National Transportation Safety Board
Aviation Accident Final Report

 

 

Location:

Norfolk, NE

Accident Number:

CEN13FA241

Date & Time:

04/27/2013, 1959 CDT

Registration:

N3970T

Aircraft:

PIPER PA-28R-180

Aircraft Damage:

Substantial

Defining Event:

Loss of control in flight

Injuries:

2 Fatal

Flight Conducted Under:

Part 91: General Aviation - Personal

Analysis

Two witnesses reported seeing an airplane matching the description of the accident airplane flying in the area of the departure airport at very low altitudes about 90 minutes before the accident flight. One witness described the flight profile as similar to "crop-duster type operations, with multiple low-altitude passes." Another witness reported that the airplane departed the airport and climbed to about 1,000 feet and then made a gradual eastbound descent to a low altitude and out of sight. He reported that the airplane reappeared in a very steep left bank and then descended out of sight again. About 3 miles east of the airport, the airplane impacted a 20-foot-high power line, which resulted in the vertical stabilizer separating from the top of the fuselage and the airplane becoming uncontrollable until it impacted terrain. Examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. A parallel set of high-tension power lines with large support poles was located about 1/2 mile east of the impacted power line. As the pilot flew the airplane at a low altitude eastbound, the high-tension power lines likely visually aligned (that is, came within the same line of sight) with the impacted power line. Therefore, it is likely that the pilot was focused on the more prominent high-tension power lines and did not observe the impacted power line.

Probable Cause and Findings

The National Transportation Safety Board determines the probable cause(s) of this accident to be:
The pilot's decision to fly at a low altitude and his subsequent failure to see and avoid power lines.

Findings

Personnel issues

Decision making/judgment - Pilot (Cause)

Monitoring environment - Pilot (Cause)

Environmental issues

Wire - Awareness of condition (Cause)

Factual Information

HISTORY OF FLIGHT

On April 27, 2013, at 1959 central daylight time, a Piper PA-28R-180 airplane, N3970T, was substantially damaged during a wire strike and subsequent ground impact near Norfolk, Nebraska. Both occupants, the private pilot and passenger, were fatally injured. The airplane was registered to Pro-Flite Incorporated and was operating under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Visual meteorological conditions prevailed and a flight plan was not filed. The flight departed from Norfolk Regional Airport (OFK), Norfolk, Nebraska at 1957.

Multiple witnesses who were piloting radio controlled airplanes on the south end of the airport saw the accident airplane takeoff from Runway 14 at OFK. After climbing to about 1,000 feet above ground level (AGL), the airplane began a steady descent eastbound to a low altitude and out of sight. Seconds later, the airplane reappeared in a steep left bank and then descended out of sight again.

Previous to the accident flight, the pilot and passenger departed Millard Airport (MLE), Omaha, Nebraska, at 1801 for their flight into OFK. About 1830, two witnesses noticed an airplane similar in type, color, and design to the accident plane flying at low altitude about 6 miles southeast of OFK. The first witness noticed this airplane flying about 100 feet AGL, banking left and right to follow a river basin. From a different location, the second witness characterized the airplane's maneuvers as similar to crop duster operations, with multiple low altitude passes about 15 to 20 feet AGL.

PERSONNEL INFORMATION

The pilot, age 26, held a private pilot certificate with an airplane single-engine land and instrument ratings. On March 25, 2010, the pilot was issued a Class 1 limited medical certificate, which required corrective lenses be worn. A review of the pilot's flight logbook indicated that he had logged 212 hours total time, with 40 hours in the make and model of the accident airplane. He had successfully completed the requirements of a flight review on September 25, 2012.

AIRCRAFT INFORMATION

The accident airplane, a Piper PA28R-180 (serial number 28R-30317) was manufactured in 1977. It was registered with the Federal Aviation Administration (FAA) on a standard airworthiness certificate for normal operations. The airplane showed a total time of 9,937 hours as of the last annual inspection, which was completed on January 17, 2013. The airplane was equipped with a Lycoming IO-360-B1E engine (serial number L29830-51E). As of the last annual inspection, the engine had accumulated a total of 5,629 hours, with 1,449 hours since last major overhaul.

METEOROLOGICAL INFORMATION

The weather observing station at OFK reported the following conditions at 1956: wind 170 degrees at 9 knots, visibility 10 miles, clear skies, temperature 21 degrees Celsius, dew point 3 degrees Celsius, altimeter setting 29.89.

WRECKAGE AND IMPACT INFORMATION

The wreckage came to rest upright against a line of trees bordering a farm field. The fuselage with the right wing attached was found lying against trees. The left wing remained partially attached by control cables. The engine and its mount were attached to the firewall. The propeller and spinner were separated and laying approximately 8 feet in front of the nose of the airplane.

A severed, 20-foot high power line/wire was located about 1,418 feet from the impact site. The power line ran parallel to a north-south gravel road. A debris path, which included the rotating beacon lens from the top of the vertical stabilizer, was on a heading of 093 degrees from the wire strike. The heading from the wire strike to the wreckage site was 060 degrees, with a line of trees about 50 feet high separating the wire strike and the wreckage site.

The airplane's windshield, top of the fuselage, and leading edge of the vertical stabilizer indicated damage consistent with a wire strike. The vertical stabilizer was found separated from the top of the fuselage. Both the forward and aft fin to fuselage attach bracket rivets were sheared.

The engine power levers (throttle, prop, mixture), were in the mid-travel positions. The horizontal stabilizer trim indicator was in the full nose down position. Flight control continuity was confirmed to all flight control surfaces.

Fuel was observed at all fuel system components and fuel carrying lines were intact with no leaks. All fuel system components were secure on their mounts. During disassembly, no defects or contaminants were observed. The fuel injector nozzles were removed and examined, with no obstructions observed. The engine driven diaphragm fuel pump was removed from its respective mount and discharged fuel when actuated by hand. Spark plugs were observed to have a color consistent with normal combustion, when compared to the Champion Spark Plug Wear Guide.

Both magnetos were secure on their respective mounts. The left magneto was impulsed and furnished spark at all outlet points. The right magneto was rotated by hand and no spark was furnished. During follow on testing, the right magneto was spun using a socket and a spark was observed at all outlet points.

All engine cylinders were visually inspected using a lighted bore scope, with no anomalies noted. The engine pistons displayed a normal carbon deposit on their tops, and the intake and exhaust valves were unremarkable. A turning tool was inserted into the vacuum pump drive pad and the engine was rotated by hand. Thumb suction and compression was obtained at all cylinders and valve train and crankshaft continuity was observed. All accessory gears were observed rotating.

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 April 29, 2013, an autopsy was performed on the pilot by a forensics pathologist at the Douglas County Morgue, as authorized by the Madison County Attorney. The cause of death was attributed to blunt force injuries. The FAA's Civil Aeromedical Institute in Oklahoma City, Oklahoma, performed toxicology tests on the pilot. No carbon monoxide, ethanol, or drugs were detected in the blood.

TESTS AND RESEARCH

About 1/2 mile east of the impacted power line/wire was a set of high tension power lines, also oriented in a north-south direction. From a position west of the impacted power line, the high tension power lines visually align (same line of sight) with the impacted power line. Additionally, the much larger support poles and lines of the high tension power lines were more visually prominent than the impacted power line.

 

History of Flight

Maneuvering-low-alt flying

Low altitude operation/event

Loss of control in flight (Defining event)

 

 

Pilot Information

Certificate:

Private

Age:

26, Male

Airplane Rating(s):

Single-engine Land

Seat Occupied:

Left

Other Aircraft Rating(s):

None

Restraint Used:

Seatbelt

Instrument Rating(s):

Airplane

Second Pilot Present:

No

Instructor Rating(s):

None

Toxicology Performed:

Yes

Medical Certification:

Class 1 With Waivers/Limitations

Last FAA Medical Exam:

03/25/2010

Occupational Pilot:

No

Last Flight Review or Equivalent:

09/25/2012

Flight Time:

(Estimated) 212 hours (Total, all aircraft), 40 hours (Total, this make and model), 171 hours (Pilot In Command, all aircraft), 41 hours (Last 90 days, all aircraft), 14 hours (Last 30 days, all aircraft)

 

 

Aircraft and Owner/Operator Information

Aircraft Make:

PIPER

Registration:

N3970T

Model/Series:

PA-28R-180

Aircraft Category:

Airplane

Year of Manufacture:

 

Amateur Built:

No

Airworthiness Certificate:

Normal

Serial Number:

28R-30317

Landing Gear Type:

Retractable - Tricycle

Seats:

4

Date/Type of Last Inspection:

01/17/2013, Annual

Certified Max Gross Wt.:

2500 lbs

Time Since Last Inspection:

 

Engines:

1 Reciprocating

Airframe Total Time:

9937 Hours as of last inspection

Engine Manufacturer:

LYCOMING

ELT:

C91 installed, not activated

Engine Model/Series:

I0360 SER

Registered Owner:

PRO-FLITE INC

Rated Power:

180 hp

Operator:

PRO-FLITE INC

Operating Certificate(s) Held:

None

 

Meteorological Information and Flight Plan

Conditions at Accident Site:

Visual Conditions

Condition of Light:

Dusk

Observation Facility, Elevation:

OFK, 1527 ft msl

Distance from Accident Site:

3 Nautical Miles

Observation Time:

1956 CDT

Direction from Accident Site:

260°

Lowest Cloud Condition:

Clear

Visibility

10 Miles

Lowest Ceiling:

None

Visibility (RVR):

 

Wind Speed/Gusts:

9 knots /

Turbulence Type Forecast/Actual:

/

Wind Direction:

170°

Turbulence Severity Forecast/Actual:

/

Altimeter Setting:

29.89 inches Hg

Temperature/Dew Point:

21°C / 3°C

Precipitation and Obscuration:

No Obscuration; No Precipitation

Departure Point:

Norfolk, NE (OFK)

Type of Flight Plan Filed:

None

Destination:

Omaha, NE (MLE)

Type of Clearance:

None

Departure Time:

1957 CDT

Type of Airspace:

 

 

Airport Information

Airport:

Norfolk Regional Airport (OFK)

Runway Surface Type:

 

Airport Elevation:

1572 ft

Runway Surface Condition:

 

Runway Used:

N/A

IFR Approach:

None

Runway Length/Width:

 

VFR Approach/Landing:

None

 

Wreckage and Impact Information

Crew Injuries:

1 Fatal

Aircraft Damage:

Substantial

Passenger Injuries:

1 Fatal

Aircraft Fire:

None

Ground Injuries:

N/A

Aircraft Explosion:

None

Total Injuries:

2 Fatal

Latitude, Longitude:

41.982222, -97.383056

 


 


Administrative Information

Investigator In Charge (IIC):

Michael J Folkerts

Report Date:

01/30/2014

Additional Participating Persons:

Paul D'Allura; Federal Aviation Administration; Lincoln, NE

John Butler; Lycoming Engines; Arlington, TX

Ron Maynard; Piper Aircraft Inc.; Vero Beach, FL

Publish Date:

10/27/2015

Investigation Docket:

http://dms.ntsb.gov/pubdms/search/dockList.cfm?mKey=86744