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Accidents · NTSB WPR16FA178 · Final report

Piper PA 28R-201T accident near Reno, Nevada, September 12, 2016

On September 12, 2016 at about 1:13 am local time, a 1977 Piper PA 28R-201T, registered N821ET, was destroyed in an accident during initial climb near Reno, Nevada (Reno/Tahoe Intl airport). It was a personal flight under general aviation rules (Part 91). 3 people were killed. The weather was visual conditions (good weather).

The NTSB's probable cause their words, unchanged

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.

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

What the record shows

Date
September 12, 2016 · about 1:13 am local time
Place
Reno, Nevada · Reno/Tahoe Intl · map
Type
Accident
Injuries
3 people were killed.
Weather
visual conditions (good weather)
Aircraft
Piper PA 28R-201T 201T, built 1977 · all PA 28R-201Ts on the register
Registration
N821ET · no longer on the register · serial 28R-7703147
Damage
Destroyed
Flight
Personal flight · general aviation rules (Part 91)

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

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.

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. Aircraft loading event during prior to flight
  2. Inflight upset during initial climb
  3. Loss of control in flight during initial climb defining event
  4. Collision with terrain or object (not controlled flight into terrain) during emergency descent

The NTSB's findings

  • cause Aircraft › Aircraft oper/perf/capability › Aircraft capability › Maximum weight › Capability exceeded
  • cause Aircraft › Aircraft oper/perf/capability › Aircraft capability › CG/weight distribution › Capability exceeded
  • cause Personnel issues › Task performance › Planning/preparation › Weight/balance calculations › Pilot
  • cause Personnel issues › Task performance › Use of equip/info › Aircraft control › Pilot
  • cause Personnel issues › Action/decision › Info processing/decision › Decision making/judgment › Pilot
  • factor Personnel issues › Physical › Impairment/incapacitation › Prescription medication › Pilot
  • factor Environmental issues › Task environment › Pressures/demands › Time/schedule pressure › Decision related to condition

Pilot

  • Certificate: private
  • Ratings: multi-engine land; single-engine land; instrument: airplane
  • Flight time: 769 hours in all; 216 in this make and model; 16.2 in the last 90 days; 6.5 in the last 30 days
  • Last flight review: December 31, 2015
  • Medical certificate: Class 3 (without waivers/limitations)
  • Seat: left
  • Injury: fatal

The aircraft

  • Airframe total time: 4,531.5 hours
  • Last inspection: annual inspection, June 9, 2016; 15 hours since
  • Maximum gross weight: 2,900 lb
  • Seats: 4
  • Landing gear: retractable
  • Engine: Continental Motors TSIO360-KBcFB (piston); 3,044 hours total

The flight

  • Departed from: RNO Reno NV at 1:11 am
  • Destination: SQL San Carlos CA
  • Flight plan: IFR
  • Runway 25, 6,102 ft by 150 ft

Weather at the time

  • Light: daylight
  • Wind: from 270° at 14 knots, gusting 23
  • Visibility: 10 statute miles
  • Sky: a few clouds at 11,000 ft
  • Temperature: 82°F (28°C), dew point 30°F (-1°C)
  • Altimeter: 29.97 inHg
  • Observation at 1:38 am from KRNO, 1 miles away

Injuries

FatalSeriousMinorNone
Flight crew1
Passengers2

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

26 documents, released by the NTSB on December 12, 2018. 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.

#DocumentWhat it is
1 Medical Factual Report PDF, 5 pages View Download
2 Sound Spectrum Study PDF, 4 pages View Download
3 Electronic Devices - Specialist's Factual Report PDF, 6 pages View Download
4 Electronic Devices Factual Report Attachment 1 - Tabular Data data file Download
5 Witness Statements - Fixed Base Operator PDF, 6 pages View Download
6 Witness Statement - Tower Controller PDF, 1 page View Download
7 Witness Statements - Nevada Bail Bondsman PDF, 5 pages View Download
8 Airframe and Engine Examination Report PDF, 13 pages View Download
9 Engine Component Examination Report PDF, 5 pages View Download
10 Propeller and Turbocharger Component Examination Report PDF, 18 pages View Download
11 Video 1 - Atlantic Fixed Base Operator Ramp, Facing Southwest AVI file Download
12 Video 2 - Reno Airport Operations, Ramp Facing Northeast video View Download
13 Video 3 - Reno Airport Operations, Gate B9 Facing Southeast video View Download
14 Video 4 - Reno Airport Operations, Parking Lot Level 3, Northeast Corner, Facing South-southwest video View Download
15 Video 5 - Reno Airport Operations, Parking Log Level 3, South End Facing South video View Download
16 Reno (Krno) Ground Control Audio audio View Download
17 Reno (Krno) Tower Control Audio audio View Download
18 Pilot Logbook Excerpts PDF, 14 pages View Download
19 Fuel Receipt PDF, 1 page View Download
20 Airplane Performance Charts PDF, 7 pages View Download
21 Turbo Intercooler System Supplement PDF, 3 pages View Download
22 Weight and Balance Calculations PDF, 5 pages View Download
23 Evidence Control Forms PDF, 16 pages View Download
24 Statement of Party Representatives to NTSB Investigation PDF, 16 pages View Download
25 Release of Aircraft Wreckage, NTSB Form 6120.15 PDF, 1 page View Download
26 Toxicological Report (Pilot) PDF, 2 pages View Download

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.