Saturday, December 16, 2017

Piper PA-28 Cherokee, N6223W, registered to Cherokee Flying Club and operated by the pilot: Fatal accident occurred June 09, 2016 near Wishek Municipal Airport (6L5), McIntosh County, North Dakota

Aviation Accident Final Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Analysis 

The private pilot was flying his aunt and cousin to a location where his cousin could receive urgent dental care. The pilot was a member of the flying club that owned the airplane, and another member of the flying club reported that he thought that the pilot and his passengers were rushing as they prepared to leave. A witness located on the airport ramp saw the airplane take off, climb with a nose-high attitude, turn right, and rapidly pitch down to a nose-low attitude. The airplane was found in a lake 1/2 mile from the airport. Downloaded data from an onboard GPS navigation device were consistent with the observations of the witness and indicated that the airplane began to turn right at 160 ft above ground level with a groundspeed of 48 knots. The right turn continued for 20 seconds during which time the airplane climbed about 40 ft and its groundspeed ranged from 53 to 59 knots. The airplane then rapidly descended into the lake.

The damage to the airplane indicated that it impacted the lake in a near-vertical, nose-down attitude with low forward velocity. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. The GPS data, the witness report, and the damage to the airplane were consistent with the pilot failing to maintain sufficient airspeed during a climbing turn after takeoff, which resulted in the airplane's wing exceeding its critical angle of attack and an aerodynamic stall.

The purpose of the flight was for an urgent medical issue. The pilot's rushed activities before flight, and his actions immediately after takeoff to enter a climbing turn at low altitude without ensuring sufficient airspeed, are consistent with the effects of self-induced pressure. 

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's failure to maintain adequate airspeed during a climbing turn after takeoff, which resulted in the airplane exceeding its critical angle of attack and an aerodynamic stall. Contributing to the accident was the pilot's self-induced pressure to quickly transport his cousin for urgent dental care. 

Findings

Aircraft
Performance/control parameters - Not attained/maintained (Cause)

Personnel issues
Aircraft control - Pilot (Cause)
Motivation/respond to pressure - Pilot (Factor)

Factual Information

History of Flight

Initial climb
Loss of control in flight (Defining event)

Uncontrolled descent
Collision with terr/obj (non-CFIT)

Aaron Nordstrom, 10
 Aaron had no fear in life and believed he could do anything he set his mind to; whether it was defeating his 3.5-year battle with cancer or riding his four-wheeler up a steep hill. “Can’t” was not in his vocabulary. He was strong, brave and daddy’s little helper.

Christine Marie Fandrich
 (September 8, 1977 - June 9, 2016)
 Chris died June 9, 2016 at Wishek, ND in a small plane crash with her son Aaron Nordstrom and her nephew Colbie Fandrich. She was 38 years old.

Colbie Fandrich, 20
At only 20 years old, Colbie wore many hats. He was a locally trained EMT, an adventure seeker of the outdoors, from wakeboarding to fishing to being a part of a ranch rodeo team. But what he loved the most was flying.



The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:
Federal Aviation Administration / Flight Standards District Office; Fargo, North Dakota
Lycoming Engines; Williamsport, Pennsylvania
Piper Aircraft Inc; Vero Beach, Florida

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf

Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms

http://registry.faa.gov/N6223W

Mike Folkerts, investigator for the National Transportation Safety Board, McIntosh County Sheriff Laurie Spitzer and Wishek Fire Chief Dave Just speak at a press conference June 10, 2016 at the Wishek Municipal Airport.


Location: Wishek, ND
Accident Number: CEN16FA212
Date & Time: 06/09/2016, 1521 CDT
Registration: N6223W
Aircraft: PIPER PA 28-140
Aircraft Damage: Substantial
Defining Event: Loss of control in flight
Injuries: 3 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On June 9, 2016, about 1521 central daylight time, a Piper PA-28-140 airplane, N6223W, impacted a lake while departing from Wishek Municipal Airport (6L5), Wishek, North Dakota. The pilot and two passengers were fatally injured, and the airplane was substantially damaged. The airplane was registered to the Cherokee Flying Club and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions existed at the time of the accident. The personal flight departed without a flight plan and was destined for Bismarck Municipal Airport (BIS), Bismarck, North Dakota.

According to the pilot's parents, the pilot was flying his aunt and cousin to Bismarck so that his cousin could receive urgent dental care. The pilot was a member of the flying club that owned the airplane. Another member of the club, who spoke with the pilot about 10 minutes before the airplane's departure, reported that he thought that the pilot and passengers were rushing as they prepared to leave. A witness located on the airport ramp saw the airplane depart on runway 14 and climb out with a nose-high attitude. According to the witness, after entering a right turn, the airplane rapidly pitched down to a nose-low attitude.

Downloaded data from a portable GPS navigation device found in the airplane revealed that the airplane made a right turn after takeoff at 160 ft above ground level and 48 knots groundspeed. The right turn continued for the next 20 seconds during which time the airplane climbed about 30 ft and its groundspeed was between 53 and 59 knots. During the next 8 seconds, the airplane rapidly descended about 200 ft and impacted a lake about 1/2 mile southwest of the airport. 


Colbie Fandrich

Pilot Information

Certificate: Private
Age: 20, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used: Lap Only
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 Without Waivers/Limitations
Last FAA Medical Exam: 07/22/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 11/09/2015
Flight Time: (Estimated) 60 hours (Total, all aircraft), 22 hours (Total, this make and model), 5 hours (Last 90 days, all aircraft), 5 hours (Last 30 days, all aircraft), 0.5 hours (Last 24 hours, all aircraft) 

The pilot, age 20, held a private pilot certificate with an airplane single-engine land rating, which was issued on November 9, 2015. On July 22, 2015, the pilot was issued a third class medical certificate with no restrictions. According to an insurance application dated January 12, 2016, the pilot had accumulated 55 total flight hours of which 17 hours were in the accident airplane. The flying club member who spoke with the pilot before the flight stated that the pilot had flown the airplane a few times since returning from college in mid-May, including a flight on the evening before the accident. The pilot's logbook was not available for review. 



Aircraft and Owner/Operator Information

Aircraft Manufacturer: PIPER
Registration: N6223W
Model/Series: PA 28-140
Aircraft Category: Airplane
Year of Manufacture: 1964
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 28-20264
Landing Gear Type: Tricycle
Seats: 4
Date/Type of Last Inspection: 04/01/2016, Annual
Certified Max Gross Wt.: 2150 lbs
Time Since Last Inspection: 21 Hours
Engines: 1 Reciprocating
Airframe Total Time: 3459 Hours at time of accident
Engine Manufacturer: LYCOMING
ELT: C91  installed, not activated
Engine Model/Series: O-320 SERIES
Registered Owner: On file
Rated Power: 150 hp
Operator: On file
Operating Certificate(s) Held: None 

The airplane was manufactured in 1964 and was equipped with a Lycoming O-320-E3D engine and a Sensenich two-blade, all-metal propeller. On April 1, 2016, the airplane underwent an annual inspection at an airframe total time of 3,459 hours and 1,235 hours since the engine had last been overhauled. The accident occurred about 21 hours after this inspection. The airplane was equipped with a red stall warning light on the instrument panel but was not equipped with a stall warning horn.

The flaps-retracted stall speeds listed in the airplane's flight manual were 64 mph (calibrated airspeed) at 0° of bank and 73 mph (calibrated airspeed) at 40° of bank, which equates to 56 knots at 0° of bank and 64 knots at 40° of bank. These stall speeds were based on a maximum gross weight of 2,150 pounds. At the time of the accident, the airplane's weight was estimated to be about 300 pounds less than maximum gross weight. 



Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: KBIS, 1660 ft msl
Observation Time: 1552 CDT
Distance from Accident Site: 60 Nautical Miles
Direction from Accident Site: 303°
Lowest Cloud Condition: Clear
Temperature/Dew Point: 33°C / 15°C
Lowest Ceiling: None
Visibility:  10 Miles
Wind Speed/Gusts, Direction: 6 knots, 160°
Visibility (RVR):
Altimeter Setting: 29.67 inches Hg
Visibility (RVV):
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Wishek, ND (6L5)
Type of Flight Plan Filed: None
Destination: BISMARCK, ND (BIS)
Type of Clearance: None
Departure Time: 1521 CDT
Type of Airspace: Class G

At 1552, the weather observation station at BIS, located about 60 miles northwest of the accident site, reported the following conditions: wind 160° at 6 knots, 10 miles visibility, clear skies, temperature 33°C, dew point 15°C, and altimeter setting 29.67 inches of mercury. 

Airport Information

Airport: WISHEK MUNI (6L5)
Runway Surface Type: Asphalt
Airport Elevation: 2035 ft
Runway Surface Condition:
Runway Used: 14
IFR Approach: None
Runway Length/Width: 3460 ft / 60 ft
VFR Approach/Landing: None 



Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Substantial
Passenger Injuries: 2 Fatal
Aircraft Fire: None
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 3 Fatal
Latitude, Longitude:  46.244722, -99.544722 (est) 

Examination of the airplane at the accident site revealed that the airplane came to rest in a nose-down attitude in about 4 ft of water. The damage to the airplane was consistent with a near-vertical descent with a low forward velocity at impact. Following recovery from the lake, the airplane and engine were examined in a nearby hangar. Both wings were intact and remained attached to the fuselage by the main wing spars. The main landing gear assemblies were attached to their respective wings, and both wing flaps were retracted.

The flight control surfaces remained attached to their respective airframe surfaces. No anomalies were noted with the flight control system. Stabilator and aileron control continuity were established from the respective controls to the "T" bar chain. Stabilator trim continuity was established from the trim tab to the trim crank handle in the overhead panel, and the stabilator trim barrel indicated a neutral trim setting. Rudder control continuity was established from the rudder to the rudder pedal assembly.

Both fuel tank caps were installed, and both fuel tank vents were found clear of debris. The fuel selector valve was in the right-wing fuel tank position. A functional check of the fuel selector valve, using low pressure air, revealed that the valve was functional. The fuel pump operated normally when hand rotated, and the carburetor was disassembled and no anomalies were noted.

The propeller remained attached to the engine, and the spinner was attached to the spinner bulkhead and crushed aft. The propeller blades were minimally damaged with one blade having minor abrasions on the leading edge of its tip.

The top Champion REM40E sparkplugs were removed from the cylinders. All displayed a normal worn condition when compared to the Champion Aviation Service Manual (AV6-R). After cleaning with compressed air and contact cleaner, both magnetos sparked normally at all leads during rotation.

The four cylinders remained attached to the crankcase. The rocker covers were removed, and no preaccident anomalies were noted with the rockers, rocker shafts, or valve springs. A borescope inspection of the four cylinders revealed no anomalies with the pistons, cylinder barrels, cylinder heads, valves, or valve seats.

The engine exhaust system was found impact damaged; however, the heat muff was intact with no significant cracks or exhaust erosion. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. 

Medical And Pathological Information

On June 10, 2016, the North Dakota Department of Health medical examiner in Bismarck, North Dakota performed an autopsy on the pilot. The cause of death was blunt force injuries with drowning. The FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma performed toxicology tests on the pilot. The results were negative for all tests conducted.

Tests And Research

The portable GPS navigation device found in the airplane, a Garmin Aera 560, was recovered from the accident site and evaluated by the NTSB Recorder Laboratory. For further details, see the GPS Factual Report in the public docket for this investigation.



NTSB Identification: CEN16FA212
14 CFR Part 91: General Aviation
Accident occurred Thursday, June 09, 2016 in Wishek, ND
Aircraft: PIPER PA 28-140, registration: N6223W
Injuries: 3 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On June 9, 2016, about 1527 central daylight time, a Piper PA-28-140 airplane, N6223W, impacted terrain while departing from Wishek Municipal Airport (6L5), Wishek, North Dakota. The pilot and two passengers were fatally injured and the airplane was destroyed. The airplane was registered to and operated by Cherokee Flying Club under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day visual meteorological conditions existed at the time of the accident. The flight departed without a flight plan and was destined for Bismarck Municipal Airport (BIS), Bismarck, North Dakota. 

According to his parents, the pilot was flying his aunt and cousin to Bismarck to obtain dental care for his cousin. A witness located on the airport ramp noticed the airplane depart on Runway 14 and climb out with a nose high attitude. After entering into a right turn, the airplane rapidly pitched down to a nose low attitude. The airplane impacted into a lake about ½ mile southwest of the airport, coming to rest in about four feet of water in a steep, nose low attitude.

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