Aviation Investigation Final Report
Location: Leicester, Massachusetts Accident Number: ERA21LA122
Date & Time: February 2, 2021, 16:55 Local Registration: N221ST
Aircraft: Piper PA46 Aircraft Damage: Substantial
Defining Event: Structural icing Injuries: 2 Serious, 1 Minor
Flight Conducted Under: Part 91: General aviation - Personal
Analysis
The pilot reported that, while descending through clouds and beginning the instrument
approach, some ice accumulated on the wings and he actuated the deice boots twice. The pilot
saw the deice boots functioning normally on the wings and could not see the tail; however, the
elevator began to shake, and he lost elevator control. The pilot applied forward pressure on the
yoke and had to trim nose-down to avoid a stall. There were no cockpit caution indications and
the pilot had disengaged the autopilot before descent. The airplane descended through the
clouds and impacted a tree before coming to rest upright in a grass area.
Postaccident examination of the wreckage, including component testing of the deice system,
did not reveal any preimpact mechanical malfunctions. The flap jackscrew position suggested
that the flaps were likely in transit between 0° and 10° flap extension at the time of impact.
Review of radar data revealed that, during the 2 minutes before the accident, the airplane’s
groundspeed averaged about 82 knots; or an approximate average airspeed of 94 knots when
accounting for the winds aloft. Current weather observations and forecast weather products
indicated that the airplane was likely operating in an area where moderate and potentially
greater structural icing conditions prevailed, and where there was the potential for the
presence of supercooled liquid droplets. Review of the pilot operating handbook for the
airplane revealed that the minimum speed for flight in icing conditions was 130 knots indicated
airspeed. It is likely that the pilot’s failure to maintain an appropriate speed for flight in icing
conditions resulted in insufficient airflow over the ice contaminated elevator and the
subsequent loss of elevator control.
Probable Cause and Findings
The National Transportation Safety Board determines the probable cause(s) of this accident to be:
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The pilot’s failure to maintain the minimum airspeed for flight in icing conditions, which
resulted in a loss of elevator control during approach due to ice accumulation.
Findings
Personnel issues Task monitoring/vigilance - Pilot
Environmental issues Conducive to structural icing - Compliance w/ procedure
Aircraft Airspeed - Not attained/maintained
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Factual Information
History of Flight
Approach-IFR initial approach Structural icing (Defining event)
Approach-IFR initial approach Loss of control in flight
Uncontrolled descent Collision with terr/obj (non-CFIT)
On February 2, 2021, about 1655 eastern standard time, a Piper PA-46-350P, N221ST, was
substantially damaged when it was involved in an accident near Leicester, Massachusetts. The
commercial pilot sustained minor injuries and the two passengers were seriously injured. The
airplane was operated as a Title 14 Code of Federal Regulations Part 91 personal flight.
The pilot stated that he received weather briefings via flight service and ForeFlight. The flight
service specialist advised the pilot that there would be some icing in clouds, with cloud tops
near 6,000 ft mean sea level msl (msl). Additionally, an AIRMET was in effect for moderate
icing from the freezing level up to 18,000 ft msl. The pilot further stated that his previous flight
that day, from Worcester, Massachusetts, to Martha’s Vineyard, Massachusetts, was
uneventful. He added that the actual conditions were better than forecast with no ice observed
during that flight and the accident flight, until descent for the RNAV (GPS) RWY11 approach to
Worcester.
Light freezing rain was reported in the area of the accident site around the time of the accident,
and the forecast icing potential indicated a 60% probability of supercooled liquid droplets
(SLD) over the accident site, at the time of the accident, at 4,000 ft msl. The current icing
potential indicated a 90% to 100% probability of SLD at 1,000 to 4,000 ft msl at the accident
site, at 1700.
The pilot reported that, while descending through clouds and beginning the approach, a little
ice built up on the wings and he actuated the deice boots twice. The pilot observed the deice
boots functioning normally on the wings and could not see the tail. He reported that the
elevator “began to shake and became ineffective” and that he “felt like the airplane was
approaching a stall.” The pilot applied forward pressure on the yoke and had to trim elevator
nose down to get the airplane to descend and avoid a stall, and he reported that any effort to
pull back on the yoke exacerbated the situation. He further stated that no caution annunciators
illuminated, and that he had disengaged the autopilot before descent. The airplane descended
through the clouds and the pilot flew toward trees to avoid a house. The airplane subsequently
contacted a tree and came to rest upright in the front yard of a residence about 3 miles from
the runway threshold.
Examination of the wreckage did not reveal evidence of any preimpact mechanical
malfunctions. Flight control continuity was confirmed from the cockpit to all control surfaces.
The flap lever was observed at the 10° flap extension position. Examination of the flap
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jackscrew revealed about five exposed threads, which corresponded to a flap position between
0° and 10°. Component testing of the deice system did not reveal any anomalies.
Review of air traffic control audio and radar data revealed that the pilot contacted the tower
controller at 1653 and reported a position of 1 mile from the RILOC intersection (about 6.5-
mile final approach). The controller acknowledged the report and cleared the pilot to land.
From that time until the flight upset about 2 minutes later, the airplane’s groundspeed
averaged about 82 knots, or an airspeed of 94 knots based on a winds aloft forecast of 060° at
17 knots, at 3,000 ft msl.
Review of a pilot operating handbook (POH) for the airplane make and model revealed a
minimum speed for flight in icing conditions as 130 knots indicated airspeed. The POH further
stated, “The ice protection system was not designed or tested for flight in freezing rain, freezing
drizzle or supercooled liquid water and ice crystals, or conditions defined as severe. Flight in
these conditions is prohibited and must be avoided.”
Pilot Information
Certificate: Commercial Age: 63,Male
Airplane Rating(s): Single-engine land; Single-engine Seat Occupied: Left
sea; Multi-engine land
Other Aircraft Rating(s): None Restraint Used: 3-point
Instrument Rating(s): Airplane Second Pilot Present: No
Instructor Rating(s): Airplane multi-engine; Airplane Toxicology Performed:
single-engine; Instrument airplane
Medical Certification: Class 3 With waivers/limitations Last FAA Medical Exam: April 19, 2019
Occupational Pilot: No Last Flight Review or Equivalent: February 17, 2020
Flight Time: 3000 hours (Total, all aircraft), 630 hours (Total, this make and model), 2875 hours (Pilot In
Command, all aircraft), 67 hours (Last 90 days, all aircraft), 28 hours (Last 30 days, all aircraft),
2 hours (Last 24 hours, all aircraft)
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Aircraft and Owner/Operator Information
Aircraft Make: Piper Registration: N221ST
Model/Series: PA46 350P Aircraft Category: Airplane
Year of Manufacture: 2014 Amateur Built:
Airworthiness Certificate: Normal Serial Number: 4636651
Landing Gear Type: Retractable - Tricycle Seats: 6
Date/Type of Last September 2, 2021 Annual Certified Max Gross Wt.: 4300 lbs
Inspection:
Time Since Last Inspection: 114 Hrs Engines: 1
Airframe Total Time: 946 Hrs at time of accident Engine Manufacturer:
ELT: C126 installed, not activated Engine Model/Series:
Registered Owner: Forza Management Co Rated Power:
Operator: Forza Management Co Operating Certificate(s) None
Held:
Meteorological Information and Flight Plan
Conditions at Accident Site: Visual (VMC) Condition of Light: Day
Observation Facility, Elevation: ORH,1009 ft msl Distance from Accident Site: 3 Nautical Miles
Observation Time: 16:42 Local Direction from Accident Site: 8°
Lowest Cloud Condition: Visibility 5 miles
Lowest Ceiling: Overcast / 1100 ft AGL Visibility (RVR):
Wind Speed/Gusts: 13 knots / 21 knots Turbulence Type None / None
Forecast/Actual:
Wind Direction: 20° Turbulence Severity N/A / N/A
Forecast/Actual:
Altimeter Setting: 29.32 inches Hg Temperature/Dew Point: -1°C / -3°C
Precipitation and Obscuration: Light - Freezing - Rain
Departure Point: Vineyard Haven, MA (MVY) Type of Flight Plan Filed: IFR
Destination: Worcester, MA (ORH) Type of Clearance: IFR
Departure Time: 16:15 Local Type of Airspace: Class D
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Airport Information
Airport: Worcester Regional Airport ORH Runway Surface Type: Asphalt
Airport Elevation: 1009 ft msl Runway Surface Condition: Wet
Runway Used: 11 IFR Approach: RNAV
Runway Length/Width: 7001 ft / 150 ft VFR Approach/Landing: Straight-in
Wreckage and Impact Information
Crew Injuries: 1 Minor Aircraft Damage: Substantial
Passenger 2 Serious Aircraft Fire: None
Injuries:
Ground Injuries: Aircraft Explosion: None
Total Injuries: 2 Serious, 1 Minor Latitude, 42.276667,-71.959444(est)
Longitude:
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Administrative Information
Investigator In Charge (IIC): Gretz, Robert
Additional Participating Joe Pezzanite; FAA/FSDO; Enfield, CT
Persons: Damian Galbraith; Piper Aircraft; Vero Beach, FL
Ryan Enders; Lycoming Engines; WIlliamsport, PA
Original Publish Date: November 1, 2022
Last Revision Date:
Investigation Class: Class 3
Note: The NTSB did not travel to the scene of this accident.
Investigation Docket: https://data.ntsb.gov/Docket?ProjectID=102592
The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with
investigating every civil aviation accident in the United States and significant events in other modes of transportation—
railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable causes of the accidents
and events we investigate, and issue safety recommendations aimed at preventing future occurrences. In addition, we
conduct transportation safety research studies and offer information and other assistance to family members and
survivors for each accident or event we investigate. We also serve as the appellate authority for enforcement actions
involving aviation and mariner certificates issued by the Federal Aviation Administration (FAA) and US Coast Guard, and
we adjudicate appeals of civil penalty actions taken by the FAA.
The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation,
“accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties … and are
not conducted for the purpose of determining the rights or liabilities of any person” (Title 49 Code of Federal Regulations
section 831.4). Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve
transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition,
statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a
civil action for damages resulting from a matter mentioned in the report (Title 49 United States Code section 1154(b)). A
factual report that may be admissible under 49 United States Code section 1154(b) is available here.
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