Aviation Accident Summaries

Aviation Accident Summary BFO94LA045

NORWOOD, MA, USA

Aircraft #1

N777JM

PIPER PA-31T

Analysis

THE FLIGHTCREW WAS ADVISED PRIOR TO INITIATING THE APPROACH THAT VISIBILITY AT THE AIRPORT HAD DECREASED TO 1/8 MI WITH LIGHT RAIN, FOG AND OBSCURATION. PUBLISHED LANDING VISIBILITY MINIMUMS FOR THE APPROACH WAS 1 MI. THE 150-FT WIDE RUNWAY HAD BEEN PLOWED 100 FT WIDE, AND THERE WERE SNOWBANKS UP TO 3 FT HIGH ON BOTH SIDES. THE AIRPLANE TOUCHED DOWN ON THE UNPLOWED PORTION OF THE RUNWAY ONTO A SNOWBANK, COLLAPSING THE LANDING GEAR. THE FLIGHTCREW STATED THAT THE APPROACH LIGHTS AND RUNWAY WERE IN SIGHT DURING THE ENTIRE APPROACH, AND THAT THE SECOND PILOT TOLD THE PIC THAT HE WAS TOO FAR LEFT AND NEEDED TO CORRECT TO THE RIGHT AS THE AIRPLANE WAS ABOUT TO TOUCH DOWN. THE TOWER CONTROLLER STATED THAT HE LOST SIGHT OF THE AIRPLANE AS IT LANDED DUE TO FOG.

Factual Information

On February 21, 1994, about 1750 hours eastern standard time, N777JM, a Piper PA-31T, being operated by Eastern Air Charter, Inc., Norwood, Massachusetts, struck a snowbank during landing at the Norwood Memorial Airport and was substantially damaged. The captain, first officer, and two of the three passengers were not injured. The third passenger received minor injuries. Instrument meteorological conditions prevailed and a instrument flight rules (IFR) flight plan was filed. The on-demand, air taxi lifeguard flight departed from Bangor, Maine, at 1637 hours and was conducted under 14 CFR 135. According to a medical doctor on board the flight, the purpose of the flight was to provide immediate ambulatory transportation of an infant who was in respiratory distress at the Eastern Maine Medical Center, Bangor, Maine. It was requested that the infant be flown to Norwood and then transported via ground transportation to the Massachusetts General Hospital, Boston, Massachusetts. The medical doctor, who was working at the Massachusetts General Hospital at the time, was told to contact an air ambulance service at the Norwood Memorial Airport to arrange for transport. The doctor and a nurse later arrived at the airport and were met by the pilot-in-command (PIC) and second-in-command (SIC). The four occupants boarded the airplane and departed for Bangor about 1330 hours. The flight arrived in Bangor about 1430 hours. About 1630 hours, the infant was placed in an airborne isolette and secured in the aircraft. The medical doctor stated that he asked the PIC about the weather conditions for the flight back to Norwood, and the PIC responded that there were "clear skies from Bangor to Boston" and a "little" fog around the Boston area, but that it was be safe to proceed. The flightcrew stated that they received a weather briefing from the Bangor Flight Service Station (FSS) prior to the accident flight to Norwood. The FAA did not provide evidence of a weather briefing from the Bangor FSS; however, the Bridgeport Automated FSS reported that the flightcrew had obtained a weather briefing for the previous flight from Norwood to Bangor at 1255 hours. At 1633 hours, an IFR clearance was requested by the flightcrew through the Bangor Air Traffic Control Tower. A clearance from Bangor to Norwood was granted. At 1637 hours, the flight was cleared for takeoff. At 1650 hours, an individual using the same callsign at the accident airplane called the Bridgeport Automated FSS from a telephone line in Norwood and requested a weather briefing for the Boston area. The individual identified himself; the name did not match either of the names for the flightcrew of the accident flight. According to the FAA Report of Aircraft Accident, at 1736 hours, N777JM was advised by Boston Approach Control to expect the Localizer Runway 35 approach at Norwood. N777JM advised that they had the current Norwood Automated Terminal Information Service (ATIS) at that time. The ATIS reported an estimated ceiling of 4,000 feet overcast and a visibility of one mile with light rain and fog. At 1737 hours, Boston Approach Control advised N777JM that the visibility at Norwood had decreased to 1/8 mile with light rain and fog. N777JM acknowledged. The airplane was 15 miles form Norwood at the time. At 1738 hours, Boston Approach Control again advised N777JM of the latest weather information at Norwood. This information included a visibility of 1/8 mile with light rain and fog and a partially obscured sky. N777JM acknowledged. At 1742 hours, Boston Approach Control cleared N777JM for the Localizer Runway 35 approach. The airplane was 6 miles from the final approach fix at this time. At 1744 hours, Boston Approach Control instructed N777JM to change radio frequencies to the Norwood Air Traffic Control Tower. At 1746 hours, N777JM reported over the final approach fix; Norwood Tower cleared the airplane to land. According to the Tower Controller: I had the aircraft in sight and cleared him to land. The visibility was 1/8 of a mile with light rain and fog but I could see the aircraft's landing lights through the fog. The aircraft appeared to make a normal approach. After observing the aircraft over the approach end of the runway, I observed the aircraft's lights bounce up and down and I soon lost sight of the arrival due to the fog. At 1751 hours, N777JM informed Norwood Tower that they were disabled on the runway. According to the PIC and SIC, the approach lights and runway were "in sight" during the entire approach. As the airplane flared for landing, the SIC told the PIC that they were "too far left, come right more right." The left main landing gear impacted a snowbank on the west edge of the runway which yawed the nose left. The left gear collapsed and the airplane came to rest. All of the occupants were evacuated safely and an ambulance arrived to pick up the infant. No pre-impact mechanical malfunctions with the airplane were reported. According to an FAA Aviation Safety Inspector, the on-scene investigation revealed that the left wing of the airplane was "destroyed," and the left main gear and nose gear were sheered off. The investigation also revealed that "the aircraft nose gear touched down 56 feet to the left of the [runway] centerline (6 feet into the snow). The runway was plowed 100 feet wide and the snow bank was measured at 2 feet 2 inches." The FAA inspector also reported that the initial snow scars were found about 1,000 feet from the approach end of runway 35 on the west edge of the runway. The airplane came to rest off the eastern edge of the runway, facing east, about 1,000 feet from the initial snow scar. The PIC held an airline transport pilot certificate with ratings for single and multiengine instrument, and had reported 14,800 hours of total flight time, including 2,000 hours in type. He had been employed by the company since October 1987. The SIC held a commercial pilot certificate with ratings for single and multiengine instrument airplane and reported a total of 950 hours, including 40 hours in type. Runway 35 is 4,007 feet in length and 150 feet in width. At the time of the accident, the runway was plowed along its full length and 100 feet wide with snowbanks up to three feet in height. This information was available to the crew via the ATIS. A flight and ground inspection of the localizer, compass locators, marker beacons, and runway lighting system was conducted by the FAA following the accident. No discrepancies were noted. According to Federal Aviation Regulation Part 135.225, paragraph (b): No pilot may begin the final approach segment of an instrument approach procedure to an airport unless the latest weather reported by the facility . . . indicates that weather conditions are at or above the authorized IFR landing minimums for that procedure. According to the published terminal procedures for the Localizer Runway 35 approach at Norwood, the landing minimums include a visibility of one statute mile.

Probable Cause and Findings

THE PILOT'S FAILURE TO ATTAIN ALIGNMENT WITH THE CENTERLINE OF THE RUNWAY, AND HIS FAILURE TO EXECUTE A MISSED APPROACH. FACTORS WHICH CONTRIBUTED TO THE ACCIDENT WERE: THE DARK NIGHT, THE PILOT'S IMPROPER DECISION TO INITIATE THE APPROACH IN BELOW-MINIMUM WEATHER CONDITIONS, THE ADVERSE WEATHER, AND THE SNOW COVERED RUNWAY.

 

Source: NTSB Aviation Accident Database

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