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CEN14FA042 · Piper PA-32R-301

5 Nov 2013 · Kirksville, MO, United States

RFG Piper PA-32R-301 · Accident: loss of control in flight on approach

From Centennial Airport (APA) to Kirksville Regional Airport (IRK)

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Event

NTSB case
CEN14FA042
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Accident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
2 · all aircraft and ground
Ground fatalities
Unknown
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
General aviation
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Instrument Meteorological Cond

Piper PA-32R-301

Aircraft type
Piper PA-32
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N408DM
Operator
RFG
Onboard fatalities
Unknown
Route
From Centennial Airport (APA), Denver, COTo Kirksville Regional Airport (IRK), Kirksville, MO
Aircraft age
About 32 years (built 1981)
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 91: General Aviation
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Approach · IFR final approach
Defining eventThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Loss of control in flight
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
Destroyed

Cause areas

  • Personnel issues › Psychological
  • Personnel issues › Task performance

Approximate · Coordinates from the NTSB case API, which marks them as estimated or does not say; no uncertainty radius is established.

NTSB narrative

The flight instructor accompanied the private pilot on a business flight to provide instrument flight instruction. Dark night instrument meteorological conditions prevailed with a 15-knot headwind that was gusting to 20 knots. The pilots were cleared for an instrument approach and instructed to change to the local advisory frequency. Recorded radar data indicated that the airplane was tracking the inbound course to the airport. One of the pilots contacted the airport on the local advisory frequency and gave two position reports; the last one reported the airplane was 5 miles from the airport. There was no other communication with the pilots. It could not be determined which pilot was flying the airplane when the accident occurred.

The wreckage was located about 3.5 miles north of the airport, and the initial tree impact was about 0.4 mile east of the last radar contact. The location of the accident site was consistent with the airplane turning left away from the inbound course and descending rapidly after the last radar contact. Given the dark night instrument meteorological conditions, the most likely explanation for the turn and rapid descent is that the flying pilot experienced spatial disorientation and lost control of the airplane. Examination of the accident site indicated that the airplane was in a nose-up attitude when it contacted the trees on the up sloping terrain, and it continued to climb, clearing the crest of the hill and continuing down the other side, before it came to rest. The wreckage path was consistent with a possible attempt to recover from the descent just before impacting the trees, but by then there was insufficient altitude to avoid the accident. Examination of the airplane and engine found no evidence of preimpact mechanical malfunctions or failures that would have precluded normal operation.

A commuter airline pilot who landed at the airport 15 minutes before the accident stated that the weather conditions were such that the lights from the radio antenna towers along the approach course illuminated the clouds around him with a white flashing light similar to airplane anti-collision lights or runway end identifier lights. If similar conditions were present during the accident airplane's approach, this phenomenon could have distracted the pilots. However, there is insufficient information to determine either the presence of this phenomenon during the accident airplane's approach or its role in this accident.

The pilots began their first flight of the day about 0804, and the accident occurred on their third flight of the day at 1912. Assuming the pilots woke up about 2 hours before they began the first flight, they had been awake about 13 hours when the accident occurred. The combined flights totaled about 5 hours 46 minutes of flight time. The cumulative flight time in conjunction with the extended time since awakening most likely resulted in the pilots experiencing some level of fatigue at the time of the accident.

Although the instructor's autopsy revealed that he had severe coronary artery disease, it could not be determined whether this contributed to the accident. The private pilot's toxicology results were positive for diphenhydramine, a sedating antihistamine, and impairment from this over-the-counter medication likely contributed to the accident whether he was actively flying or observing the instructor fly the approach at the time of the loss of control.

Probable cause

A loss of control due to spatial disorientation. Contributing to the accident were the private pilot's impairment due to a sedating antihistamine and both pilots' fatigue.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record CEN14FA042
Event ID
20131106X11708
Case number
CEN14FA042
Dataset
full-current
Source SHA-256
5cf380f0061817c0331a6b2d8cc7e0ee3a79bea469a1001dc5c10e56f35f5ab3
Source notes (4)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: local date, investigation status, coordinates. Values present in the bulk record are kept.
  • The date is the local date; the NTSB stores the UTC date 2013-11-06.
  • API snapshot SHA-256: 63b226fe249177396fb5b068ad37719d784891e56040fca185a70cc5d282390c; retrieved 2026-09-14T16:06:50.825Z.