# NTSB WPR19TA085: Piper PA46, N997MA, Aurora, OR, February 6, 2019 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Class 3 · Final report - Date: February 6, 2019, 15:30 local (23:30 UTC) - Place: Aurora, OR - Coordinates: 45.24139, -122.768608 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=45.2414&lon=-122.7686&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR pattern final: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - Highest injury: Serious injuries - Injuries: 2 serious - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration - NTSB case key (mKey): 99003 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR19TA085 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/99003/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=99003 - Page: https://openairdocs.org/ntsb/WPR19TA085 ## 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 NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: aircraft control](https://openairdocs.org/ntsb-findings/02063040): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA 46-350P, 40 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7104620), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Performance/control parameters: angle of attack](https://openairdocs.org/ntsb-findings/01062042): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA 46-350P, 6 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md?model=7104620), [All aircraft, 990 cases](https://openairdocs.org/ntsb-findings/01062042/cases.md) - [Performance/control parameters: airspeed](https://openairdocs.org/ntsb-findings/01062010): Aircraft › Aircraft oper/perf/capability · Not attained/maintained (probable cause); cases with it: [Piper PA 46-350P, 15 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7104620), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Action: delayed action](https://openairdocs.org/ntsb-findings/02041025): Personnel issues › Action/decision · Instructor/check pilot (probable cause); cases with it: [Piper PA 46-350P, 4 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md?model=7104620), [All aircraft, 894 cases](https://openairdocs.org/ntsb-findings/02041025/cases.md) - [Attention/monitoring: monitoring other person](https://openairdocs.org/ntsb-findings/02021535): Personnel issues › Psychological · Instructor/check pilot (probable cause); cases with it: [Piper PA 46-350P, 2 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md?model=7104620), [All aircraft, 200 cases](https://openairdocs.org/ntsb-findings/02021535/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR pattern final: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) (defining event); cases with it: [Piper PA 46-350P, 11 cases](https://openairdocs.org/ntsb-events/241/sequence.md?model=7104620), [All aircraft, 1,529 cases](https://openairdocs.org/ntsb-events/241/sequence.md) - [Approach-VFR pattern final: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA 46-350P, 40 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7104620), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## 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](https://openairdocs.org/aircraft/N997MA), registered now, S/N 4636126, built 1997 (OpenAirDocs) - Reported make and model: Piper PA46 (350P) - Registry model: [Piper PA 46-350P](https://openairdocs.org/model/piper-pa-46-350p) (registry code 7104620) (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: 4636126 - Year built: 1997 - Airframe hours: 2670 - Engines: 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 ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 64; injuries: serious; 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 - Flight instructor; age 70; injuries: serious; 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 ## 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 20190206009959A](https://openairdocs.org/incident/20190206009959A), Feb 6, 2019: Piper PA 46-350P, Aurora, OR, Destroyed. N997MA, a 1997 PA-46-350P, was returning to kuao under VFR after an instructional flight. PIC was [privacy data omitted] holder of commercial pilot certificate… ## Docket (2 files) The files NTSB released with the investigation on November 10, 2021, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=99003. 3.1 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 12 pages, 687 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=12913370&FileExtension=pdf&FileName=REDACTED%206120-1%20Pilot_Operator%20Aircraft%20Accident_Incident%20Report%20-%20Pate-Rel-Rel.pdf - Video of accident - courtesy of airport operations (item 2, AVI, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=8229382&FileExtension=avi&FileName=video%20of%20accident-Rel.avi 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.