# NTSB WPR22FA264: Piper PA-28-235, N8542W, Seguin, TX, July 22, 2022 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 3 · Field · Final report - Date: July 22, 2022, 18:45 local (23:45 UTC) - Place: Seguin, TX - Coordinates: 29.502565, -97.991575 - Nearby events: https://openairdocs.org/map.md?lat=29.5026&lon=-97.9916&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Defining event: [Maneuvering: 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: FAA-FSDO, Piper Aircraft, Textron Lycoming - NTSB case key (mKey): 105551 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR22FA264 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/105551/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=105551 - Page: https://openairdocs.org/ntsb/WPR22FA264 ## Probable cause The pilot’s failure to maintain adequate airspeed while maneuvering at a low altitude after being distracted when the engine cowling opened during flight, which led to a loss of control and subsequent impact with terrain. Contributing to the accident was the failure of the pilot to conduct an adequate preflight inspection. ## 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-28-235, 28 cases](https://openairdocs.org/ntsb-findings/02063040/cases.md?model=7102810), [All aircraft, 9,295 cases](https://openairdocs.org/ntsb-findings/02063040/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-28-235, 3 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md?model=7102810), [All aircraft, 1,681 cases](https://openairdocs.org/ntsb-findings/01062010/cases.md) - [Aircraft](https://openairdocs.org/ntsb-findings/01030000): Aircraft › Aircraft structures · Inadequate inspection (probable cause); cases with it: [Piper PA-28-235, 1 case](https://openairdocs.org/ntsb-findings/01030000/cases.md?model=7102810), [All aircraft, 72 cases](https://openairdocs.org/ntsb-findings/01030000/cases.md) - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · Pilot (probable cause); cases with it: [Piper PA-28-235, 2 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=7102810), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md) - [Inspection: preflight inspection](https://openairdocs.org/ntsb-findings/02061510): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-28-235, 3 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md?model=7102810), [All aircraft, 551 cases](https://openairdocs.org/ntsb-findings/02061510/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Maneuvering: Part(s) separation from AC](https://openairdocs.org/ntsb-events/338); cases with it: [Piper PA-28-235, 2 cases](https://openairdocs.org/ntsb-events/338/sequence.md?model=7102810), [All aircraft, 563 cases](https://openairdocs.org/ntsb-events/338/sequence.md) - [Maneuvering: Miscellaneous/other](https://openairdocs.org/ntsb-events/900); cases with it: [Piper PA-28-235, 2 cases](https://openairdocs.org/ntsb-events/900/sequence.md?model=7102810), [All aircraft, 1,556 cases](https://openairdocs.org/ntsb-events/900/sequence.md) - [Maneuvering: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-28-235, 11 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7102810), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) - [Maneuvering: Collision with terr/obj (non-CFIT) ](https://openairdocs.org/ntsb-events/470); cases with it: [Piper PA-28-235, 35 cases](https://openairdocs.org/ntsb-events/470/sequence.md?model=7102810), [All aircraft, 10,189 cases](https://openairdocs.org/ntsb-events/470/sequence.md) ## Analysis The pilot departed from a grass strip for a personal cross-country flight with a passenger. Radar data and the location of the accident site indicate the airplane made a left turn after takeoff and descended into trees, coming to rest about ¼ mile from the airport. The data also showed the airplane’s airspeed decreased after takeoff. The airplane was destroyed by impact forces and postimpact fire. The day before the accident flight, a resident of the airpark reported that the accident airplane had stopped near their residence located near the departure end of runway 14. The pilot had said to the resident that his cowling had opened and that he needed to secure it before taking off. The airplane departed a few minutes later and returned to the airport about 45 minutes later. On the day of the accident, the passenger reported to a friend during a video chat that the pilot had trouble starting the engine before the flight and the friend could see that the engine cowling was open. In addition, photos of the airplane taken during its takeoff roll showed that the right aft edge of the engine cowling was not flush with the fuselage. Given the recurring problem with the cowling latch, it is likely the latch was not properly secured during the preflight, which allowed it to open during the flight. The pilot likely became distracted with the opened engine cowling, which then led to a loss of control inflight. Toxicology testing revealed that the pilot had used cannabis, but whether he was experiencing effects of the drug at the time of the accident could not be determined. The potentially sedating antihistamine cetirizine was also detected in the pilot, but testing was unable to determine if it was at therapeutic levels and therefore more likely to cause any side effects. Thus, this investigation was unable to determine if effects from the pilot’s use of cannabis and cetirizine were a factor in this accident. ## Factual narrative On July 22, 2022, about 1845 central daylight time, a Piper PA-28-235 airplane, N8542W, was destroyed when it was involved in an accident near Seguin, Texas. The pilot and passenger were fatally injured. The airplane was operated by the pilot as a Title 14 Code of Federal Regulations Part 91 personal cross-country flight. The accident flight departed Elm Creek Airpark (0TX6), Seguin, Texas, with a reported destination of Natchitoches Regional Airport (IER), Natchitoches, Louisiana. Radar track data revealed a track consistent with the accident airplane departing runway 14 at 0TX6 and then entering a left turn. The accident site is about 1/4 mile east of 0TX6 and about 1,000 ft east of the last radar hit. Airspeed data showed a decreasing airspeed from 64 knots (ground speed) to 54 knots at the last radar hit. Altitude could not be determined from the target data available. The airplane struck trees and impacted terrain shortly after the left turn, after which a postimpact fire ensued. A friend of the passenger reported that he was in contact with the passenger via a video call before the airplane departed on the evening of the accident flight. The passenger stated that they were having maintenance issues and that the pilot could not get the engine started. During the video conversation, the friend could see that the engine cowling was openNo record of conversation in the docket regarding this conversation between the friend and the passenger. The photo taken by the passenger is also not in the docket. . The exact maintenance issues with the airplane were not discussed. A photo was also taken by the passenger that showed the right side of the airplane, with the pilot on the wing near the open airplane entry door. Additionally, the photo showed that the engine cowling’s right side aft latch appeared not flush with the cowling and the aft edge of the cowling was not flush with the fuselage. Shortly after, another photo of the airplane was captured by a local resident as it crossed in front of his hangar, about 400 ft down runway 14 after it started its departure roll. The photo shows that the right-side upper cowling appears as if it was not secured. The day before the accident flight, a resident of the airpark reported that the accident airplane had stopped near their residence located near the departure end of runway 14. The pilot had said to the resident that his cowling had opened and that he needed to secure it before taking off. The airplane departed a few minutes later and returned to the airport about 45 minutes later. Examination of the accident site revealed that a postaccident fire occurred consuming some of the wreckage. All major structural components of the airplane were located. The upper engine cowling and portions of the lower cowling were located furthest in the debris field. The four cowling latches and fasteners remained attached to the upper cowling. The left cowling latch and fasteners remained attached to the receiver ends ofthe thermally damaged sections of the lower cowling. The right cowling latch and fasteners were intact and not attached to their corresponding receiver ends on the lower cowling. The aft latch assembly was bent. The right lower cowling fastener receivers were not found during the examination. Postaccident examination of the airframe and engine revealed no evidence of any preimpact mechanical malfunctions or failures that would have precluded normal operation. Toxicology testing performed at the Federal Aviation Administration Forensic Sciences Laboratory found Tetrahydrocannabinol (THC) was detected in the pilot. 11-hydroxy-THC (11-OH-THC) was also detected in blood and urine, but not in his lung tissue. Carboxy-delta-9-THC (THC-COOH) was detected in the pilot’s lung tissue and in his urine. The antihistamine cetirizine was detected in the pilot’s blood, urine and in his liver tissue. The generally non-impairing substances acetaminophen, atorvastatin, sildenafil, desmethylsildenafil, loratadine, and desloratadine were detected in the pilot’s urine and/or liver tissue; acetaminophen was also detected in his chest blood. ## Aircraft - Registration: [N8542W](https://openairdocs.org/aircraft/N8542W), registered now, S/N 28-10043, built 1963 (OpenAirDocs) - Reported make and model: PIPER PA-28-235 - Registry model: [Piper PA-28-235](https://openairdocs.org/model/piper-pa-28-235) (registry code 7102810) (OpenAirDocs) - Registry engine: [Lycoming 0-540 series](https://openairdocs.org/engine/lycoming-0-540-series) (registry code 41532, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-10043 - Year built: 1963 - Engines: LYCOMING O-540 SERIES 250 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Airworthiness certificate: Standard, Normal - Destination: IER, Natchitoches, LA - Airport: 0TX6, Elm Creek Airpark, runway 14, 1,925 × 75 ft, grass/turf - Equipment: Unknown ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 66; injuries: fatal; private; airplane ratings: single-engine land; medical: class 3, with waivers/limitations; seat: left; flight hours: 315 total ## Weather - Conditions: Visual (VMC), Day - Wind: 150° at 13 knots - Visibility: 10 statute miles - Temperature: 99 °F, dew point 61 °F - Altimeter: 29.89 inHg - Icing: Unknown - Turbulence: Unknown - Observed at: KBAZ, 13 nm away - METAR: KBAZ 222351Z AUTO 15013KT 10SM FEW085 37/16 A2989 RMK AO2 SLP112 T03670161 10389 20344 56016 ## 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 20220722012939A](https://openairdocs.org/incident/20220722012939A), Jul 22, 2022: Piper PA-28-235, Seguin, TX, Destroyed, 2 fatal. On July 22, 2022, around 1845 local/central time, Piper PA-28-235, [privacy data omitted] was destroyed shortly after takeoff, departing from Elm Creek Airpark… ## Other investigations on N8542W (1) 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. - [NTSB CHI71DGG11](https://openairdocs.org/ntsb/CHI71DGG11), Sep 6, 1970: Piper PA-28 (N8542W), Columbus Grv, OH, substantial damage ## Docket (12 files) The files NTSB released with the investigation on April 25, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=105551. 6.1 MB in all. - Record of conversation-angler (item 1, PDF, 2 pages, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16750089&FileExtension=pdf&FileName=Record%20of%20Conversation-Angler-Rel.pdf - Record of conversation-engram (item 2, PDF, 1 page, 153 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16991003&FileExtension=pdf&FileName=Record%20of%20Conversation-Engram_Redacted-Rel.pdf - Record of conversation-anonymous caller (item 3, PDF, 1 page, 152 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16991108&FileExtension=pdf&FileName=Record%20of%20Conversation-Anonymous%20Caller_Redacted-Rel.pdf - NTSB accident site and wreckage examination summary (item 4, PDF, 11 pages, 9 photos, 2.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16749491&FileExtension=pdf&FileName=WPR22FA264%20Accident%20Site%20and%20Wreckage%20Examination%20Summary-Rel.pdf - Ov radar track (item 5, CSV, 151 B): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16797519&FileExtension=csv&FileName=WPR22FA264%20-%20OV%20Track%20Data-Rel.csv - Photo array-google earth images (item 6, PDF, 4 pages, 416 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16750338&FileExtension=pdf&FileName=Photo%20Array-GE%20Images-Rel.pdf - Photo array-ntsb onsite photos (item 7, PDF, 8 pages, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16750099&FileExtension=pdf&FileName=Photo%20Array-NTSB%20Onsite-Rel.pdf - Toxicology report-pilot (item 8, PDF, 2 pages, 316 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16749821&FileExtension=pdf&FileName=Tox%20Report_Redacted-Rel.pdf - Medical factual (item 9, PDF, 6 pages, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15391867&FileExtension=pdf&FileName=WPR22FA264_Sequin_TX_Medical_Factual_FINAL_042723-Rel.pdf - Electronic device - specialist's factual report (item 10, PDF, 4 pages, 421 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=14941342&FileExtension=pdf&FileName=Electronic%20Device%20-%20Specialist%27s%20Factual%20Report-WPR22FA264-Rel.pdf - Statement of party representatives to NTSB investigation-lycoming (item 11, PDF, 1 page, 176 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16749718&FileExtension=pdf&FileName=N8542W%20Lyc%20party%20form_Redacted-Rel.pdf - Statement of party representatives to NTSB investigation-piper (item 12, PDF, 1 page, 231 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16749811&FileExtension=pdf&FileName=NTSB%20Party%20Form%20-%20WPR22FA264%20-%20Piper_Redacted-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.