# NTSB WPR22FA055: Piper PA-31-350, N64BR, Medford, OR, December 6, 2021 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: December 5, 2021, 16:52 local (Dec 6, 2021, 00:52 UTC) - Place: Medford, OR - Coordinates: 42.36066, -122.87706 - Nearby events: https://openairdocs.org/map.md?lat=42.3607&lon=-122.8771&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining event: [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed - Report: Approved by Office Director - Investigation class: Class 3 - NTSB office: Western Pacific Region - Parties: Federal Aviation Administration, Lycoming Engines, Hartzell Propellers, Piper Aircraft - NTSB case key (mKey): 104346 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22FA055 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/104346/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=104346 - Page: https://openairdocs.org/ntsb/WPR22FA055 ## Probable cause The pilot’s failure to maintain aircraft control during the initial climb into clouds due to spatial disorientation, which resulted in an uncontrolled descent and collision with terrain. ## 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-31-350, 13 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7103110), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md) - [Perception/orientation/illusion: spatial disorientation](https://openairdocs.org/ntsb-findings/02022025): Personnel issues › Psychological · Pilot (probable cause); cases with it: [Piper PA-31-350, 2 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md?model=7103110), [All aircraft, 358 cases](https://openairdocs.org/ntsb-findings/02022025/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Other weather encounter](https://openairdocs.org/ntsb-events/400); cases with it: [Piper PA-31-350, 4 cases](https://openairdocs.org/ntsb-events/400/sequence.md?model=7103110), [All aircraft, 1,127 cases](https://openairdocs.org/ntsb-events/400/sequence.md) - [Takeoff: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-31-350, 7 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7103110), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The airplane was departing into instrument meteorological conditions using a standard instrument departure. The takeoff instructions consisted of making a climbing right turn direct to a nondirectional beacon. After departing, the pilot made a radio communication to an air traffic controller asking if he will tell him when to turn. The controller replied that he would not be calling his turn and that the pilot should fly the departure as published making a climbing right turn to overfly the approach end of the runway. The pilot acknowledged the communication, which was his last transmission. The airplane made a 360° turn and descended below the cloud layer. The airplane then climbed back into the cloud layer and made an inverted loop, descending into the ground in a near-vertical attitude. A postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions or failures. Recorded audio of the airplane before the accident was consistent with the engines operating. The signatures on both propellers were consistent with one another and consistent with the engines operating at a similar rpm. The pilot was qualified and recently underwent recurrent training. The reasons the pilot became spatially disoriented could not definitely determined. The pilot left the anti-collision lights on while in the clouds, which may have resulted in him having flicker vertigo. ## Factual narrative According to a publication from the Flight Safety Foundation: “Flicker vertigo is an imbalance in brain-cell activity caused by exposure to the low-frequency flickering (or flashing) of a relatively bright light (such as a rotating beacon; a strobe light; or sunlight seen through a windmilling propeller). Flicker vertigo can result in nausea, dizziness, headache, panic, confusion, and — in rare cases — seizures and loss of consciousness, which could result in a pilot's loss of control of an aircraft” … and “Flicker vertigo also can develop in someone viewing strobe lights or rotating beacons — or their reflections off clouds or water.” The Piper PA-31-350 Navajo Chieftain (Panther conversion), airplane was manufactured in 1977 and was powered by two Lycoming TIO-540-J2B series engines driving two, four-bladed Q-Tip propellers. The airplane was equipped with a Garmin GNS 530W and an autopilot. The last examination was recorded as being completed on December 04, 2021, at a tachometer time of 1,754.4 hours. The invoice stated that an auxiliary hose assembly was replaced the day before the accident following a leak. The mechanic that replaced the fuel line could not recall the position that he left the fuel selector after completing the maintenance. The airplane’s Pilot Operating Handbook stated, “Anti-collision lights should not be operating when flying through cloud, fog or haze, since the reflected light can produce spatial disorientation.” Investigators compiled a comparison of ADS-B data from two airplanes that departed before the accident airplane (at 1507 and 1556) and two that departed after (1734 and 1813). A comparison of flight tracks from the three airplanes that departed runway 14 revealed that the accident airplane had started its right turn earlier than the other three airplanes, and the radius of its turn was tighter than the other three airplanes. ( Figure 4 below). Figure 4: Other Departures Flight Paths Before and After the Accident Flight On December 05, 2021, at 1652, a Piper PA-31-350 Navajo Chieftain airplane, N64BR, was substantially damaged when it was involved in an accident in Medford, Oregon. The pilot and passenger were fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight. The pilot and passenger made a flight on November 24 from the airplane’s home airport in Fallon, Nevada, to Medford. After landing, the pilot noticed the airplane was leaking a large amount of fuel from the right wing root. The pilot arranged to make the necessary repairs with a fixed based operator (FBO) at the airport and drove a rental car back home to Nevada. On December 4, a mechanic at the FBO notified the pilot that the maintenance to the airplane was completed. The pilot responded that he would plan to get to the airport about 1430 the following day (on the day of the accident). The pilot and passenger drove to Medford arriving about 1600. The exact radio communication times could not beconfirmed for the accident flight. The pilot received an instrument flight rules (IFR) clearance and was issued the BRUTE7 departure procedure with the LANKS transition. The published BRUTE SEVEN Standard Instrument Departure (SID) with a takeoff from runway 14 consisted of a “climbing right turn direct MEF [Medford] NDB [nondirectional beacon],” and continue to the BRUTE intersection on a bearing of 066°. After receiving the clearance, the controller informed the pilot the overcast layer base was at 200 ft above ground level (agl) the tops of the layer was at 2,500 ft. After the airplane departed the pilot made a radio communication to the controller asking “will you be calling my turn for the BRUTE7?” The controller replied that he would not be calling his turn and that the pilot should fly the departure as published making a climbing right turn to overfly the approach end of runway 14 before proceeding to the BRUTE intersection (Figure 1 below). The pilot acknowledged the communication, which was his last transmission. Several seconds later, the controller stated that he was receiving a low-altitude alert that the airplane’s altitude was showing 1,700 ft. He made several attempts to reach the pilot with no response. Figure 1: The Airplane’s Flight Track Overlayed a Visual Depiction of the BRUTE7 Departure The radar and automatic dependent surveillance-broadcast (ADS-B) information indicated that the airplane arrived in the run-up area for runway 14 about 1643 and then continued onto the runway about 6 minutes thereafter. The airplane departed about 1649:30 and, after crossing over the south end of the runway, it climbed to about 1,550 ft mean sea level, equivalent to 200 ft agl (Figure 2 below). The airplane then began a gradual right turn and climbed to 1,950 ft, maintaining an airspeed between 120-130 kts. As the airplane turn continued to the north, the altitude momentarily decreased to 1,650 ft (about 350 ft agl) with the airspeed increasing to 160 kts. Thereafter, the airplane then increased the bank angle and made a 360-degree turn, initially climbing to 2,050 ft. At the completion of the turn, the airplane descended to 1,350 ft, consistent with it maneuvering below the cloud layer. The airspeed increased to about 160 kts and several seconds later, the airplane climbed to 2,250 ft with the derived airspeed showing below 15 kts. Six seconds later was the last radar return, located about 990 ft north-northwest of the accident site. Figure 2: The Airplane’s ADS-B Flight Track Video footage was obtained from several fixed security cameras on buildings around the accident site. A review of the footage revealed that the airplane descended below the cloud layer and then climbed back up. About 16 seconds thereafter, the airplane is seen descending in a near-vertical attitude (Figure 3 below). The airplane’s position and strobe light appeared to be illuminated throughout the video. Figure 3: Excerpts of Security Camera Footage Video footagerevealed that the airplane disappeared into a cloud layer and then reappeared immediately before the accident. Automated 5-minute observations were generated by an Automated Surface Observation System (ASOS) at the Medford Airport. The 5-minute observation generated at 1650 included wind calm; visibility of 3 statute miles; mist; an overcast cloud layer at 200 feet. It recorded the temperature at 39 degrees Fahrenheit; dew point 39 degrees Fahrenheit and an altimeter setting of 30.39 inHg. High-Resolution Rapid Refresh (HRRR) model sounding for near the accident site at 1700 indicated cloud tops for the cloud layer nearest the surface around MFR was about 2,200 to 2,500 feet above mean sea level. The pilot had previously owned a PA-31-350 and purchased the accident airplane in 2013. According to his electronic logbooks he had amassed about 1,520 hours in a PA-31-350 of which 273 hours was in actual instrument meteorological conditions. The logbooks indicated that the pilot had departed from Medford in August 2018 and 2019 by way of the JACKSON1 and EAGLE6 departure procedures, respectively. In early November 2021 the pilot went to recurrent SIMCOM training. The training consisted of 4 flight hours; 2 hours of simulated IMC, both of which is in the same make and model. During the exchange of the clearance instructions on the accident flight, the pilot requested the controller read back the departure procedure and transition phonetically. The pilot’s family and a business associate stated this was very normal for the pilot and he would often have people clarify names and instructions. The National Transportation Safety Board’s Performance Division reviewed the audio from recorded videos. A performance engineer stated that the engine speeds were estimated retrospectively through spectral analysis of sound recorded by a camera on a nearby commercial building. This analysis revealed that the estimated engine speed remained consistent within the range of 2,500±100 rpm throughout the time before the accident, consistent with normal operation. From the sound analysis alone, it was not possible to ascertain whether the recorded sound originated from both engines operating at the same speed or from a single engine. The accident site was adjacent to the garage bays of an automobile dealership located about 2,800 ft west-southwest from the departure end of runway 14. A majority of the wreckage had been consumed by fire and sustained major crush deformation. Various items in the cockpit were not burned, including numerous paper sectionals and IFR charts, of which there were several current departure procedure plates for the Medford Airport. Investigators could not completely confirm control continuity because of the impact and thermal damage. All the propeller blades on both engines exhibited chordwise scoring, leading edge chips, and were twisted and bent. The signatures on both propellers were consistent with one another and consistent with the enginesoperating at a similar rpm. The fuel caps were found secure in the wings. In the wing root area of the right wing, the fuel system components had sustained damage from both impact and thermal effects. The fuel selector valve was found positioned to the outboard tank, and the firewall shutoff valve was found in the open position. Within the wing root area of the left wing, the fuel system components had suffered damage from both impact and thermal effects. The fuel selector valve was located near the outboard tank; the firewall shutoff valve was found in the closed position, and the cross-feed valve was open. The fuel selector in the cockpit was thermally damaged and the positions could not be determined. It is unknown if the positions of the fuel selector valves were positioned in that way prior to impact or why the pilot would have configured the selectors in that manner. A postaccident examination of the airplane revealed no evidence of preimpact mechanical malfunctions or failures. ## Aircraft - Registration: [N64BR](https://openairdocs.org/deregistered/N64BR-2023-03-04), registration cancelled 2023-03-04, S/N 31-7752124, built 1977 (OpenAirDocs) - Reported make and model: PIPER PA-31-350 - Registry model: [Piper PA-31-350](https://openairdocs.org/model/piper-pa-31-350) (registry code 7103110) (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: 31-7752124 - Year built: 1977 - Airframe hours: 8809 - Engines: Lycoming TIO-540-J2BD reciprocating; Lycoming TIO-540-J2B reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, August 18, 2021, 2 hours before - Destination: FLX, Fallon, NV - Flight plan: IFR - Airport: MFR, Rogue Valley Intl - Medford, runway 14, 8,800 × 150 ft, asphalt - Equipment: Stall warning system, Auto-pilot, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 69; injuries: fatal; commercial; airplane ratings: single-engine sea, single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review November 4, 2021; seat: left; restraint: 4-point; toxicology performed; flight hours: 2,167 total, 1,520 in this make and model, 2,089 as pilot in command, 2 in the last 30 days, 0 in the last 24 hours ## Weather - Conditions: Instrument (IMC), Day - Wind: calm - Lowest ceiling: 200 ft overcast - Temperature: 39 °F, dew point 39 °F - Altimeter: 30.39 inHg - Observed at: KMFR, 1 nm away - METAR: KMFR 060055Z 00000KT 35M BR OVC0022 04/04 A3039 910 I 100 -100 000/00 RMK AO2 T00390039 ## 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 20211205020619A](https://openairdocs.org/incident/20211205020619A), Dec 5, 2021: Piper PA-31-350, Medford, OR, Destroyed, 2 fatal. Aircraft departed Medford airport at about 1550 local time, the pilot initially querried tower about when to start the right turn on the IFR departure (SID).… ## Docket (14 files) The files NTSB released with the investigation on December 14, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=104346. 1.2 GB in all. - Investigation supplemental materials (item 1, PDF, 26 pages, 26 photos, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16228345&FileExtension=pdf&FileName=Z%20-%20Attachment%201%20-%20Investigation%20Supplement-Rel.pdf - Sound spectrum study (item 2, PDF, 7 pages, 774 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15712514&FileExtension=pdf&FileName=Medford_Sound_Spectrum_Study_final-Rel.pdf - Tower communications (item 3, MP3, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16138813&FileExtension=mp3&FileName=KMFR-Twr-Dec-06-2021-0030Z-Rel.mp3 - Records of conversation (item 4, PDF, 2 pages, 90 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16228467&FileExtension=pdf&FileName=Z-%20Attachment%2004-%20Records%20of%20Conversation-Rel.pdf - Pilot's recent training records (item 5, PDF, 6 pages, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16178618&FileExtension=pdf&FileName=Z%20-%20Attachment%205%20-%20Pilot%20Recent%20Training%20Records_Redacted-Rel.pdf - ADS-B tabular data (item 6, CSV, 100 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16178864&FileExtension=csv&FileName=Z%20-%20Attachment%2007%20Tabular%20ADSB%20Data-Rel.csv - ADS-B google earth file (item 7, KMZ, 7 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16179132&FileExtension=kmz&FileName=Z%20-%20Attachment%2008%20-%20ADSB%20google%20earth%20file-Rel.kmz - ADS-B medford flights (before and after the accident) (item 8, PDF, 6 pages, 328 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16179152&FileExtension=pdf&FileName=Z-%20Attachment%2003%20-%20Flights%20from%20Medford-Rel.pdf - Statement of party representatives to NTSB investigation (item 9, PDF, 3 pages, 998 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16178628&FileExtension=pdf&FileName=Z%20-%20Attachment%2009%20-%20Party%20Forms_Redacted-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 10, PDF, 1 page, 246 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16179226&FileExtension=pdf&FileName=Z%20-%20Attachment%2010%20-%20Wreckage%20Release_Redacted-Rel.pdf - Toxicological report (item 11, PDF, 1 page, 310 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16178638&FileExtension=pdf&FileName=Z%20-%20Attachment%2013%20-%20Tox%20-%20redacted_Redacted-Rel.pdf - Flicker vertigo (item 12, PDF, 3 pages, 91 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16228734&FileExtension=pdf&FileName=Z-%20Attachment%2010-%20Flicker%20Vertigo-Rel.pdf - Security videos (item 13, ZIP, 1.1 GB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16415979&FileExtension=zip&FileName=Videos%20for%20docket-Rel.zip - Autopsy memorandum (item 14, PDF, 1 page, 110 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16178884&FileExtension=pdf&FileName=Z%20-%20Attachment%2013%20-%20Autopsy%20Form-Rel.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.