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Accidents · NTSB CEN19FA088 · Final report

Piper PA46 accident near Shreveport, Louisiana, February 28, 2019

On February 28, 2019 at about 4:40 pm local time, a 1999 Piper PA46, registered N428CD, was substantially damaged in an accident during initial climb near Shreveport, Louisiana (Shreveport Downtown airport). It was a personal flight under general aviation rules (Part 91). 2 people were killed. The weather was instrument conditions (cloud, fog or low visibility).

The NTSB's probable cause their words, unchanged

The pilot's conduct of a departure into instrument meteorological conditions (IMC), which resulted in spatial disorientation and subsequent loss of airplane control. Contributing to the accident was the pilot's poor instrument flying skills and his decision to depart into IMC with an unresolved autopilot maintenance issue.

Source: NTSB aviation accident database, copy made October 5, 2026. Docket and reports at the NTSB.

What the record shows

Date
February 28, 2019 · about 4:40 pm local time
Place
Shreveport, Louisiana · Shreveport Downtown · map
Type
Accident
Injuries
2 people were killed.
Weather
instrument conditions (cloud, fog or low visibility)
Aircraft
Piper PA46 350P, built 1999 · all PA46s on the register
Registration
N428CD · registry record · serial 4636232
Damage
Substantial damage
Flight
Personal flight · general aviation rules (Part 91)

The NTSB's narrative final · quoted from the NTSB record

The instrument-rated private pilot and passenger departed into instrument meteorological conditions with a 600-ft cloud ceiling in an airplane that was about 550 lbs over gross weight. Air traffic control data showed the airplane in a climbing left turn that continued beyond the assigned heading. After reaching 1,400 ft msl, the airplane continued turning left and its altitude and speed began to vary. The airplane continued in a left spiral, completing more than two full circles, then decelerated in a right turn and rapidly descended until impact with terrain. Examination of the flight control system revealed no evidence of mechanical malfunctions and downloaded engine data indicated normal engine operation. Downloaded data from the autopilot system revealed three in-flight error codes. The first error code, which likely occurred about 1 minute after takeoff, would have resulted in the autopilot, if it was engaged at the time, disengaging. The subsequent error codes likely occurred during the erratic flight profile, with the autopilot disengaged. Before the accident flight, the pilot had informed a mechanic, who is also a pilot, of intermittent issues with the autopilot system and that these issues were unresolved. The mechanic had flown with the accident pilot previously and assessed his instrument flying skills as weak. The flight instructor who provided initial flight training for the turbine engine transition stated the pilot's instrument flying proficiency was poor when he was hand flying the airplane. Toxicology testing revealed that the pilot had used marijuana, and his girlfriend stated the pilot would take a marijuana gummy before bedtime to sleep more soundly. However, given that no psychoactive compounds were found in blood specimens, it is unlikely that the pilot was impaired at the time of the accident. The instrument conditions at the time of the accident, the airplane's erratic flightpath, and the pilot's reported lack of instrument proficiency when flying by hand support the likelihood that the pilot experienced spatial disorientation sometime after takeoff. In addition, given the reports of the intermittently malfunctioning autopilot that had not been fixed, it is likely the pilot experienced an increased workload during a critical phase of flight that, in combination with spatial disorientation, led to the pilot's loss of airplane control.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Loss of control in flight during initial climb defining event
  2. Collision with terrain or object (not controlled flight into terrain) during uncontrolled descent

The NTSB's findings

  • cause Personnel issues › Task performance › Use of equip/info › Aircraft control › Pilot
  • cause Personnel issues › Psychological › Perception/orientation/illusion › Spatial disorientation › Pilot
  • factor Personnel issues › Experience/knowledge › Experience/qualifications › Recent instrument experience › Pilot
  • cause Personnel issues › Action/decision › Info processing/decision › Decision making/judgment › Pilot
  • cause Environmental issues › Conditions/weather/phenomena › Ceiling/visibility/precip › Below VFR minima › Effect on operation
  • factor Personnel issues › Action/decision › Info processing/decision › Decision making/judgment › Pilot
  • factor Aircraft › Aircraft systems › Auto flight system › Autopilot system › Inoperative
  • factor Personnel issues › Task performance › Use of equip/info › Use of automation › Pilot
  • factor Personnel issues › Experience/knowledge › Knowledge › Aeronautical knowledge › Pilot

Pilot

  • Certificate: private
  • Ratings: single-engine land; instrument: airplane
  • Flight time: 1,393 hours in all; 323 in this make and model; 17 in the last 90 days; 7 in the last 30 days
  • Last flight review: May 4, 2018
  • Medical certificate: Class 3 (with waivers/limitations)
  • Seat: left
  • Injury: fatal

Passenger

  • Seat: rgt
  • Injury: fatal

The aircraft

  • Airframe total time: 1,901 hours
  • Last inspection: annual inspection, March 29, 2018; 113 hours since
  • Maximum gross weight: 4,299 lb
  • Seats: 6
  • Landing gear: retractable
  • Engine: Pratt & Whitney PT6A-35 (turboprop); 384 hours total

The flight

  • Departed from: DTN Shreveport LA at 4:37 pm
  • Destination: F05 Vernon TX
  • Flight plan: IFR
  • Runway 32, 5,018 ft by 150 ft

Weather at the time

  • Light: daylight
  • Wind: from 320° at 8 knots
  • Visibility: 4 statute miles
  • Sky: overcast at 600 ft
  • Temperature: 45°F (7°C), dew point 41°F (5°C)
  • Altimeter: 30.09 inHg
  • Observation at 4:53 pm from KDTN, 1 miles away

Injuries

FatalSeriousMinorNone
Flight crew1
Passengers1

Documents from the investigation the NTSB's docket: the evidence folder behind the report

18 documents, released by the NTSB on April 13, 2020. View them here, or download them; the NTSB redacts some personal details before release, and this site shows the NTSB's own titles rather than its file names.

The same docket at the NTSB · documents without a copy here are fetched from the NTSB when you open them.

Everything on this page comes from the NTSB's public records. The narrative, probable cause and findings are the NTSB's own words; the coded tables behind the report are written out in plain English, with pilots' ages, home towns and medical details left out. The documents and photographs are the NTSB's docket, shown as the NTSB released them. This site's own text never names anyone involved. A preliminary report can change; the final report usually follows one to two years later, and the page is refreshed when it does.