# NTSB WPR12LA048: Piper PA-32RT-300T, N36824, Hailey, ID, November 30, 2011 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: November 29, 2011, 19:00 local (Nov 30, 2011, 02:00 UTC) - Place: Hailey, ID - Coordinates: 43.338054, -114.219169 - Nearby events: https://openairdocs.org/map.md?lat=43.3381&lon=-114.2192&mi=10 - Phase of flight: [Initial climb](https://openairdocs.org/ntsb-phases/350) (OpenAirDocs' grouping) - Defining event: [Initial climb: Course deviation](https://openairdocs.org/ntsb-events/281) - Highest injury: Serious injuries - Injuries: 1 serious, 1 minor - Status: Completed, report February 14, 2013 - Report: Approved by Office Director - NTSB office: Western Pacific Region - Parties: Boise FSDO - NTSB case key (mKey): 82422 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR12LA048 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/82422/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=82422 - Page: https://openairdocs.org/ntsb/WPR12LA048 ## 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 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-32RT-300T, 3 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md?model=7103216), [All aircraft, 1,310 cases](https://openairdocs.org/ntsb-findings/01062012/cases.md) - [Attention/monitoring: task monitoring/vigilance](https://openairdocs.org/ntsb-findings/02021520): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-32RT-300T, 1 case](https://openairdocs.org/ntsb-findings/02021520/cases.md?model=7103216), [All aircraft, 330 cases](https://openairdocs.org/ntsb-findings/02021520/cases.md) - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-32RT-300T, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=7103216), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md) - [Terrain: mountainous/hilly terrain](https://openairdocs.org/ntsb-findings/03021010): Environmental issues › Physical environment · Contributed to outcome; cases with it: [Piper PA-32RT-300T, 1 case](https://openairdocs.org/ntsb-findings/03021010/cases.md?model=7103216), [All aircraft, 329 cases](https://openairdocs.org/ntsb-findings/03021010/cases.md) - [Light condition: dark](https://openairdocs.org/ntsb-findings/03036020): Environmental issues › Conditions/weather/phenomena · Contributed to outcome; cases with it: [Piper PA-32RT-300T, 2 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md?model=7103216), [All aircraft, 448 cases](https://openairdocs.org/ntsb-findings/03036020/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Initial climb: Course deviation](https://openairdocs.org/ntsb-events/281) (defining event); cases with it: [Piper PA-32RT-300T, 1 case](https://openairdocs.org/ntsb-events/281/sequence.md?model=7103216), [All aircraft, 52 cases](https://openairdocs.org/ntsb-events/281/sequence.md) - [Initial climb: Off-field or emergency landing](https://openairdocs.org/ntsb-events/440); cases with it: [Piper PA-32RT-300T, 4 cases](https://openairdocs.org/ntsb-events/440/sequence.md?model=7103216), [All aircraft, 3,365 cases](https://openairdocs.org/ntsb-events/440/sequence.md) ## 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](https://openairdocs.org/deregistered/N36824-2012-01-26), registration cancelled 2012-01-26, S/N 32R-7887087, built 1978 (OpenAirDocs) - Reported make and model: PIPER PA-32RT-300T - Registry model: [Piper PA-32RT-300T](https://openairdocs.org/model/piper-pa-32rt-300t) (registry code 7103216) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32R-7887087 - Airframe hours: 3879 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 56; injuries: minor; 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 ## 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 20111129027469A](https://openairdocs.org/incident/20111129027469A), Nov 29, 2011: Piper PA-32RT-300T, Hailey, ID, Substantial damage. At appoximaely 1845 hrs. Local N36824 a PA-32RT-300T was cleared to taxi way brovo and runway 13.the taxi to the end of the run was uneventul. N36824 was… ## Docket (9 files) The files NTSB released with the investigation on December 19, 2012, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=82422. 9.8 MB in all. - GPS 17 - Specialist's Factual Report (item 1, .PDF, 948 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360596&FileExtension=.PDF&FileName=GPS%2017%20-%20Specialist%27s%20Factual%20Report-Master.PDF - GPS 17 - Attachment 1 - Tabular Data (CSV) (item 2, .CSV, 4 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360597&FileExtension=.csv&FileName=GPS%2017%20-%20Attachment%201%20-%20Tabular%20Data%20(CSV)-Master.csv - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 3, .PDF, 604 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40360408&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - GPS Ground Track on Google Earth (item 4, .PDF, 191 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383776&FileExtension=.PDF&FileName=GPS%20Ground%20Track%20on%20Google%20Earth-Master.PDF - Record of Conversation - Collins (item 5, .PDF, 144 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383775&FileExtension=.PDF&FileName=Record%20of%20Conversation%20-%20Collins-Master.PDF - Century Flight Systems, Inc. Report (item 6, .PDF, 7 photos, 7.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383777&FileExtension=.PDF&FileName=Century%20Flight%20Systems,%20Inc.%20Report-Redacted.PDF - Evidence Control Forms (item 7, .PDF, 576 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383781&FileExtension=.PDF&FileName=Evidence%20Control%20Forms-Redacted.PDF - Parts Return Form (item 8, .PDF, 113 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383782&FileExtension=.PDF&FileName=Parts%20Return%20Form-Redacted.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 9, .PDF, 217 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40383780&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.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.