NTSB Factual Report

HISTORY OF FLIGHT

On June 23, 2009, at 1057 central daylight time, a Piper PA-28-180 single-engine airplane, N7795N, was substantially damaged when it impacted terrain while maneuvering near Sanborn, Iowa. The private pilot, a pilot-rated passenger, and another passenger sustained fatal injuries. Visual meteorological conditions prevailed, and a flight plan was not filed for the 14 Code of Federal Regulations Part 91 personal flight. The flight departed the Fort Atkinson Municipal Airport (61C), Fort Atkinson, Wisconsin, approximately 0807 and was en route to Winner, South Dakota.

Family members reported the pilot and passengers were flying to South Dakota for a hunting trip.

Prior to departure, the airplane was refueled by the pilot and passengers with 12 gallons of fuel at a self-serve fuel pump at 61C. The total amount of fuel on board the airplane at the time of departure could not be determined. A witness, who overheard portions of the pilot and passengers' conversations while they were removing the airplane from the hangar, stated that one person in the group mentioned that filling the tanks to the tabs would not be enough fuel to make it to their destination. The witness overheard the group say they planned for a fuel stop along the route of flight. A family member of one passenger stated that in the days preceding the accident flight, the passenger mentioned that they could not depart with full fuel tanks due to the high temperatures and expected weight of the airplane.

The airplane was equipped with a portable Garmin GPSMAP 295 global positioning system (GPS) receiver. A specialist with the NTSB's Vehicle Recorder Division extracted the data stored in the receiver. A review of the data indicated the average GPS altitude during the first 6 minutes and 45 seconds of recorded track log data was 801 feet mean sea level (msl). Field elevation for 61C was reported as 801 feet (surveyed).

The GPS data indicated the airplane departed from 61C approximately 0807. A Google Earth overlay of the GPS track log data indicated that the airplane departed 61C to the south and turned right to a westerly heading. From 0822 to 0947, the airplane continued in a westerly heading at altitudes between 4,700 and 4,900 feet msl. At 0947, the airplane entered a gradual climb to an altitude of approximately 9,000 feet msl, and at 1013, the airplane began a gradual descent to an altitude of approximately 2,400 feet msl. From 1022 to 1055, the airplane continued in a westerly heading at altitudes between 2,400 and 2,900 feet msl. For the last 2 minutes of recorded track log data, the airplane began a descent from 2,500 feet, and the groundspeed decreased. The last 3 track log data points indicated the airplane began a left turn to the south. The last data point was recorded at 1057:40; at an altitude of 1,497 feet msl.

According to several witnesses located near the accident site, the airplane was observed to be flying at a low altitude. Two witnesses, located northeast of the accident site, observed the airplane at a low altitude and the engine was "coughing, sputtering, and missing." The engine quit shortly thereafter, restarted, and quit again. The witnesses lost sight of the airplane behind trees. Approximately 5 minutes later, the witnesses heard sirens and emergency vehicles. Witnesses and rescue personnel who responded to the accident reported no smell or evidence of fuel at the accident site.

Fixed-based operator personnel, located at the Sheldon Municipal Airport (SHL) which was approximately 3 miles west of the accident site, were monitoring the airport’s UNICOM frequency at the time of the accident. The personnel stated that the accident airplane had not transmitted any communications over the SHL UNICOM frequency.

PERSONNEL INFORMATION

The pilot, age 64 and seated in the left seat, held a private pilot certificate with an airplane single-engine land rating. The pilot was issued a third-class medical certificate on July 18, 2007. A review of the pilot’s logbook revealed he had accumulated approximately 722 total flight hours. The pilot completed a flight review on November 1, 2007, in a Piper PA-28-151 airplane. The most recent entry in the pilot’s logbook was dated April 28, 2009.

The pilot-rated passenger, age 65 and seated in the right seat, held a private pilot certificate with an airplane single-engine land rating. He was issued a third-class medical certificate on September 20, 2005, which was expired at the time of the accident. The pilot-rated passenger was a co-owner of the accident airplane.

During a telephone conversation between the NTSB investigator-in-charge and the other co-owner of the airplane, the co-owner reported that he assumed the pilot in the left seat would have been the pilot of the accident flight, and not the pilot-rated passenger. The pilot had flown the accident airplane in the past and owned a Piper PA-28-151 airplane.

AIRCRAFT INFORMATION

The 1968-model Piper PA-28-180, serial number 28-5244, was a single-engine, low-wing, fixed tri-cycle landing gear, semi-monocoque design airplane. The airplane was powered by a normally aspirated, direct drive, air-cooled, horizontally opposed, carburetor equipped, four-cylinder Lycoming O-360-A4A (serial number L-13561-36A), rated at 180 horsepower, and equipped with a two-blade fixed pitch propeller. The airplane was configured to carry a maximum of four occupants.

The airplane was issued a standard airworthiness certificated on December 4, 1968, and was certificated for normal or utility category operations. The airplane was registered to the owners on May 2, 2002. A review of the airframe logbook revealed the most recent annual inspection was completed on April 16, 2009, at a total time of 4,729 hours. The engine underwent its most recent 100-hour inspection on April 16, 2009, at a total time of 40 hours since major overhaul. At the time of the accident, the airframe had accumulated a total time of 4,738 hours.

The airplane’s fuel system consisted of two 25-gallon tanks, with a total of 48 gallons of usable fuel. A placard on the wing adjacent to each fuel cap noted, “Cap to Bottom of Filler Neck Indicator 18 gal.” Information extracted from the Piper Owner’s Handbook indicated that at a maximum gross weight of 2,400 pounds, the airplane would have a fuel flow of 10 gallons per hour (gph) at 75 percent power setting, and 8.7 gph at 65 percent power setting.

METEOROLOGICAL INFORMATION

The weather at the time as reported by witnesses was clear skies and the winds were light and variable.

At 1055, the Sheldon Municipal Airport automated weather observing system (AWOS), recorded the wind from 260 degrees at 3 knots, visibility 10 statute miles, sky clear, temperature 32 degrees Celsius, dew point 26 degrees Celsius, and an altimeter setting of 29.93 inches of mercury.

WRECKAGE AND IMPACT INFORMATION

Examination of the accident site revealed that the airplane touched down in a corn field with the corn stalks measuring 2 to 3 feet in height. The airplane traveled through the corn field for approximately 100 feet and impacted a ditch; 2 feet from the top of a gravel road. The airplane nosed over and came to rest inverted at a measured GPS elevation of 1,482 feet. The airplane wreckage was distributed along a measured magnetic heading of 180 degrees from the initial touchdown location in the corn field to the resting point. Three paths, consistent with the three landing gears, were cut through the corn and ended at the edge of the corn field, adjacent to the ditch. No evidence of corn cut by a propeller was noted.

The left wing remained partially attached to the fuselage and was displaced aft. The outboard 3 feet of the wing was crushed and bent aft. The aileron and flap remained attached to the wing. The fuel cap was secured and approximately 1 cup of fuel was drained from the fuel tank. The right wing remained partially attached to the fuselage. The aileron and flap remained attached to the wing. The fuel cap was secure and approximately 2 1/2 cups of fuel were drained from the fuel tank. The flap handle and flap chain mechanism were found in the UP position.

The empennage, horizontal and vertical stabilizers, rudder, and elevator, were not damaged. Green debris, consistent with corn stalk remnants, was present on the leading edge of the horizontal stabilator. The elevator trim was measured to be in the neutral position.

Flight control continuity was established to all flight control surfaces with the exception of the left aileron. The left aileron cable was found separated and broom-strawed near the wing root.

The left side of the fuselage was wrinkled near the trailing edge of the wing root. The right side displayed wrinkling and the cabin windows were broken. The door and door post had been removed by rescue personnel. The door lock mechanism was engaged. The forward cabin floor was crushed upward and aft. All seat frames were broken and the forward lap belt seat restraints were found secured and then cut for extrication purposes. The right rear lap belt restraint was secured and separated from the floor attach fittings. The left rear lap belt restraint was secured and cut by rescue personnel. The baggage was removed and weighed by fire personnel. The weight of the baggage was 208 pounds. Several sectional charts and miscellaneous pieces of paperwork were found scattered in the cockpit area. The Sheldon Municipal Airport page from the Iowa Airport Directory was found removed from the spiral-bound directory and clipped onto a knee board.

The instrument panel was crushed and destroyed. The cockpit engine controls were found in the following positions: Throttle – 3/4 position, Mixture – full rich, and carburetor heat – mid position. The fuel pump switch was in the ON position, and the fuel selector was in the left tank position.

The engine remained partially attached to the firewall and was aft and to the right side of the fuselage. The propeller was rotated by hand and mechanical continuity was noted throughout the engine crankcase and accessory gear section. The magnetos sparked at all ignition harness leads. The carburetor housing was separated from the engine and remained attached via the control cables. The carburetor was disassembled and no fuel was found in the carburetor. The carburetor floats were intact and no deformation was noted. The propeller was separated from the crankshaft flange. One blade displayed a slight bend aft and one blade was bent aft. No leading edge damage was noted on either propeller blade.

MEDICAL AND PATHOLOGICAL INFORMATION

Autopsies were performed on the occupants by the Iowa Office of the State Medical Examiner, Ankeny, Iowa, on June 25, 2009, and specimens from the pilot and pilot-rated passenger were retained for toxicological analysis by the Federal Aviation Administration (FAA) Civil Aeromedical Institute’s (CAMI) Forensic and Accident Research Center, Oklahoma City, Oklahoma.

The autopsies listed the cause of death for the occupants as blunt force injuries of the thorax. The pilot-rated passenger autopsy indicated, “His past medical history was significant for heart disease. …The heart was enlarged and had old heart attacks; however, the coronary artery bypass grafts appeared patent.”

Toxicological tests were negative on the pilot for carbon monoxide, cyanide, ethanol, and all screened substances. Toxicological tests were negative on the pilot-rated passenger for carbon monoxide, cyanide, and ethanol. An unspecified level of Clopidogrel was detected in the urine, and an unspecified level of Metoprolol was detected in the urine and blood.

NTSB Probable Cause

A loss of engine power due to fuel exhaustion as a result of the pilot's improper fuel planning and failure to refuel.