PIPER PA-60-601P

Burlington, CO — July 6, 2023

Event Information

DateJuly 6, 2023
Event TypeACC
NTSB NumberCEN23FA285
Event ID20230708192561
LocationBurlington, CO
CountryUSA
Coordinates39.04903, -102.33752
Highest InjuryFATL

Aircraft

MakePIPER
ModelPA-60-601P
CategoryAIR
FAR Part091
Aircraft DamageDEST

Conditions

Light ConditionDAYL
WeatherIMC

Injuries

Fatal1
Serious0
Minor0
None0
Total Injured1

Event Location

Probable Cause

The pilot’s visual flight rules flight into instrument meteorological conditions, which resulted in a loss of control in flight and subsequent impact with terrain.

Full Narrative

HISTORY OF FLIGHTOn July 6, 2023, at an unknown time, a Piper PA-60-601P airplane, N100PB, was destroyed when it was involved in an accident near Burlington, Colorado. The pilot was fatally injured. The airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.

Video surveillance at the Kit Carson County Airport (ITR), Burlington, Colorado, showed the airplane depart the runway about 1330 mountain daylight time. A review of air traffic control (ATC) communications and radar data revealed that the pilot was not in contact with ATC, and there were no radar returns for any aircraft flying in the vicinity of ITR around the time of the accident. A review of ADS-B data sources did not reveal any track data for the flight. There were no witnesses to the accident, and the actual time of the accident could not be determined.

The airplane impacted a fallow cornfield about 11.8 nautical miles (nm) southwest of the departure airport.

In a conversation between the accident pilot, the airport manager, and another pilot, the accident pilot stated that he had a problem with both GPS’s; otherwise, he said that he would file IFR (instrument flight rules) but instead he had to go VFR (visual flight rules). Later, he was asked where he was headed, and he replied, “about as far west as you can get.” PERSONNEL INFORMATIONA pilot logbook was not recovered; however, on the pilot’s last application for an FAA medical certificate, he reported his total flight experience of 20,000 hours and 150 hours in the last 6 months. AIRCRAFT INFORMATIONMaintenance records were not located for the airplane.
The airplane’s total fuel capacity was 173.5 gallons (165.5 gallons usable); the airplane was equipped with two wing fuel tanks and a fuselage tank. According to fuel receipts, the pilot serviced the airplane with 113.4 gallons of 100 low-lead aviation fuel from the self-serve pumps at ITR before the airplane departed on the flight. METEOROLOGICAL INFORMATIONThe accident occurred near Burlington, Colorado, at a field elevation of about 4,275 ft msl. The meteorological investigation was conducted using official National Weather Service (NWS) and National Oceanic and Atmospheric Administration (NOAA) data sources.
A surface analysis chart valid at 1200 MDT showed the accident site positioned between a 1023-hectopascals (hPa) high pressure system over Iowa with a ridge extending southwestward over Kansas and a 1018-hPa bubble high over central Colorado. A trough was located between the two high pressure systems extending over eastern Colorado and western Kansas. Wind near the surface were generally from the southeast at 10 knots. Several reporting stations in eastern Colorado, including Burlington (KITR), indicated mist, low visibility, and overcast or obscured skies throughout the morning, with a gradual lifting trend into marginal visual flight rules (MVFR) conditions by early afternoon.
The closest official weather reporting station was Kit Carson County Airport (KITR), located about 13 nautical miles north of the accident site. The automated surface observation at 1353 MDT reported wind from 130° at 14 knots, visibility 10 statute miles, few clouds at 1,000 ft above ground level (agl), overcast ceiling at 1,800 ft agl, temperature 19°C, dew point 16°C, and altimeter setting 30.13 inches of mercury.
Earlier in the morning, between approximately 0600 and 1200 MDT, low instrument flight rule (LIFR) conditions prevailed, with visibility frequently below one statute mile in fog and vertical visibility as low as 200 ft. These conditions began improving shortly before the accident time window, and transitioned to MVFR.
A High-Resolution Rapid Refresh (HRRR) numerical model sounding at 1300 MDT for a grid point near the accident site indicated a saturated atmosphere with a surface temperature of 16°C, dew point 15°C, relative humidity 96 percent, and a calculated density altitude of 5,328 ft. The lifted condensation level (LCL) and level of free convection (LFC) were calculated at 296 ft agl. Cloud ceilings were estimated as broken at 300 ft and overcast at 800 ft agl, with stratiform tops near 10,000 ft. An additional layer of altocumulus clouds was present between 15,600 and 20,000 ft. Precipitable water content was measured at 1.16 inches. The freezing level was identified near 15,500 ft.
The HRRR sounding also indicated a high probability of carburetor or induction icing from the surface to 12,000 ft, given the temperature and humidity profile. Winds at the surface were from 120° at 11 knots, veering with altitude and increasing to 20–27 knots by 18,000 ft. No clear air turbulence or mountain wave activity was noted below this level.
Satellite imagery from GOES-16 at 1331 MDT revealed widespread low stratiform clouds over eastern Colorado. Cloud top temperatures near the accident site measured 285 Kelvin (approximately 11°C), corresponding to top altitudes around 8,000 ft. Convective clouds associated with dissipating cumulonimbus were observed both west and east of the site.
No pilot weather reports (PIREPs) were recorded within 60 nautical miles of the accident site between 1000 and 1800 MDT.
The Terminal Aerodrome Forecast (TAF) for Goodland, Kansas (KGLD), approximately 28 miles east of the accident site, issued at 1120 MDT, forecast IFR conditions with wind from 160° at 11 knots, visibility 2 statute miles in mist, overcast ceiling at 800 ft AGL, and showers in the vicinity for the accident time.
The Area Forecast Discussion issued by NWS Goodland at 1132 MDT described a saturated near-surface air mass, widespread fog and low ceilings over eastern Colorado, and potential for severe weather development later in the afternoon and evening. Conditions for supercell development were forecasted, with potential hazards including large hail, damaging winds, flash flooding, and tornadoes.
Graphical Forecasts for Aviation (GFA) at 1330 MDT depicted low IFR conditions over the accident site, with overcast cloud bases near 4,500 ft msl (approximately 275 ft agl) and tops extending up to 25,000 ft. A Graphic AIRMET for IFR conditions was valid for the region at the time of the accident.
Several AIRMETs were in effect over the accident region, including AIRMET Sierra for IFR conditions and mountain obscuration, AIRMET Tango for moderate turbulence below FL180, and AIRMET Zulu for potential icing above the freezing level. No SIGMETs, Convective SIGMETs, or Center Weather Advisories were issued for the area during the relevant time period.
A review of FAA Leidos Flight Service and ForeFlight systems indicated that no official weather briefing was obtained by the pilot before departure. It could not be determined what sources, if any, the pilot used to obtain weather information in accordance with Title 14 Code of Federal Regulations Part 91.103. AIRPORT INFORMATIONMaintenance records were not located for the airplane.
The airplane’s total fuel capacity was 173.5 gallons (165.5 gallons usable); the airplane was equipped with two wing fuel tanks and a fuselage tank. According to fuel receipts, the pilot serviced the airplane with 113.4 gallons of 100 low-lead aviation fuel from the self-serve pumps at ITR before the airplane departed on the flight. WRECKAGE AND IMPACT INFORMATIONThe airplane impacted a fallow cornfield about 11.8 nm southwest of ITR. A 350-ft-long debris path, oriented on a 345° magnetic heading, preceded the location of the main wreckage. The airplane impacted the ground in a near wings-level nose-down attitude. The nose landing gear wheel and fork were found separated from the strut about 325 ft from the initial point of impact. The wing tips were found separated from both wings along the wreckage debris path on their respective sides.
Examination of the airframe and engine revealed no preimpact mechanical malfunctions or failures that would have precluded normal operation. The fuselage was fractured from the wing and the wing spars remained attached as one assembly. Flight control continuity could not be verified because the control push/pull tubes for the ailerons, elevators, and rudder exhibited extensive impact and fire damage. Both ailerons and flaps exhibited impact and fire damage. The hydraulic flap actuators were found retracted, consistent with 0° of flap extension. Both elevators remained attached to the horizontal stabilizer and exhibited impact damage. The elevator trim tabs measured about 10° tab down. The rudder was found about 125 ft from the empennage and the vertical stabilizer was fractured from its mount and crushed.

The landing gear selector handle was found to be in the up and locked position, and the landing gear was found retracted.
The instrument panel was destroyed by impact and fire. The altimeter indicated 4,200 ft and was set to 30.13 in Hg. The attitude indicator and other avionics were destroyed. The pressurization controller was set to 12,500 ft. The right magneto switch was found attached to its mounting location on the instrument panel and in the Off position. The left magneto switch was found intact but separated from its mounting location and was also in the “Off” position.
The right engine remained attached to its engine mounts and nacelle, and the left engine was located among the debris field attached to its mount, which had fractured from its nacelle. The throttle quadrant was destroyed by impact and fire damage.
The left engine exhibited significant impact damage to the crank flange, oil sump, starter mount, alternator mount, and exhaust. Spark was observed at all leads on the left magneto when rotated by hand. The right magneto was impact fractured and not able to be rotated. The crankshaft was rotated by hand, and thumb compression was observed at all cylinders, and the drivetrain was continuous throughout. The Nos. 3 and 4 intake rocker arms were observed to have less lift than the other rockers. The engine was disassembled, and multiple lifters and camshaft lobes were spalled.
The right engine exhibited significant impact damage to the oil sump, starter mount, alternator mount, and exhaust. Both magnetos displayed thermal damage. The left magneto was rotated by hand, and spark was observed at all leads. The right magneto was not able to be rotated due to impact damage. The crankshaft was rotated by hand; thumb compression was observed at all cylinders and the drivetrain was continuous throughout.
The right propeller was separated from the engine propeller shaft flange. One blade was separated from the hub, and its leading edge was lodged into the right engine intercooler core. The other two blades remained in the hub but could be rotated in their housing by hand. The left propeller was separated from the engine propeller shaft flange. One propeller blade was separated from the hub, and the remaining two blades appeared to be in the normal range of operation. All 6 blades exhibited chordwise gouging as well as other signatures that were consistent with rotation at impact. MEDICAL AND PATHOLOGICAL INFORMATIONAn autopsy of the pilot was performed by the Weld County Coroner’s Office, Greeley, Colorado, at the request of the Kit Carson County Coroner. According to the autopsy report the cause of death was multiple blunt force injuries and the manner of death was an accident.
Toxicology testing performed on the pilot’s specimens at the FAA Forensic Sciences Laboratory detected ethanol at 0.012 g/hg in liver tissue, at 0.037 g/hg in muscle tissue, at 0.014 g/hg in lung tissue, and at 0.043 g/hg in kidney tissue (in tissue, concentrations in g/hg are approximately equivalent to concentrations in g/dL).
Ethanol is a type of alcohol. It is the intoxicating alcohol in beer, wine, and liquor, and, if consumed, can impair judgment, psychomotor performance, cognition, and vigilance. FAA regulation imposes strict limits on flying after consuming ethanol, including prohibiting pilots from flying with a blood ethanol level of 0.04 g/dL or greater. Alcohol consumption is not the only possible source of ethanol in postmortem specimens. Ethanol can sometimes be produced by microbes in a person’s body after death. Postmortem ethanol production is made more likely by extensive traumatic injury.

About This NTSB Record

This aviation event was investigated by the National Transportation Safety Board (NTSB). NTSB investigates all U.S. civil aviation accidents to determine probable cause and issue safety recommendations to prevent future accidents.

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