# NTSB WPR23LA236: Piper PA-46-310P, N146MS, Springfield, KY, March 24, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Limited · Final report - Date: March 24, 2023, 13:32 local (17:32 UTC) - Place: Springfield, KY - Coordinates: 37.68, -85.01 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=37.6800&lon=-85.0100&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Defining event: [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) - Highest injury: No injuries - Injuries: 4 uninjured - Status: Completed - Report: Approved by Office Director - Investigation class: Class 4 - Basic report with no Prelim publish - NTSB office: Western Pacific Region - Parties: FAA - NTSB case key (mKey): 192427 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR23LA236 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/192427/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=192427 - Page: https://openairdocs.org/ntsb/WPR23LA236 ## Probable cause The pilot’s failure to activate the pitot heat in a timely manner during flight into icing conditions, which resulted in a temporary failure of the flight instruments and a subsequent loss of control. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Use of equip/info: use of equip/system](https://openairdocs.org/ntsb-findings/02063015): Personnel issues › Task performance · Pilot (probable cause); cases with it: [Piper PA-46-310P, 2 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7104605), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Ice/rain protection system: pitot/static anti-ice](https://openairdocs.org/ntsb-findings/01023030): Aircraft › Aircraft systems · Incorrect use/operation (probable cause); cases with it: [Piper PA-46-310P, 1 case](https://openairdocs.org/ntsb-findings/01023030/cases.md?model=7104605), [All aircraft, 4 cases](https://openairdocs.org/ntsb-findings/01023030/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Enroute-cruise: Loss of control in flight](https://openairdocs.org/ntsb-events/240) (defining event); cases with it: [Piper PA-46-310P, 14 cases](https://openairdocs.org/ntsb-events/240/sequence.md?model=7104605), [All aircraft, 5,002 cases](https://openairdocs.org/ntsb-events/240/sequence.md) ## Analysis The pilot reported that light rain and trace clear air icing were forecast along his intended route of flight, and he encountered those conditions during climb out. As the airplane was climbing through 14,000 ft mean sea level (msl) in instrument meteorological conditions, he noticed the airspeed had decreased 10-15 knots. He checked the wings for ice and did not notice any accumulation but activated the pitot heat at that time as a precaution. After the pitot heat was activated the Primary Flight Display (PFD) and Multi-Function Display (MFD) displayed a red X and went black. Subsequently, the autopilot commanded the airplane to descend. The pilot reported that he was unable to read his standby instruments due to the violent shaking of the airplane during the descent. As the airplane emerged into VMC conditions, the airplane was in an unusual attitude. He disconnected the autopilot and was able to recover the airplane to a level attitude. At this time, the PFD and MFD operation returned. An air traffic controller reported to the pilot that he had lost about 5,000 ft in altitude and airspeed had increased over 200 kts. The pilot responded that his avionics were working again, and that the aircraft was operating normally. He continued with the flight and landed without further incident. Substantial damage was discovered to both wings following the flight. The airplane’s “Before Takeoff checklist” calls for the pitot heat to be activated for flight into icing conditions when visible moisture below +5° C, is anticipated or encountered. A Federal Aviation Administration inspector examined the airplane after the event and verified the pitot heat was operational. The circumstances of the accident are consistent with the pilot failing to activate the pitot heat in a timely manner, which allowed ice to accumulate on the pitot static system. The PFD, MFD, and autopilot subsequently malfunctioned and the pilot lost control of the airplane. ## Aircraft - Registration: [N146MS](https://openairdocs.org/aircraft/N146MS), registered now, S/N 46-8408032, built 1984 (OpenAirDocs) - Reported make and model: PIPER PA-46-310P - Registry model: [Piper PA-46-310P](https://openairdocs.org/model/piper-pa-46-310p) (registry code 7104605) (OpenAirDocs) - Registry engine: [Continental TSIO-520 series](https://openairdocs.org/engine/continental-tsio-520-series) (registry code 17040, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 46-8408032 - Year built: 1984 - Engines: Continental TIO-520 310 horsepower reciprocating - Damage: Substantial damage - Flight: Business, Part 91 - Registered owner: Magnolia Partners Aviation LLC - Airworthiness certificate: Standard, Normal - Departed: IOB, Mount Sterling, KY - Destination: ADP, Arkadelphia, AR - Flight plan: IFR - Equipment: Electronic multifunction display, Auto-pilot, ADS-B, Stall warning system, Satellite tracking device, Onboard weather, Handheld GPS, Electronic primary flight display ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 65; injuries: none; commercial; airplane ratings: multi-engine land, single-engine sea; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review May 23, 2023; seat: left; restraint: 3-point; flight hours: 8,700 total, 112 in this make and model, 4,000 as pilot in command, 114 in the last 90 days, 49 in the last 30 days, 3.7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 20° at 7 knots - Visibility: 10 statute miles - Temperature: 81 °F, dew point 52 °F - Altimeter: 30.10 inHg - Observed at: KLEX, 28 nm away - METAR: METAR KLEX 241654Z 02007KT 10SM FEW080 27/11 A3010 RMK AO2 SLP185 T02670111 ## 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 20230324003219A](https://openairdocs.org/incident/20230324003219A), Mar 24, 2023: Piper PA-46-310P, KY, No damage. Approximatly 13:26 EDT on March 24th, 2023 [privacy data omitted], a Piper malibu was on an IFR flight plan from mount sterling/montgomery county airport… ## Docket (4 files) The files NTSB released with the investigation on December 21, 2023, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=192427. 4.3 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 3.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16135187&FileExtension=pdf&FileName=NTSB%206120_Redacted-Rel.pdf - Accident pictures (item 2, PDF, 2 pages, 923 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16134480&FileExtension=pdf&FileName=WPR23LA236%20Accident%20Pictures%20Final%201-Rel.pdf - POH excerpts (item 3, PDF, 3 pages, 38 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16178918&FileExtension=pdf&FileName=POH%20Excerpts%20Final-Rel.pdf - Memorandum for record a�� final (item 4, PDF, 2 pages, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16408895&FileExtension=pdf&FileName=Memorandum%20for%20Record%20Final%201-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.