WPR19TA085

NTSB accident investigation · Piper PA46 · Aurora, OR · February 6, 2019

Accident · Serious injuriesClass 3Final report
Date
February 6, 2019, 15:30 local (23:30 UTC)
Place
Aurora, OR
Injuries
2 serious
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N997MAPiper PA46
Defining event
Approach-VFR pattern final: Aerodynamic stall/spin
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Federal Aviation Administration
FAA report
20190206009959A
Case key
99003

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 exceedance of the airplane’s critical angle of attack while maneuvering for landing during a simulated power-off approach and landing, which resulted in an aerodynamic stall and loss of control and the flight instructor’s failure to adequately monitor the pilot.

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 46-350P: 40 casesAll aircraft: 9,295 casesProbable cause
Performance/control parameters: angle of attackAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA 46-350P: 6 casesAll aircraft: 990 casesProbable cause
Performance/control parameters: airspeedAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA 46-350P: 15 casesAll aircraft: 1,681 casesProbable cause
Action: delayed actionPersonnel issues › Action/decision · Instructor/check pilotPiper PA 46-350P: 4 casesAll aircraft: 894 casesProbable cause
Attention/monitoring: monitoring other personPersonnel issues › Psychological · Instructor/check pilotPiper PA 46-350P: 2 casesAll aircraft: 200 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

The pilot reported that the purpose of the instructional flight was to practice commercial pilot maneuvers. He and the instructor returned to the airport at the conclusion of the flight and discussed how to conduct a power-off 180° approach and landing. When the airplane was abeam the 1,000-foot markings on the runway, the pilot reduced engine power to idle and started a left turn toward the runway. He stated that he realized the airplane was “probably not going to make the runway” and that the airplane was “not on final course.” He recalled the airplane turning sharply to the left as he pulled up on the control yoke and added right rudder. The pilot did not report any mechanical malfunctions or anomalies with the airplane. A video of the event showed the airplane in a left turn as it descended toward the runway. The airplane’s left bank decreased to a wings-level attitude before the airplane entered a steeper left bank, followed immediately by a right bank as the airplane descended into the ground short of the runway. Both the pilot's description and the video are consistent with the pilot exceeding the airplane’s critical angle of attack while maneuvering toward the runway, resulting in an aerodynamic stall, loss of control, and impact with terrain.

Factual narrative

On February 6, 2019, about 1530 Pacific standard time, a Piper PA 46-350P, N997MA, was substantially damaged when it was involved in an accident near Aurora, Oregon. The private pilot and flight instructor were seriously injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. The pilot reported that the purpose of the flight was to practice commercial pilot maneuvers. After practicing slow flight, chandelles, lazy eights, and eights on pylons, they returned to the airport and discussed how to conduct a practice a power-off 180° landing as they entered the traffic pattern. When the airplane was abeam the 1,000-foot runway markings, the pilot reduced the power to idle and started a left turn toward the runway. He stated that he realized that the airplane was “probably not going to make the runway” and that the airplane was “not on final course.” He recalled the airplane turning sharply to the left as he was pulled up on the control yoke and added right rudder. He could not recall whether he applied power. The pilot did not report any mechanical malfunctions or anomalies with the airplane. A video of the event showed the airplane in a left turn as it descended toward the runway. The airplane’s left bank decreased to a wings-level attitude before the airplane entered a steeper left bank, followed immediately by a right bank as the airplane descended into the ground short of the runway. The airplane’s right wing and fuselage sustained substantial damage.

Aircraft

Registration
N997MA
Reported as
Piper PA46 (350P)
Category
Airplane
Serial number
4636126
Built
1997
Airframe hours
2,670
Engine
Lycoming TIO-540 SER, 310 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 1, 2018
Departed
UAO · Aurora, OR
Destination
UAO · Aurora, OR
Airport
UAO · Aurora State Airport, runway 35, 5,003 × 100 ft, asphalt

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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
64
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine sea, Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, Without waivers/limitations
Last flight review
July 1, 2017
Seat
Left
Restraint
3-point
Flight hours
970 total · 23 in this make and model · 865 as pilot in command · 23 in the last 90 days · 6 in the last 30 days · 0 in the last 24 hours
Role
Flight instructor
Age
70
Injuries
Serious
Certificates
Flight instructor, Commercial
Airplane ratings
Single-engine land, Single-engine sea
Instrument ratings
Airplane
Medical
Class 2, With waivers/limitations
Seat
Right
Restraint
3-point

Weather

Conditions
Visual (VMC) · Day
Wind
Calm
Visibility
10 statute miles
Lowest ceiling
2,900 ft broken
Temperature
37 °F, dew point 27 °F
Altimeter
30.32 inHg
Observed at
UAO

Docket · 2

The files NTSB released with the investigation on November 10, 2021, on NTSB’s docket system: statements, records, photos and specialists’ reports. 3.1 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.