# NTSB WPR10FA239: Piper PA-24-250, N6967P, Redmond, OR, May 14, 2010 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: May 14, 2010, 07:18 local (14:18 UTC) - Place: Redmond, OR - Coordinates: 44.253887, -121.149719 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=44.2539&lon=-121.1497&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 1 fatal - Status: Completed, report July 18, 2011 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Piper Aircraft, Federal Aviation Administration - NTSB case key (mKey): 76001 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR10FA239 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/76001/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=76001 - Page: https://openairdocs.org/ntsb/WPR10FA239 ## Probable cause The pilot's failure to maintain airspeed, which resulted in a stall and collision with terrain. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Performance/control parameters: pitch control](https://openairdocs.org/ntsb-findings/01062022): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA-24-250, 1 case](https://openairdocs.org/ntsb-findings/01062022/cases.md?model=7102404), [All aircraft, 526 cases](https://openairdocs.org/ntsb-findings/01062022/cases.md) - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-24-250, 34 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102404), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); 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) - [Initial climb: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241); cases with it: [Piper PA-24-250, 12 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7102404), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Uncontrolled descent: 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 A witness who was located in a vehicle adjacent to the accident site reported that while conducting a routine daily runway inspection, he observed the airplane in a near vertical attitude above the departure end of the active runway. The witness estimated that the airplane was about 100 to 200 feet above the ground when it performed a 360-degree roll and stalled. It then entered a nose-low attitude, made another 360-degree roll, and descended below a tree line. Another witness reported that he observed the airplane depart the active runway and initiate a normal climb. As the airplane reached the departure end of the runway it entered an abrupt climb at an approximate 90-degree angle. The witness further stated that the airplane climbed for approximately 200 feet, nosed over, and descended into the ground. A postaccident examination of the engine and airframe revealed no pre impact mechanical malfunctions. Toxicology tests of post-mortem samples from the pilot detected Amlodipine, a prescription medication used for the treatment of high blood pressure. The medication typically does not have any adverse effects, and is routinely approved by the Federal Aviation Administration. ## Factual narrative HISTORY OF FLIGHT On May 14, 2010 about 0718 Pacific daylight time, a Piper PA-24-250, N6967P, sustained substantial damage when it impacted terrain during takeoff initial climb from the Roberts Field Airport (RDM), Redmond, Oregon. The airplane was owned and operated by the pilot under the provisions of Title 14 Code of Federal Regulations Part 91. The commercial pilot, sole occupant of the airplane, was killed. Visual meteorological conditions prevailed and no flight plan was filed for the personal flight. The cross-country flight was originating at the time of the accident with an intended destination of Burns, Oregon. A witness who was located on runway 4, between taxiway Golf and Hotel reported that while conducting a routine daily runway inspection, he observed the accident airplane initiate takeoff roll on runway 10. The witness stated that he continued inspecting runway 4 and diverted his attention away from the accident aircraft. As the witness passed taxiway Hotel, he stopped his vehicle and reestablished visual contact with the accident airplane. The witness stated that he observed the airplane in an almost vertical attitude above the departure end of runway 10. The witness estimated that the airplane was about 100 to 200 feet above the ground when it performed a 360-degree roll, "stalled", entered a nose down attitude, performed a second 360-degree roll, and descended below a tree line. The witness stated that he did not observe the airplane impact the ground. A second witness, located in the air traffic control tower, reported that he observed the accident airplane depart runway 10 and that it appeared to be "on a normal climb." The witness stated that as the airplane was about one-half mile beyond the departure end of runway 10, it entered an abrupt climb at an approximate 90-degree angle. The witness further stated that the airplane climbed for approximately 200 feet, nosed over, "descended very steeply", and impacted terrain north of runway 10/28. Family members of the pilot reported to local law enforcement that the pilot was moving the airplane from RDM to Burns, Oregon, in order to show the airplane to a potential buyer. PERSONNEL INFORMATION The pilot, age 87, held a commercial pilot certificate with airplane single-engine land and airplane land ratings. A third-class airman medical certificate was issued on December 20, 2007. A limitation stated "must wear corrective lenses for distant vision, must possess glasses for near vision, not valid for any class after." The pilot's logbook was not recovered for examination. The pilot reported on his most recent medical certificate application; he had accumulated 10,000 total flight hours. AIRCRAFT INFORMATION The four-seat, low-wing, retractable gear airplane, serial number (S/N) 24-2108, was manufactured in 1960. It was powered by a Lycoming O-540-A1D5 engine, serial number L-3030-40, rated at 250 horse power. The airplane was equipped with a two-bladed variable pitch Hartzellpropeller. Review of copies of aircraft maintenance logbook records showed an annual inspection was completed June 1, 2009, at a recorded tachometer reading of 2,131.48 hours, airframe total time of 2,131.48 hours, and engine time since major overhaul of 1,147.9 hours. The tachometer hour reading observed at the accident site was 2,143.38 hours. The airplane was last refueled at a local fixed base operator on May 13, 2010 with 41 gallons of 100-low lead aviation fuel. According to a representative from Butler Aviation, no debris or anomalies were observed in a fuel sample taken from the fuel pumps and trucks following the accident. Using the reported empty weight of the airplane and according to a weight and balance sheet located within the wreckage, at the pilot's most recent reported weight and with full fuel, the airplane was found to be within weight and balance limitations at the time of the accident. METEOROLOGICAL INFORMATION A review of recorded data from the automated weather observation station located at RDM revealed that at 0723, weather conditions were wind calm, visibility 10 statute miles, clear sky, temperature 9 degrees Celsius, dew point 3 degrees Celsius, and an altimeter setting of 30.04 inches of Mercury. AIRPORT INFORMATION The Roberts Field Airport (RDM), Redmond, Oregon, operates under Class-Delta airspace during the hours of 0530 to dusk. The airport features two asphalt runways, runway 4/22 and runway 10/28. Runway 10/28 is 7,006 feet in length, and 100 feet wide. Runway 10 features a 0.5 percent upslope gradient. The reported field elevation was 3,080 feet mean sea level (msl). WRECKAGE AND IMPACT INFORMATION Examination of the accident site revealed that wreckage debris was scattered throughout approximately 400 feet, oriented along an approximate 310-degree bearing from the first identified point of contact (FIPC). The FIPC was identified by a ground scar that contained various paint chips and green lens fragments consistent with the right wing navigational lens. The ground scar extended about 50 feet across taxiway Zulu (dirt taxiway located north of runway 10/28) to a one-foot by two-foot crater in soft terrain. Portions of the engine cowling and one propeller blade were located within the crater. Portions of the right wing, empennage, vertical stabilizer, engine components, Plexiglas, and fuselage structure were located throughout the debris path between the crater and main wreckage. The main wreckage consisted of the left wing, cockpit, and forward portion of the fuselage. The left wing was observed inverted and the cockpit and forward portion of the fuselage were in an upright position. The engine and portions of the right wing were located about 30 feet beyond the main wreckage. Examination of the airframe revealed that flight control continuity was established throughout the airplane to all primary flight control surfaces from the cabin area. The horizontal stabilator trim drum was observed in a positionconsistent with a full nose-up, tab down setting. The stabilator trim drum was free to move by hand. Both ends of the trim cables were separated. The portion of the stabilator trim control cable, when pulled, moved the stabilator trim drum to a setting and exhibited broomstraw and cable curling signatures, consistent with high tension stress and overload. The opposing cable was separated and exhibited broomstraw signatures, consistent with overload separation. Examination of the airframe revealed no evidence of any pre impact mechanical malfunctions. Examination of the engine revealed that it was separated from the airframe. The alternator, carburetor, and engine driven fuel pump were displaced from the engine. The propeller remained attached to the crankshaft propeller flange. All cylinders remained attached to the engine crankcase. The oil sump was intact and breeched adjacent to the carburetor mount. The oil sump suction screen was removed and found free of debris. The propeller, top spark plugs, left and right magnetos, vacuum pump, propeller governor, and rocker box covers were removed from the engine. The engine crankshaft was manually rotated by hand using a hand tool mounted to an accessory drive on the rear of the engine. Rotational continuity was established throughout the engine and valve train. Thumb compression and suction was obtained on all six cylinders. The propeller hub remained attached to the engine crankshaft propeller flange. One of the two propeller blades was separated from the hub. The propeller blades were labeled A and B for identification purposes. Propeller blade A remained attached to the propeller hub and was loose within the propeller hub. The propeller exhibited a forward bend that originated about 12 inches outboard of the propeller hub. The propeller blade exhibited a slight twist near the propeller blade tip. Leading edge gouges were observed on the outboard 10 inches of the propeller blade. The outboard propeller blade tip exhibited numerous gouges. Propeller blade B was separated from the propeller hub and was bent opposite the direction of rotation. The leading edge of the propeller blade exhibited gouging throughout most of its span. Chord wise scratching was observed on the outboard 15 to 20 inches of the propeller blade face. Examination of the engine revealed no evidence of any pre impact mechanical malfunctions. MEDICAL AND PATHOLOGICAL INFORMATION The Deschutes County Medical Examiner conducted an autopsy on the pilot on May 15, 2010. The medical examiner determined that the cause of death was “Blunt force traumatic injuries.” 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. The test was positive for an unspecified level of Amlodipine within the Urine and Blood. ## Aircraft - Registration: [N6967P](https://openairdocs.org/deregistered/N6967P-2012-11-07), registration cancelled 2012-11-07, S/N 24-2108, built 1960 (OpenAirDocs) - Reported make and model: PIPER PA-24-250 - 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: 24-2108 - Airframe hours: 2143 - Engines: LYCOMING O-540-A1D5 250 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Operator: Sheldon Arnett - Registered owner: Sheldon Arnett - Last inspection: Annual, June 1, 2009, 12 hours before - Departed: RDM, Redmond, OR - Destination: Burns, OR - Airport: RDM, Roberts Field Airport, runway 10, 7,006 × 100 ft, macadam ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 87; injuries: fatal; commercial; airplane ratings: single-engine land, multi-engine land; medical: class 3, with waivers/limitations; toxicology performed; flight hours: 10,000 total ## Weather - Conditions: Visual (VMC), Day - Wind: calm - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 48 °F, dew point 37 °F - Altimeter: 30.04 inHg - Observed at: RDM ## 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 20100514033939A](https://openairdocs.org/incident/20100514033939A), May 14, 2010: Piper PA-24-250, Redmond, OR, Destroyed, 1 fatal. Aircraft took off normally with retracted gear and flaps. Between 200 and 400 ft. altitude, aircraft pitched nose up at approximately 90 degrees, climbed… ## Other investigations on N6967P (1) 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 CHI67F0117](https://openairdocs.org/ntsb/CHI67F0117), Aug 10, 1966: Piper PA-24 (N6967P), Northbrook, IL, substantial damage ## Docket (8 files) The files NTSB released with the investigation on April 28, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=76001. 8.9 MB in all. - Global Positioning System Device - Specialist's Factual Report with 1 Embedded Image (item 1, .PDF, 1 photo, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40337654&FileExtension=.PDF&FileName=Global%20Positioning%20System%20Device%20-%20Specialist%27s%20Factual%20Report%20with%201%20Embedded%20Image-Master.PDF - Witness Statements (item 2, .PDF, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344779&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Summary of On-Scene Examination of the Accident Site and Airframe (item 3, .PDF, 192 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344780&FileExtension=.PDF&FileName=Summary%20of%20On-Scene%20Examination%20of%20the%20Accident%20Site%20and%20Airframe-Master.PDF - Summary of On-Scene Examination of the Engine (5 photos embedded) (item 4, .PDF, 5 photos, 3.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344781&FileExtension=.PDF&FileName=Summary%20of%20On-Scene%20Examination%20of%20the%20Engine%20(5%20photos%20embedded)-Master.PDF - Toxicological Report - Pilot (item 5, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344782&FileExtension=.PDF&FileName=Toxicological%20Report%20-%20Pilot-Master.PDF - Statement of Party Representatives to NTSB Investigation - Piper Aircraft (item 6, .PDF, 262 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344783&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation%20-%20Piper%20Aircraft-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 7, .PDF, 45 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344784&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Accident Site Photos (4 embedded photos) (item 8, .PDF, 4 photos, 4.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344785&FileExtension=.PDF&FileName=Accident%20Site%20Photos%20(4%20embedded%20photos)-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.