WPR10FA330

NTSB accident investigation · Piper PA-28R-180 · Dixon, MT · June 27, 2010

Accident · FatalField investigationFinal report
Date
June 27, 2010, 16:00 local (22:00 UTC)
Place
Dixon, MT
Injuries
4 fatal
Damage
Substantial damage
Phase of flight
Maneuvering
Aircraft
N7581JPiper PA-28R-180
Defining event
Maneuvering-low-alt flying: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed · report June 27, 2011
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Northstar Jet, Federal Aviation Administration, Textron Lycoming, Piper Aircraft Company
FAA report
20100627038859A
Case key
76545

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot’s failure to maintain adequate airspeed and aircraft control while maneuvering, resulting in an aerodynamic stall and collision with mountainous terrain.

Findings · 3

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28R-180: 5 casesAll aircraft: 1,681 casesProbable cause
Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-28R-180: 17 casesAll aircraft: 9,295 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Not specifiedPiper PA-28R-180: 2 casesAll aircraft: 329 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The airplane departed with the pilot and three passengers for a sightseeing flight. Recorded radar data showed that the airplane departed the airport, proceeded north over a national forest, and then traveled south. The last radar return indicated that the airplane was at an altitude about 300 feet above ground level and 2,800 feet mean sea level (msl), following a river. Witnesses reported seeing a blue and white single-engine airplane matching the paint scheme of the accident airplane flying low over the river about the same time as the last radar return. The wreckage was located 4.5 miles south of the river at an elevation of 4,600 feet msl in mountainous terrain. The accident scene was confined to the immediate vicinity of the wreckage, and had been subjected to a localized ground fire. The confined configuration of the wreckage was consistent with a vertical descent and ground impact. Examination of the airframe and engine found no preimpact malfunctions or failures that would have precluded normal operation. Toxicology revealed that an inactive metabolite of marijuana was detected in specimens from the pilot. No blood was available for testing and the findings indicate only that the pilot likely used marijuana in the days or weeks preceding the accident.

Factual narrative

HISTORY OF FLIGHT On June 27, 2010, approximately 1600 mountain daylight time, a Piper PA-28R-180, N7581J, impacted mountainous terrain 10 miles southwest of Dixon, Montana. The airplane was owned by a private individual, operated by Northstar Jet, and was rented to the pilot, who operated it under Title 14 Code of Federal Regulations Part 91. The private pilot and his three passengers were killed. The airplane was substantially damaged, and consumed by a post impact fire. Visual meteorological conditions prevailed, and no flight plan had been filed. The flight originated from the Kalispell City Airport, Kalispell, Montana, about 1409. The airplane was reported missing on June 27, 2010. A search was conducted by the Sanders and Lake County Sheriff Departments. The wreckage was located by aerial search crews on the afternoon of June 30 th in rugged and remote mountainous terrain. A ground search and rescue team confirmed four fatalities at the accident site. The Lake County Sheriff and the airplane’s owner conveyed that the pilot had rented the single engine, blue and white airplane, and departed with one passenger from Missoula International Airport, Missoula, Montana, about 1330. Around 1409, he departed Kalispell City Airport with three passengers for a sightseeing flight. Initial radar data showed the airplane departing Kalispell and heading north over the Flathead National Forest, then traveling south along the east side of Flathead Lake. The last radar return was at 1552, located in the vicinity of Dixon, at an altitude of about 300 feet above ground level (agl), 2,800 feet mean sea level (msl). Witnesses reported seeing a blue and white single-engine airplane flying low over the Flathead River between Perma and Dixon around 1600. PERSONNEL INFORMATION The pilot, age 25, held a private pilot certificate for airplane single-engine land issued on June 26, 2009, and a second-class airman medical certificate issued March 21, 2008, with no limitations. The pilot’s logbook was not located, and is presumed to have been destroyed in the post impact fire. The operator and the pilot’s certified flight instructor (CFI) both stated that the pilot had received all his flight training at the Missoula International Airport, had accumulated about 100 hours of total flight time, and had about 30 hours in the accident airplane. Rental records indicate that the pilot’s most recent flights in the accident airplane were on November 25, 2009, and June 25, 2010. AIRCRAFT INFORMATION The four-seat, low-wing, retractable landing gear airplane, serial number 28R-30971, was manufactured in 1968. It was powered by a Lycoming IO-360-B1E 180 horsepower (hp) engine and was equipped with a Hartzell model HC2YK-1BF two bladed constant speed propeller. Review of copies of maintenance logbook records showed an annual inspection was completed on April 9, 2010, at a recorded total airframe time of 6,234.5 hours. The engine time since major overhaul (TSMO) was 1,772.9 hours. Anentry dated June 9, 2010, stated that the airplane had been stripped, repainted, and a successful test flight had been performed. The operator reported that the airplane departed Missoula with full fuel tanks (50 gallon) and that no fuel was taken on at Kalispell City Airport. Airplane climb performance can be estimated utilizing the rate of climb verses density altitude chart provided in the PA-28R-180 Owners Handbook (gear & flaps up, gross weight 2,500 pounds). The calculated density altitude at 5,000 feet msl and 27 degrees Celsius is 7,500 feet. The estimated rate of climb at maximum gross weight is 480 feet per minute. METEOROLOGICAL INFORMATION The weather observation recorded at Missoula International Airport (36 miles southeast of the accident site) by the automated surface observation system (ASOS) at 1553, was winds from 140 degrees at 3 knots; 10 statute miles visibility; sky clear; and the temperature at 27 degrees Celsius. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on July 3, 2010, by the State of Montana Medical Examiner, Missoula. The autopsy findings state the cause of death was “blunt force injuries.” Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Science Research Lab CAMI, Oklahoma City, Oklahoma. The toxicology report stated that 0.0029 ug/ml tetrahydrocannabinol Carboxylic Acid (marihuana) was detected in brain tissue, tetrahydrocannabinol carboxylic acid (marihuana) was detected in muscle tissue, and 0.0304 ug/ml tetrahydrocannabinol carboxylic acid (marihuana) was detected in urine. WRECKAGE AND IMPACT INFORMATION Search teams located the wreckage the afternoon of June 30, approximately 10 miles southwest of Dixon at an elevation of 4,685 feet msl, which also corresponded to a position 4.5 miles south of the Flathead river. The wreckage was positioned near the bottom of a heavily wooded steep valley populated with lodgepole pine trees and young maples. The slope of the hill side was measured to be 28 degrees. The wreckage was positioned on the ground with the left wing, right wing, engine, and tail in their appropriate positions. The right wing pointed up hill, and the wreckage was orientated on a 069-degree magnetic bearing line, measured from tail to nose. The center fuselage and cabin area had been completely consumed by a post impact fire. Two trees directly adjacent to the wreckage, behind the left wing, had evidence of fresh breaks and damage consistent with recently being topped, and another tree exhibited fresh damage to the trunk and branches at the same elevation as the topped trees. Tree branches and needles below showed browning consistent with fuel blight. Blackened ground and charred vegetation were consistent with a localized ground fire around the wreckage. Control continuity was established from all control surface bell cranks to their cockpit connection points. The right horizontal stabilator was sheared off at the interface betweenit and the empennage, about 40 percent of the left stabilator was present, and the vertical stabilizer with the rudder attached was present on the empennage. Fragments of the stabilator were located beneath the topped trees. The stabilator trim jack screw was extended 1 inch, which corresponds to a neutral pitch setting. The fuel selector valve was located but the fire damage was too extensive to be able to determine valve position. Both main landing gear were in the down position, with ground divots next to each mount. The nose landing gear appeared to be in the in transit position. The flap handle was down, and the right flap was flush with the wing upper skin. The left flap and aileron were separated from the wing, and located on the ground a few feet downhill from the wing. The engine was separated from the engine mount, and laid inverted in line with the centerline of the fuselage. The entire engine was black and sooted from thermal exposure. The engine intake manifold and exhaust manifolds were impact separated from the engine; the throttle body had separated from its mounting pad. Both magnetos were attached to the engine, and the fuel distribution valve was present with all four fuel lines leading to the engine cylinders. The engine could not be rotated by hand. The propeller was attached to the crankshaft propeller flange, and the spinner was undamaged. Both blades exhibited minimal leading edge damage, and the outer third of each blade was bent aft approximately 15 degrees. Further examination of the engine by the manufacturer’s technical representative revealed no anomalies that would preclude normal engine operation prior to impact.

Aircraft

Registration
N7581J
Reported as
Piper PA-28R-180
Category
Airplane
Serial number
28R-30971
Airframe hours
6,234
Engine
Lycoming IO-360 SER, 180 horsepower, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · April 9, 2010
Departed
KS27 · Kalispell, MT
Destination
KS27 · Perma, MT
Flight plan
Unknown
Airport
KS27 · Kalispell City Airport

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
25
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 2, Without waivers/limitations
Last flight review
June 26, 2009
Seat
Left
Toxicology
Performed
Flight hours
100 total · 30 in this make and model · 2 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
140° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 43 °F
Altimeter
29.95 inHg
Observed at
KMSO, 18 nm away

Docket · 12

The files NTSB released with the investigation on April 13, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 8.4 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.