WPR20FA008

NTSB accident investigation · Piper PA 24 · Angel Fire, NM · October 20, 2019

Accident · FatalClass 3 · FieldFinal report
Date
October 20, 2019, 08:45 local (14:45 UTC)
Place
Angel Fire, NM
Injuries
2 fatal
Damage
Substantial damage
Phase of flight
Takeoff
Aircraft
N7742PPiper PA 24
Defining event
Takeoff: Collision during takeoff/land
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 3
NTSB office
Western Pacific Region
Parties
Hartzell Propeller, Lycoming Engines, FAA-FSDO, Piper Aircraft
FAA report
20191020020289A
Case key
100440

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 airplane’s degraded performance due to high-density altitude and gusting wind conditions, which resulted in its inability to maintain altitude during the initial takeoff climb. Contributing to the accident was the pilot’s lack of experience with high altitude flying and his decision to depart in high-density altitude and gusting wind conditions.

Findings · 6

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.

Wind: gustsEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentPiper PA-24: 1 caseAll aircraft: 1,199 cases
Terrain: high elevationEnvironmental issues › Physical environment · Effect on equipmentPiper PA-24: 1 caseAll aircraft: 16 cases
Temp/humidity/pressure: high density altitudeEnvironmental issues › Conditions/weather/phenomena · Effect on equipmentPiper PA-24: 2 casesAll aircraft: 278 casesProbable cause
Performance/control parameters: climb rateAircraft › Aircraft oper/perf/capability · Attain/maintain not possiblePiper PA-24: 1 caseAll aircraft: 265 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 and passenger were departing on a personal flight from the high elevation airport. Friends of the pilot reported that this was his first time flying into the airport and that he wanted to depart to the south and head back toward the airport because of the wind and to gain altitude. An eyewitness who was driving saw the airplane flying from the airport as it appeared to be struggling to remain in flight. The airplane turned to fly over the road and toward the eyewitness, who thought it was preparing to land. As the airplane approached, it pitched up and turned to the west to avoid power lines crossing the road. The airplane impacted trees, a building and terrain, sustaining substantial damage. Several other witnesses saw the airplane as is departed the airport and described the airplane as unstable. A security camera, located along the road, captured the airplane flying wings level with the landing gear extended, over the road about 50 ft above ground level. As the airplane approached the light poles and power lines, the airplane banked right and traveled behind trees and buildings out of view. It is likely that the pilot was maneuvering the airplane to land on the road. The calculated density altitude about the time of the accident was 9,360 ft, which would have reduced the airplane's climb performance. Wind was from the west at 9 knots gusting to 21 knots. After the airplane departed the airport to the south toward rising terrain, the airplane turned east over a road, changing the direction of wind to a tailwind, which would have also reduced the airplane’s climb performance by decreasing the airplane’s airspeed. The airplane was also topped with fuel which likely put the airplane near its maximum allowable weight for takeoff. Given these conditions, it is unlikely that the airplane was capable of clearing the rising terrain on the day of the accident. Postaccident examination of the airframe and engine revealed no anomalies that would have precluded normal operation. In addition, airplane damage signatures, witness accounts, and a video indicated that the engine was producing power at the time of the accident. Medical evidence showed that the pilot had heart disease, which placed him at increased risk of a sudden impairing or incapacitating cardiac event. However, operational evidence (such as the pilot’s maneuvering to avoid obstacles and attempt to navigate to a suitable landing site) is inconsistent with sudden impairment or incapacitation; therefore, it is unlikely that the pilot’s heart disease contributed to the accident.

Factual narrative

The accident airplane, serial number 24-2956, was manufactured in 1961. It was powered by a Lycoming O-360-A1D, reciprocating engine rated at 180-horsepower at 2,700 RPM, serial number 691467, which drove a Hartzell 2-bladed, constant-speed propeller (part number HC-92ZK-8D), serial number 1110L. The airplane’s two fuel tanks have a total capacity of 60 gallons. According to airport personnel, on the morning of the accident flight, the airplane was refueled with about 20 gallons, which filled both tanks. Published manufacturer performance data for takeoff distance exists for altitudes from sea level up to 6,000 ft based on standard temperature and pressure. The expected takeoff ground roll could not be determined for the accident takeoff as the environmental conditions exceeded those used in the calculations provided by the manufacturer when the airplane was manufactured. Approximate weight and balance requirements were calculated and were found to be within the normal operating envelope. According to pilot’s operating handbook’s crosswind component graph, the airplane would have experienced about a 9 knot crosswind and about a 2 knot tailwind. AXX was situated at an elevation of 8,379 ft msl. It was equipped with one runway, designated 17/35, which measured 8,900 ft by 100 ft. Runway 17 had an average uphill gradient of .64% and had a difference of about 57 ft between the runway ends. AXX was not equipped with an air traffic control tower. Signage before entering the runway area, caution about the field elevation and to remind pilots of their airplane’s performance at that elevation. The airport directory describes the airport as in a mountain valley and has rising terrain in all directions, strong gusty crosswinds possible, and high-density altitude probable. On October 20, 2019, about 0845 mountain daylight time, a Piper PA-24, N7742P, was substantially damaged when it was involved in an accident near Angel Fire, New Mexico. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 cross-country flight. According to friends of the pilot who stated they had helped with the refueling and preflight of the accident airplane that morning, this was his first time flying into Angel Fire Airport (AXX), Angel Fire, New Mexico. The pilot stated to his friends that he was going to depart to the south and then head back toward the airport because of the winds and to gain altitude. The pilot started the engine and let it warm up for about 10-15 minutes. The airplane taxied to the departure end of runway 17 where the pilot performed an engine run-up and magneto checks. The pilot’s friends watched as the airplane started its takeoff roll and became airborne a little past halfway down the runway. Shortly thereafter, they saw the airplane’s landing gear retract and soon lost sight of the airplane behind the parallel taxiway, which rises in elevation above the runway. An eyewitness was drivingnorth when she saw the airplane flying south from the airport which was located on the east side of the highway. The airplane was very low and it appeared to be struggling to remain in flight. The airplane turned right to fly over the road and toward the eyewitness, who subsequently drove her vehicle into the ditch alongside the highway. As the airplane was descending, it appeared to the eyewitness that the airplane was preparing to land on the road. The eyewitness noticed a section of power lines that cross the road in front of her location and hoped that the airplane was going avoid hitting them. As the airplane approached the power lines, the airplane pitched up and turned to the west, impacting trees, a building, and the terrain. Several other witnesses saw the airplane as is departed the airport and described the airplane as unstable. A security camera with a southward view, located at a business between the airport and the accident site, captured the airplane flying overhead about 50 ft above ground level, over the adjacent road. The airplane was flying wings level and the landing gear was extended. As the airplane approached the light poles and power lines in the background, the airplane banked right and traveled behind trees and buildings until it went out of view. Another security camera located near the accident site captured the airplane impacting trees and a building, before cartwheeling to the ground in a nose-down attitude. The airplane’s engine was heard producing power in the video. The airplane came to rest in an inverted position and a postaccident fire ensued. Figure 1-Aerial view of the accident site and approximate flight path. The University of New Mexico, Office of the Medical Investigator performed the pilot’s autopsy. According to the autopsy report, the cause of death was blunt trauma and the manner of death was an accident. The autopsy identified moderate-to-severe multivessel coronary artery disease with two coronary artery stents present. There was an area of old heart muscle scarring and microscopic changes consistent with old heart attack. The autopsy, including the remainder of the heart examination, did not identify other significant natural disease. Two laboratories performed toxicological testing of postmortem specimens from the pilot. One laboratory detected amlodipine, metoprolol, and atorvastatin in heart blood and urine, as well as clopidogrel in urine. The other laboratory did not detect any tested-for substances. At 0845 MDT, AXX reported a wind from 270° at 9 knots with gusts to 21 knots, visibility of 10 statute miles or greater, ceiling overcast at 7,000 ft agl, temperature of 5°C and a dew point temperature of -13°C, altimeter setting of 29.87 inches of mercury; remarks: station with a precipitation discriminator, temperature of 5.3°C and dew point temperature of -13.3°C. A weather study using the approximate airport elevation, and temperature, dew point temperature and altimeter setting from AXX,density altitude at 0845 at the surface was calculated to be 9,360 ft msl. The automated weather observing system located at AXX, reports new observations to pilots via very high frequency broadcasts every minute, which will include density altitude if the density altitude is 1,000 ft or more above the highest point of the runway. An Area Forecast Discussion (AFD) was issued by the Albuquerque National Weather Service Weather Forecast Office at 0525 MDT. Presented here is the “Aviation” section of that AFD. Strong W/NW winds will ramp up through the morning peaking in the afternoon as a Pacific cold front passes through the area from west to east. Gusts of 25-35kts will be common for the northern half of the state… Airmen’s Meteorological Information (AIRMET) TANGO advisories for moderate turbulence below FL180 and low level wind shear (LLWS) potential were issued at 0245 MDT and were valid for the accident site at the accident time. At 0845 MDT, about the time of the accident, new AIRMET TANGO advisories were issued for moderate turbulence below FL180, strong surface winds and LLWS potential for areas that included the accident site. The 65-year-old pilot held a commercial pilot certificate with rating for multiengine land, single engine land and instrument airplane. His most recent third-class Federal Aviation Administration (FAA) airman medical certificate was issued on dated March 7, 2019. At that time, he had reported 1,000 total hours of flight experience and 15 flight hours in the last 6 months. The pilot’s logbooks were not located during the investigation. There was no evidence found that showed that the pilot had any mountain flying training or experience. Examination of the accident site revealed that the first identified point of contact were three trees located on the north side of a building. The main wreckage was found inverted and was the furthest in the debris field. The debris field was about 250 ft long and on a directional heading of about 190° magnetic. Flight control cable continuity was established, and all major structural components were found. The wreckage was relocated, and an engine examination was conducted. There was no evidence of in-flight airframe, engine, or flight control malfunction or failure.

Aircraft

Registration
N7742P
Reported as
Piper PA 24 (Undesignat)
Category
Airplane
Serial number
24-2956
Built
1961
Airframe hours
3,651
Engine
Lycoming O&VO-360 SER, reciprocating
Damage
Substantial damage
Fire
On-Ground
Flight
Personal · Part 91
Operator
Schenk Richard J
Registered owner
Schenk Richard J
Airworthiness certificate
Standard, Normal
Last inspection
Annual · December 3, 2018
Departed
AXX · Angel Fire, NM
Destination
GBD · Great Bend, KS
Airport
AXX · Angel Fire, runway 17, 8,900 × 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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
65
Injuries
Fatal
Certificate
Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 3, With waivers/limitations
Seat
Left
Toxicology
Performed
Flight hours
1,000 total

Weather

Conditions
Visual (VMC) · Day
Wind
270° at 9 knots, gusting 21
Visibility
10 statute miles
Lowest ceiling
7,000 ft overcast
Temperature
41 °F, dew point 9 °F
Altimeter
29.87 inHg
Observed at
KAXX, 2 nm away

Docket · 19

The files NTSB released with the investigation on August 25, 2022, on NTSB’s docket system: statements, records, photos and specialists’ reports. 96.0 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.