# NTSB WPR24LA017: Piper PA 46-350P, N509Z, Eastsound, WA, October 13, 2023 - Type: NTSB accident investigation - Classification: Accident · No injuries · Class 4 · Limited · Final report - Date: October 13, 2023, 11:48 local (18:48 UTC) - Place: Eastsound, WA · Orcas Island Airport - Coordinates: 48.708337, -122.91059 - Nearby events: https://openairdocs.org/map.md?lat=48.7083&lon=-122.9106&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Defining event: [Approach-VFR go-around: Aerodynamic stall/spin](https://openairdocs.org/ntsb-events/241) - 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: Federal Aviation Administration - NTSB case key (mKey): 193258 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=WPR24LA017 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/193258/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=193258 - Page: https://openairdocs.org/ntsb/WPR24LA017 ## Probable cause The pilot's unstable approach and improper configuration of the flaps during a go-around which resulted in an aerodynamic stall and subsequent impact with terrain. ## 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 46-350P, 4 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md?model=7104620), [All aircraft, 1,391 cases](https://openairdocs.org/ntsb-findings/02063015/cases.md) - [Performance/control parameters: configuration](https://openairdocs.org/ntsb-findings/01062017): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Piper PA 46-350P, 1 case](https://openairdocs.org/ntsb-findings/01062017/cases.md?model=7104620), [All aircraft, 80 cases](https://openairdocs.org/ntsb-findings/01062017/cases.md) - [Performance/control parameters: descent/approach/glide path](https://openairdocs.org/ntsb-findings/01062040): Aircraft › Aircraft oper/perf/capability · Not attained/maintained; cases with it: [Piper PA 46-350P, 5 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md?model=7104620), [All aircraft, 809 cases](https://openairdocs.org/ntsb-findings/01062040/cases.md) - [Flight control system: tE flap control system](https://openairdocs.org/ntsb-findings/01022750): Aircraft › Aircraft systems · Incorrect use/operation; cases with it: [Piper PA 46-350P, 1 case](https://openairdocs.org/ntsb-findings/01022750/cases.md?model=7104620), [All aircraft, 74 cases](https://openairdocs.org/ntsb-findings/01022750/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Approach-VFR go-around: 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) ## Analysis The pilot reported that during his final approach, about 25 ft above the ground (agl), the airplane’s airspeed was too fast for the remaining available runway. The pilot initiated a go-around and raised the flaps prior to establishing a positive climb rate. Subsequently, the stall indicator warning sounded, and the airplane did not climb. The pilot then lowered the nose and the airplane impacted terrain. The right wing sustained substantial damage. The pilot reported that there were no preaccident mechanical failures or malfunctions with the airplane that would have precluded normal operation. ## Aircraft - Registration: [N509Z](https://openairdocs.org/deregistered/N509Z-2024-09-26), registration cancelled 2024-09-26, S/N 4636726, built 2018 (OpenAirDocs) - Reported make and model: PIPER AIRCRAFT INC PA 46-350P - Registry model: [Piper PA 46-350P](https://openairdocs.org/model/piper-pa-46-350p) (registry code 7104619) (OpenAirDocs) - Registry engine: [Lycoming TIO-540-AE2A](https://openairdocs.org/engine/lycoming-tio-540-ae2a) (registry code 41999, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 4636726 - Year built: 2018 - Airframe hours: 575 - Engines: LYCOMING TIO-540-AE2A 350 horsepower reciprocating - Damage: Substantial damage - Flight: Executive/Corporate, Part 91 - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 17, 2023, 78 hours before - Departed: KYKM, Yakima, WA - Destination: KORS, Eastsound, WA - Airport: ORS, Orcas Island, runway 16, 2,901 × 60 ft, asphalt - Equipment: Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Handheld GPS, Auto-pilot, Onboard weather, Stall warning system, ADS-B ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 48; injuries: none; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 2, with waivers/limitations; last flight review April 4, 2022; seat: left; restraint: 3-point; flight hours: 2,456 total, 659 in this make and model, 2,349 as pilot in command, 44 in the last 90 days, 29 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 5 knots - Visibility: 9 statute miles - Temperature: 54 °F - Altimeter: 29.78 inHg - Observed at: KORS, 0.5 nm away - METAR: METAR KORS 131835Z AUTO 33005KT 9SM CLR 12/ A2978 RMK AO2= ## 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 20231013017209A](https://openairdocs.org/incident/20231013017209A), Oct 13, 2023: Piper Aircraft Inc PA 46-350P, Orcas Island, WA, Substantial damage. Pilot started approach into Orcas Island Airport. Realized the pilot was higher and faster than what he should have been upon reaching runway. Pilot decided to… ## Docket (9 files) The files NTSB released with the investigation on June 6, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=193258. 23.0 MB in all. - Pilot/operator aircraft accident report, NTSB form 6120.1 (item 1, PDF, 9 pages, 12.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16241817&FileExtension=pdf&FileName=WPR24LA017%20N509Z%206120_Redacted-Rel.pdf - Pilot provided G1000 data (item 2, CSV, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17043458&FileExtension=csv&FileName=log_231013_104026_KYKM-Rel.csv - Memorandum for record a�� telephone interview, pilot (item 3, PDF, 1 page, 72 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17019829&FileExtension=pdf&FileName=Memorandum%20of%20Record%20J%20Stenehjem%2010182023%20Phone-Rel.pdf - POH PA-46-350P malibu normal procedures 4-33 go-around (item 4, PDF, 2 pages, 108 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17021374&FileExtension=pdf&FileName=POH%204-33%20Go-around%20PA-46-350P%20Malibu-Rel.pdf - POH 4-33 4-41 go around and stall (item 5, PDF, 2 pages, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17020904&FileExtension=pdf&FileName=POH%204-33%204-41%20Go%20around%20and%20stall-Rel.pdf - Kmz file (item 6, KMZ, 170 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17062067&FileExtension=kmz&FileName=20231013_A65D9E_530236545-Rel.kmz - ADS b xlsx file (item 7, XLSX, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17061861&FileExtension=xlsx&FileName=20231013_A65D9E_530236545_ADSB-Rel.xlsx - Photos (item 8, PDF, 1 page, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16248840&FileExtension=pdf&FileName=WPR24LA017%20Picture-Rel.pdf - Release of aircraft wreckage, NTSB form 6120.15 (item 9, PDF, 1 page, 132 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=17020101&FileExtension=pdf&FileName=Release%20of%20Wreckage%20WPR24LA017-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.