WPR19FA042

NTSB accident investigation · Piper PA-24-250 · Aberdeen, ID · December 17, 2018

Accident · FatalClass 2 · FieldFinal report
Date
December 17, 2018, 07:55 local (14:55 UTC)
Place
Aberdeen, ID
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Initial climb
Aircraft
N6283PPiper PA-24-250
Defining event
Initial climb: Loss of control in flight
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 2
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration, Lycoming Engines, Piper Aircraft
FAA report
20181217022159A
Case key
98775

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

On this page

Probable cause

The pilot's diverted attention during the takeoff climb due to a loss of engine power, which resulted in the airplane’s exceedance of the critical angle of attack and subsequent stall/spin.

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.

Use of equip/info: aircraft controlPersonnel issues › Task performance · PilotPiper PA-24-250: 34 casesAll aircraft: 9,295 casesProbable cause
Attention/monitoring: attentionPersonnel issues › Psychological · PilotPiper PA-24-250: 2 casesAll aircraft: 226 casesProbable cause
Ignition system: magneto/distributorAircraft › Aircraft power plant · FailurePiper PA-24-250: 2 casesAll aircraft: 101 casesProbable cause
Fuel system: fuel selector/shutoff valveAircraft › Aircraft systems · Incorrect use/operationPiper PA-24-250: 4 casesAll aircraft: 176 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-24-250: 9 casesAll aircraft: 990 casesProbable cause

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

Security camera video captured the airplane during the initial climb after takeoff. The video showed that as the airplane entered the view of the camera, it appeared to be in a shallow climb; however, about 14 seconds later, the airplane descended in a near vertical manner, out of view of the camera. The airplane impacted open terrain about 1,850 ft west of the departure end of the runway. Examination of the airframe revealed no mechanical anomalies that would have precluded normal operation; however, the left fuel selector valve was in the left wingtip tank position, and the right selector valve was in in a position between the right main fuel tank and right wingtip tank position. The Airplane Flight Manual Supplement for the wingtip fuel tank installation stated that the wingtip tank fuel was to be used in level flight only. It is likely that because of the placement of the fuel port in the wingtip fuel tanks, when the airplane was in a climb attitude, the fuel may not have reached the fuel port in the tank. As a result, the pilot’s improper positioning of the fuel valves could have led to fuel starvation during the takeoff climb and resulted in a loss of engine power. Additionally, examination of the engine revealed that both magnetos were found in poor condition and showed evidence of little maintenance being performed. The left magneto drive shaft would not rotate. Disassembly of the left magneto revealed excessive wear on the bearing race that is attached to the drive shaft. The excessive wear allowed the magnets to contact the magneto housing, which resulted in the magneto being grounded, thus inoperative. The inoperative magneto would have partially reduced engine power. It is likely that the pilot experienced a loss of engine power to some degree during takeoff initial climb and his attention could have been diverted as part of troubleshooting the loss of engine power. The pilot's diverted attention most likely allowed for the airplane to exceed its critical angle of attack, resulting in a stall and subsequent spin at an altitude too low for recovery.

Factual narrative

Narrative additional information place holder No maintenance records were located during the investigation. Federal Aviation Administration (FAA) Airworthiness records showed that the airplane was equipped with Brittain Mark II auxiliary fuel wingtip tanks in 1960. The Airplane Flight Manual Supplement for the wingtip fuel tank installation stated in part, "auxiliary wing tip tank fuel to be used in level flight only." A placard showing the limitation for the auxiliary wingtip fuel tanks was observed near the fuel selector valve handles. Narrative airport information place holder Narrative communications place holder Narrative damage to aircraft place holder Narrative fire place holder Narrative flight recorders place holder On December 17, 2018, about 0755 mountain standard time, a Piper PA-24-250 airplane, N6283P, was substantially damaged when it was involved in an accident near Aberdeen, Idaho. The pilot sustained fatal injuries. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Review of airport security camera video recordings revealed that the accident airplane departed from runway 25 at Aberdeen Municipal Airport (U36), Aberdeen, Idaho, and entered a shallow climb, remaining on a westerly heading. About 14 seconds after the airplane entered the camera’s field of view, it descended in a near vertical manner, out of view of the camera. The wreckage was located about 1 hour after the accident by a nearby resident. There were no known witnesses to the accident. Narrative injuries to persons place holder The Bingham County Coroner's Office, Blackfoot, Idaho, performed an autopsy of the pilot. The pilot's cause of death was blunt force trauma. The FAA's Forensic Sciences Laboratory performed toxicology testing on the pilot's tissue samples, which identified acetaminophen and ibuprofen in the urine. Narrative meteorological information place holder Narrative organizational and management information place holder Narrative other damage place holder Narrative survival aspects place holder Narrative tests and research place holder Narrative useful or effective investigation techniques place holder The airplane impacted open terrain about 1,850 ft west of the departure end of runway 25. The airplane came to rest upright on a heading of about 279° magnetic, at an altitude of 4,156 ft mean sea level. A ground impression consistent with the right-wing tip fuel tank was observed adjacent to the right-wing tip fuel tank. In addition, an area of compressed dirt was observed to the right of the fuselage/cowling area. All major structural components were located at the accident site. A scent of fuel was present at the accident site. The fuselage was mostly intact. The engine, cowling, and forward portion were slightly displaced to the right. The fuselage structure aft of the cabin area was buckled and displaced upward and to the right. The vertical stabilizer, rudder, stabilator, and stabilator trim tab remainedattached and secure to their respective mounts. The stabilator trim actuator appeared to be in a position near neutral. The fuel selector valves were found intact. The left fuel selector valve was in the left tip fuel tank position, and the right selector valve was in in a position between the right main fuel tank and right tip fuel tank position. All internal passages of both fuel selector valves were found to be free of obstructions. The right wing remained attached to the fuselage. The bottom side of the wing was compressed upward throughout its span. Multiple tears in the leading edge along with bending and buckling throughout was observed. The right-wing tip fuel tank remained attached and exhibited an approximate 45° crush angle extending from the bottom of the tip tank to the top. Both the right main fuel tank and right wingtip fuel tank were breached. The left wing remained attached to the fuselage. The bottom side of the wing exhibited upward crushing throughout its span. The left wingtip fuel tank remained attached. Both the left main fuel tank and left wingtip fuel tank were breached. Flight control continuity was established from all primary flight control surfaces to the cockpit controls. No separations in the control cables were observed. The engine remained attached to the fuselage via its mounts. The carburetor, left and right magnetos, fuel pump, vacuum pump, oil filter, and starter were separated. The engine crankshaft was rotated by hand using the propeller. Rotational continuity was established throughout the engine and valve train. Thumb compression and suction was established on all six cylinders along with equal movement of the intake and exhaust rocker arms was observed when the crankshaft was rotated. All six cylinders were examined using a lighted borescope and found to be unremarkable. The left and right magnetos were examined at a magneto repair facility under the supervision of an FAA inspector. The inspector stated that both magnetos were in poor condition and showed evidence of little maintenance. The right magneto was placed on a test bench and produced spark on all posts through varying rpm ranges. The left magneto drive shaft would not rotate. The magneto was disassembled and excessive wear on the bearing race attached to the shaft was observed. The inspector stated that the wear on the bearing race allowed the magnets to contact the magneto housing, which grounded the magneto. The inspector added that the bearings were in poor condition and the grease appeared to be very old.

Aircraft

Registration
N6283P
Reported as
Piper PA-24-250
Category
Airplane
Serial number
24-1393
Built
1959
Engine
Lycoming O-540-A1G5, 250 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Departed
U36 · Aberdeen, ID
Destination
Vernal, UT
Airport
U36 · Aberdeen Muni, runway 25, 3,690 × 50 ft, asphalt
Equipment
Stall warning system

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
42
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, Without waivers/limitations
Last flight review
February 26, 2018
Seat
Left
Restraint
Lap only
Toxicology
Performed
Flight hours
292.2 total · 172.6 in this make and model · 243.3 as pilot in command · 48.7 in the last 90 days · 4.6 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
50° at 3 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
14 °F, dew point 10 °F
Altimeter
30.26 inHg
Observed at
KPIH, 14 nm away

Docket · 9

The files NTSB released with the investigation on November 18, 2020, on NTSB’s docket system: statements, records, photos and specialists’ reports. 14.8 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.