WPR16FA178 · Piper PA 28R-201T
Piper PA 28R-201T · Accident: loss of control in flight during initial climb
From Reno Tahoe International Airport (RNO) to San Carlos Airport (SQL)
Event
- NTSB case
- WPR16FA178
- 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
- 3 · 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
- Visual Meteorological Cond
Piper PA 28R-201T
- Aircraft type
- Piper PA-28
- 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
- N821ET
- Operator
- Unknown
- Onboard fatalities
- Unknown
- Route
- From Reno Tahoe International Airport (RNO), Reno, NVTo San Carlos Airport (SQL), San Carlos, CA
- Aircraft age
- About 39 years (built 1977)
- 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
- Initial climb
- 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
- Aircraft › Aircraft oper/perf/capability
- Personnel issues › Action/decision
- Personnel issues › Task performance
Approximate · Coordinates as recorded by the NTSB; no uncertainty radius is established.
NTSB narrative
The private pilot and two passengers were departing on a cross-country flight to transfer the rear-seat passenger to California, where a series of warrants had been issued for her arrest. A California-based bail bondsman was seated in the front right seat and the pilot was seated in the front left seat. The arrested passenger was restrained on the rear left seat by the lap belt.
Witnesses, surveillance camera footage, and recorded data from on board the airplane indicated that the airplane began its takeoff roll and climbed to about 200 ft above ground level (agl) before leveling off. One witness stated that the airplane immediately began to rock its wings, and the nose pitched up to a high angle and remained in that attitude as the airplane continued to fly over the runway. About 2/3 of the way down the runway, the airplane began to veer right of the runway centerline and entered a right, descending turn. The last recorded data showed the airplane in a 41° right bank with a 64° nose-down attitude. The airplane impacted a lamppost, vehicles, and the ground in a parking lot with the landing gear extended.
Postaccident examination did not reveal any anomalies with the airframe or engine that would have precluded normal operation. Sound spectrum analysis of the background noise recorded during the pilot's radio transmissions, along with examination of the propeller's internal and external witness signatures, revealed that the engine was likely producing takeoff power throughout the flight. The rear-seat passenger was found buckled in her seat after the accident; her legs were cuffed by leg-chains, and her hands were cuffed to her waist through a belly chain, thus, there was no evidence to suggest that the rear seat passenger interfered with the flight.
The pilot fueled the airplane almost to capacity before he definitively established the total weight of all occupants for the accident flight. Furthermore, he added more fuel than originally requested to avoid paying a facility fee to the fixed base operator (FBO). Further, the pilot's statements to FBO personnel indicated that he was concerned about the airplane being overweight. Although the pilot could have defueled the airplane in order to remain within weight and balance limitations, this would have been a time-consuming process, and it is likely that he felt pressured to proceed with the flight as planned in order to return the passenger to California that evening. Also, the time spent defueling would have resulted in the flight taking place in night conditions over mountainous, dark, uninhabited terrain.
The airplane was about 178 lbs over its maximum gross weight and loaded at or just beyond its aft center of gravity limit when it departed on the flight. Under such conditions, the airplane likely encountered longitudinal instability during takeoff and altitude and pitch oscillations. Strong gusty wind conditions and high density altitude (6,900 ft) further exasperated the situation and likely resulted in the pilot's difficulty controlling the airplane during the initial climb, which ultimately led to a loss of control.
The airplane was fitted with an aftermarket turbo intercooler system. Its manufacturer did not provide specific performance data, instead stating that the engine performance would have been "equal to or better than" standard equipment. It is possible that the pilot felt this system would have given the airplane increased performance capability.
Toxicology testing indicated the pilot had recently used 3 separate opioid drugs in addition to a sedating benzodiazepine (diazepam), and either meprobamate or its parent drug, carisoprodol. Although medical records indicated that the pilot had at one point been prescribed one opioid (oxycodone) and carisoprodol, the nearly simultaneous use of three separate opioids strongly suggests that he was misusing these substances. All of these medications are sedating and carry specific warnings against using them in combination. While the levels identified in cavity blood may be higher or lower than antemortem drug levels, the toxicology tests suggest that the pilot had 4 impairing substances in his blood at the time of the accident, and it is likely that his use of the combination of impairing medications contributed to his poor decision-making and willingness to attempt/proceed with the flight as planned.
Probable cause
The pilot's decision to depart with the airplane loaded above its maximum gross weight and at or just beyond its aft center of gravity limitations, which resulted in a loss of control during the initial climb. Contributing to the accident was the pressure to complete the flight as planned, and the pilot's use of multiple impairing drugs, which degraded his decision-making.
Verbatim NTSB analysis and probable cause from the NTSB dataset
Sources
NTSB record WPR16FA178
- Event ID
- 20160911X20520
- Case number
- WPR16FA178
- 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. Values present in the bulk record are kept.
- The date is the local date; the NTSB stores the UTC date 2016-09-12.
- API snapshot SHA-256: 9b076732f0f57630364f35393399d254ee73055ad91c415754497d9b5d384fd8; retrieved 2026-09-14T21:59:58.643Z.