks spread throughout the area, adjacent to a heavily wooded area. The measured elevation of the accident site was 8,321 feet msl. Areas of rising terrain were observed to the north, east, and west of accident site. The wreckage energy path was about 50 feet in length, oriented on an approximate 320-degree magnetic heading. The first identified point of contact was a ground scar, about two feet wide and about two feet in length. Fragments of green lens, consistent with the right wing navigation light and fragments of the outboard right wingtip were observed within the initial ground scar. A second ground scar, about 30-35 feet in length and about 5 feet in width extended from the initial ground scar. The second ground scar contained fragments of plexi-glass and the outside air temperature gauge. Examination of the airframe revealed that it came to rest upright on an approximate heading of 220 degrees magnetic. The fuselage, wings, and empennage were mostly consumed by fire. All major structural components were present at theaccident site. Flight control continuity was established from all primary flight controls to the cockpit control wheel. Examination of the airframe and flight control system revealed no evidence of pre impact mechanical malfunction. The engine was recovered to a secure location for further examination. Examination of the recovered engine revealed that all cylinders remained attached to the crankcase and exhibited thermal discoloration. All fuel and oil lines were fire damaged. The exhaust was intact and exhibited impact damage. All engine accessories remained attached to the engine except for the carburetor, which had separated below its respective mount. The top spark plugs, left and right magnetos, the vacuum pump, propeller, and rocker arm covers were removed. The engine crankshaft was manually rotated by hand using a drive tool at the accessory drive pad. Rotational continuity was established throughout the engine and valve train. Thumb compression and suction were obtained on all four cylinders. Equal lifting movement was observed on all intake and exhaust valve rocker arms. The propeller remained attached to the engine crankshaft. The propeller blades were marked "A" and "B" for identification purposes. Propeller blade "A" was twisted opposite the direction of rotation from about 10 inches inboard of the propeller blade tip. Leading edge gouges were observed on the outboard 2 inches of the blade tip. Chordwise scratching was observed on the aft face of the propeller blade. Propeller blade "B" exhibited a slight "S" bend through the outboard three quarters of the blade. Chordwise scratching was observed from mid span of the blade and extended to the blade tip. Leading edge gouges and polishing was observed from about mid span to the blade tip. Examination of the recovered engine revealed no evidence of pre impact mechanical malfunction. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy on the pilot was performed on August 8, 2009. The medical examiner determined that the cause of death was “blunt force trauma.” The FAA's Civil Aeromedical Institute (CAMI) in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. According to CAMI's report, carbon monoxide, cyanide, volatiles, and drugs were tested, and had positive results for an unspecified amount of Famotidine within the blood and urine. ## Aircraft - Registration: [N6905B](https://openairdocs.org/deregistered/N6905B-2011-03-02), registration cancelled 2011-03-02, S/N 22-4179, built 1956 (OpenAirDocs) - Reported make and model: PIPER PA-22-150 - Registry model: [Piper PA-22-150](https://openairdocs.org/model/piper-pa-22-150) (registry code 7102210) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 22-4179 - Airframe hours: 2578 - Engines: LYCOMING O-320 150 horsepower reciprocating - Damage: Destroyed - Flight: Personal, Part 91 - Operator: Kevin Chambers - Registered owner: Kevin Chambers - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 27, 2009 - Departed: OGD, Ogden, UT - Destination: Alpine, WY ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 57; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; toxicology performed; flight hours: 503 total ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 5 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 66 °F, dew point 43 °F - Altimeter: 29.96 inHg - Observed at: LGU, 25 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 20090807012329A](https://openairdocs.org/incident/20090807012329A), Aug 7, 2009: Piper PA22150, Paris, ID, Destroyed, 2 fatal. (-23) Aircraft was near gross weight on high density altitude day. The aircraft did not have the performance to climb high enough to get through the mountain… ## Docket (15 files) The files NTSB released with the investigation on August 12, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74420. 16.9 MB in all. - Witness Statements (item 1, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323944&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Witness Locations (item 2, .PDF, 613 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323946&FileExtension=.PDF&FileName=Witness%20Locations-Master.PDF - Record of Conversation - Wife of the Pilot (item 3, .PDF, 22 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323978&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Wife%20of%20the%20Pilot-Master.PDF - Airframe Examination Memo (item 4, .PDF, 24 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323947&FileExtension=.PDF&FileName=Airframe%20Examination%20Memo-Master.PDF - Engine Examination Memo (item 5, .PDF, 676 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323948&FileExtension=.PDF&FileName=Engine%20Examination%20Memo-Master.PDF - Reports from Parties to the Investigation - Piper Report (item 6, .PDF, 771 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324024&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation%20-%20Piper%20Report-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 7, .PDF, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323968&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 8, .PDF, 53 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40324155&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Toxicological Report - Pilot (item 9, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323950&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Pilot-Master.PDF - Toxicological Report - Passenger (item 10, .PDF, 96 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323951&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Passenger-Master.PDF - Photo 1: View of the main wreckage. (item 11, .PDF, 4.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40317258&FileExtension=.PDF&FileName=Photo%201%3A%20View%20of%20the%20main%20wreckage.-Master.PDF - Photo 2: View of the main wreckage. (item 12, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323964&FileExtension=.PDF&FileName=Photo%202%3A%20View%20of%20the%20main%20wreckage.-Master.PDF - Photo 3: View of the main wreckage. (item 13, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323965&FileExtension=.PDF&FileName=Photo%203%3A%20View%20of%20the%20main%20wreckage.-Master.PDF - Photo 4: View of the wreckage debris path from point of initial impact. (item 14, .PDF, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323966&FileExtension=.PDF&FileName=Photo%204%3A%20View%20of%20the%20wreckage%20debris%20path%20from%20point%20of%20initial%20impact.-Master.PDF - Photo 5: View of the wreckage debris path from second ground scar. (item 15, .PDF, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40323967&FileExtension=.PDF&FileName=Photo%205%3A%20View%20of%20the%20wreckage%20debris%20path%20from%20second%20ground%20scar.-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.