WPR12LA048

NTSB accident investigation · Piper PA-32RT-300T · Hailey, ID · November 30, 2011

Accident · Serious injuriesLimited investigationFinal report
Date
November 29, 2011, 19:00 local (Nov 30, 2011, 02:00 UTC)
Place
Hailey, ID
Injuries
1 serious, 1 minor
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N36824Piper PA-32RT-300T
Defining event
Initial climb: Course deviation
Weather
Visual (VMC) · Night
Status
Completed · report February 14, 2013
Report
Approved by Office Director
NTSB office
Western Pacific Region
Parties
Boise FSDO
FAA report
20111129027469A
Case key
82422

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 course heading and terrain clearance because he was distracted by efforts to engage the autopilot shortly after takeoff on a dark night in mountainous terrain.

Findings · 5

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: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-32RT-300T: 3 casesAll aircraft: 1,310 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · PilotPiper PA-32RT-300T: 1 caseAll aircraft: 1,386 casesProbable cause
Terrain: mountainous/hilly terrainEnvironmental issues › Physical environment · Contributed to outcomePiper PA-32RT-300T: 1 caseAll aircraft: 329 cases
Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomePiper PA-32RT-300T: 2 casesAll aircraft: 448 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

During takeoff from an airport in a narrow valley on a dark night, the pilot lost sight of the lights around the runway environment while he attempted to engage the autopilot to assist in his navigation of the pre-programmed route. When he determined that his first attempt to engage the autopilot had not been successful, the pilot repeated the steps of the autopilot engagement process. As the pilot was completing his second attempt to engage the autopilot, the tower air traffic controller asked him if he was making a turn to the downwind leg. About the same time, the terrain warning signal on one of the airplane’s global positioning system units began to sound. The pilot then realized that while he was trying to engage the autopilot, the airplane’s heading had drifted and the airplane was headed toward rapidly rising terrain. Because it appeared to the pilot that he would not be able to avoid that terrain, he slowed the airplane and performed an emergency landing on “rough and comparatively level” snow-covered ground. Several of the autopilot components and associated flight instruments were examined and tested; however, there was no evidence of preaccident mechanical malfunctions or failures that would have precluded normal operation or engagement. It is likely that the pilot's distraction with the autopilot engagement resulted in his failure to maintain his course alignment and clearance from terrain.

Factual narrative

On November 29, 2011, about 1900 mountain standard time, a Piper PA-32RT-300T, N36824, impacted the terrain during controlled flight about one mile east of Friedman Memorial Airport, Hailey, Idaho. The pilot received minor injuries, his passenger received serious injuries, and the airplane, which was owned and operated by the pilot, sustained substantial damage. The 14 Code of Federal Regulations Part 91 personal transportation flight, which had just departed Hailey for Nampa, Idaho, was being operated in night visual meteorological conditions. No flight plan had been filed. According to the pilot, he had planned to depart Hailey while it was still light, but a delay in his passenger’s activities resulted in a takeoff after dark. Prior to departing Hailey, he set up the entire route from Hailey through the instrument approach into Nampa, on his panel-mount GNS480 Global Positioning System (GPS), and then set up his yoke-mounted GPSMAP496 as a backup. His plan was to engage the autopilot soon after takeoff, and then to rely primarily on the coupled autopilot to maintain his heading in the narrow valley south of the airport, and to track the rest of the preset route. After listening to the Automatic Terminal Information Service recording, he continued with his plan to takeoff to the south in good visibility, with a tailwind of about 7 knots, on what he characterized as a dark night. After liftoff, because of the airplane’s light weight (two occupants), and the higher than standard performance capabilities resulting from the cold ambient air temperature, the airplane climbed rapidly with a nose high pitch attitude. As a result of the high pitch attitude, the pilot lost direct visual reference with the lights around the runway environment before the airplane reached the departure end of the runway. Once he lost sight of the runway environment, the pilot transferred his attention, and his reference for controlled flight, to the airplane’s instrument panel. During that process, the pilot attempted to engage the autopilot, so that he could rely on it to navigate the narrow valley running south from Hailey. Because the autopilot did not engage on the first attempt, the pilot went through the autopilot activation procedure a second time. Just as he was coming to the end of that process, the Hailey Tower controller asked him if he was turning downwind. About the same time, the GPSMAP496 terrain warning signal started sounding, and at that point in time that the pilot realized that while he was focused on getting the autopilot engaged, the airplane had turned from its original heading, and that it was heading east toward rapidly raising terrain. When the pilot saw the terrain, he quickly reached the conclusion that he would not be able to avoid it, so he slowed the airspeed to about 65 knots, and maneuvered the airplane toward an area of comparatively level ground, where he executed a controlled crash on the snow-covered hillside. Because the pilot was notsure if there had been something wrong with the airplane’s Century 2000 autopilot system, or whether he simply had not placed the autopilot engagement switch fully in the engage position, during the postaccident investigation process the NTSB Investigator-In-Charge (IIC) had a number of the airplane’s components removed and tested at Century Flight Systems in Mineral Wells, Texas. The components that were taken to Century Flight Systems for testing under the direct oversight of another NTSB Accident Investigator were as follows: 1. 1D937-2050-311FF18 Flight Computer (s/n 2178G); 2. 52D67 Attitude Gyro (s/n T72374M); 3. 52D254 Directional gyro (s/n A6156G); 4.1C784-2-879 Roll Servo (s/n 1501; 5. 1C784-3-1052 Pitch Servo (s/n 1511). Although the test sequence found that impact damage kept the attitude gyro from erecting after spin-up, and that impact damage to two of the male electrical connector pins on the directional gyro resulted in no electrical output to the test screen, all other components showed normal, in specification, results, and no preimpact anomalies were found that would have kept the autopilot from engaging. When the pilot completed the RECOMMENDATIONS section of the NTSB Form 6120.1 (Pilot/Operator Aircraft Accident/Incident Report), he made the following two recommendations: 1. Do not depart an airport in mountainous areas when single pilot and mountainous terrain is within 5 nautical miles of the airport; 2. Do not troubleshoot discrepancies within 5 nautical miles of the terrain, instead treat any discrepancy as an inoperable item.

Aircraft

Registration
N36824
Reported as
Piper PA-32RT-300T
Category
Airplane
Serial number
32R-7887087
Airframe hours
3,879
Engine
Lycoming TIO-540 SER, 300 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Tower Paul A
Registered owner
Tower Paul A
Airworthiness certificate
Standard, Normal
Last inspection
Annual · July 15, 2011
Departed
Hailey, ID
Destination
KMAN · Nampa, ID

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
56
Injuries
Minor
Certificate
Private
Airplane ratings
Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Last flight review
January 4, 2010
Seat
Left
Flight hours
2,003 total · 1,302 in this make and model · 1,921 as pilot in command · 19 in the last 90 days · 4 in the last 30 days · 1 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
310° at 7 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
39 °F, dew point 25 °F
Altimeter
30.20 inHg

Docket · 9

The files NTSB released with the investigation on December 19, 2012, on NTSB’s docket system: statements, records, photos and specialists’ reports. 9.8 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.