Aviation Accident Summaries

Aviation Accident Summary CHI97FA308

St. Ignaces, MI, USA

Aircraft #1

N9399W

Piper PA-28-235

Analysis

The noninstrument-rated pilot departed for a cross-country flight in instrument meteorological conditions (IMC). The airplane was reported missing the following day. Radar data showed the airplane traveling south from the airport about 25 miles over Lake Huron, then turning north before disappearing from radar. The airplane was not located during the initial search but was found about 21 years after it was reported missing in a heavily forested area. A friend of the pilot stated that, while flying together in IMC, he allowed the pilot to assume control of the airplane three times and that, each time, the pilot experienced vertigo and the friend had to intervene to regain airplane control. Weather conditions along the flight route included cloud ceilings as low as 400 ft above ground level. It is possible the pilot departed believing he could fly under the cloud ceilings. However, radar data showing the airplane flying south and then turning north before disappearing from radar indicates that the airplane likely encountered weather too adverse for the pilot to navigate through and that the pilot subsequently altered the flight route to find improved weather or an alternate landing location but subsequently crashed the airplane. Based on available evidence, it could not be determined if the pilot experienced vertigo, spatial disorientation, or controlled flight into terrain due to the low visibility conditions. Given the weather conditions and that the pilot was not instrument rated, he should not have departed in IMC; instead, he should have delayed his departure until the weather conditions improved to allow flight in visual meteorological conditions.

Factual Information

HISTORY OF FLIGHTOn September 14, 1997, a Piper PA-28-235 airplane, N9399W, impacted terrain near St. Ignace, Michigan. The noninstrument-rated pilot and passenger were fatally injured, and the airplane was destroyed. The airplane was owned by the pilot who was operating it as a Title 14 Code of Federal Regulations Part 91 personal flight. Instrument meteorological conditions prevailed at the departure airport and along the flight route, and no flight plan was filed for the cross-country flight, which originated from Drummond Island Airport (KY66), Drummond Island, Michigan, about 1553 destined for Livingston County Spencer J. Hardy Airport (OZW), Howell, Michigan. According to a friend of the pilot, the pilot was scheduled to return to OZW on the afternoon of September 14. The next day, the pilot's employer contacted the friend and notified him that the pilot had not shown up for work. The friend, who was also a pilot, reported the airplane missing and assisted in the subsequent search. He stated that an instrument-rated pilot had departed from, but then returned to, KY66 before the accident flight due to the weather conditions and that accident pilot knew of the returned flight before departing KY66. The U.S. Coast Guard initiated a search for the missing airplane in September 1997, and its search plan stated that Toronto Air Route Traffic Control Center National Track Analysis Program (NTAP) data showed that the airplane departed KY66 at 1553, flew 20 to 25 miles south over Lake Huron, and then turned 180° north before disappearing from radar. The search plan also stated that pilots in the area reported ceilings of about 200 ft. The search ended unsuccessfully after 4 days. The wreckage was not found until July 11, 2018, when U.S. Forest Service personnel saw it while conducting a timber survey. The referenced NTAP data were not located during the investigation, which took place after the wreckage was found. PERSONNEL INFORMATIONThe pilot held a private pilot certificate with an airplane single engine-land rating; he did not have an instrument rating. The pilot's friend stated that, while flying with the pilot in IMC, he allowed the pilot to assume control of the airplane three times and that, each time, the pilot experienced vertigo and the friend had to intervene to regain airplane control. No pilot logbooks were recovered during the investigation. AIRCRAFT INFORMATIONThe four seat, all-metal, unpressurized airplane was equipped with low-mounted wings and fixed-tricycle landing gear. The airplane was powered by a six-cylinder Lycoming O-540 engine, which drove a two-bladed, constant-speed propeller. No maintenance logbooks were found during the investigation. METEOROLOGICAL INFORMATIONIn September 1997, KY66 had no weather-reporting capability. The closest weather reporting facility to the departure airport was Chippewa County International Airport (KCIU), Sault Ste Marie, Michigan, located 35 miles west-northwest of KY66, 25 miles northeast of the accident site, and immediately north of the route of flight. The airport had an automated weather observing system (AWOS) that was not equipped with a precipitation discriminator. The KCIU weather observation at 1614 included wind from 230º at 7 knots, visibility 3 1/2 miles, scattered clouds at 1,000 ft above ground level (agl), temperature 18ºC, dew point 16°C, and an altimeter setting of 30.08 inches of mercury (Hg). The closest weather reporting facility to the accident site was Mackinac Island Airport (KMCD), Mackinac Island, Michigan, located 9 miles east-southeast of the site. The airport had an AWOS that was not equipped with a precipitation sensor. The KMCD weather observation at 1615 included wind from 250º at 6 knots, visibility 2 miles in fog, ceiling broken at 400 ft agl, temperature 17ºC, dew point temperature 17ºC, and an altimeter setting of 30.08 inches of Hg. AIRPORT INFORMATIONThe four seat, all-metal, unpressurized airplane was equipped with low-mounted wings and fixed-tricycle landing gear. The airplane was powered by a six-cylinder Lycoming O-540 engine, which drove a two-bladed, constant-speed propeller. No maintenance logbooks were found during the investigation. WRECKAGE AND IMPACT INFORMATIONThe airplane wreckage was located in marshy and densely forested terrain in the Hiawatha National Forest 5 miles northwest of Mackinac County Airport, St Ignace, Michigan. A tree southwest of the wreckage was broken off about 30 ft agl, and an angular, smooth cut was observed. Parts of the airplane were found between the cut tree and the wreckage. A 10-ft-diameter pond located immediately aft of the airplane's empennage contained fragmented airplane components. No evidence of postimpact fire was found. Consistent with exposure to the elements and natural processes, the airplane was partially submerged in the boggy soil, and tree roots had entangled portions of the wreckage. In areas, young trees had grown up through gaps and holes in the wreckage. Corrosion and rust were evident in areas of wreckage partially submerged in the soil. The fuselage came to rest upright on an approximate 030° magnetic heading. The cabin area was collapsed from aft crushing damage to the forward fuselage. The firewall was crushed aft into the instrument panel. The instrument panel was fragmented, and the instruments were displaced. Portions of the belly and aft wing carry-through were peeled from the bottom of the fuselage and were lying beneath the empennage. Both the left and right wings were impact-damaged and separated from the fuselage. The left aileron was impact-damaged but remained attached to the wing. The right aileron was impact-damaged, and a portion remained attached to the wing. The remainder of the aileron was found near the fuselage. The left and right flaps were separated and found near the fuselage. Flight control continuity was established in both wings between the ailerons and the point where the wings separated from the fuselage. Both wing control cable separations were consistent with overload. The empennage was canted right about 45° compared to the fuselage. The stabilator, vertical stabilizer, and rudder remained attached to the empennage. Continuity of the stabilator, rudder, and stabilator trim cables to the cabin area was established. The engine came to rest upright at the base of several trees and was partially buried under leaves and tree roots. It was canted right about 90° compared to the fuselage. The accessory housing was separated and was lying next to the engine. One magneto was found below the instrument panel, and the other magneto was not found. Examination of the engine was limited due to the position of the engine and its entanglement with trees. The engine could not be rotated, and engine continuity could not be verified. The engine data plate was not located. Although limited by the condition and age of the wreckage, the engine examination did not reveal any preimpact mechanical malfunctions or failures that would have precluded normal operation. The propeller remained attached to the engine, and the two blades remained in place in the hub. Both blades were in a position beyond coarse pitch. One blade was found embedded in the side of a tree, and it was S-bent and exhibited tip curling. The blade's leading edge was nicked, and it exhibited chordwise scratching. The other blade had sunken into the soil, was bent back about 45°, and exhibited chordwise scratching, tip curling, and leading-edge dents. ADDITIONAL INFORMATIONAccording to the Federal Aviation Administration pilot safety brochure on spatial disorientation, the following are basic steps that should help prevent spatial disorientation: •Take the opportunity to experience spatial disorientation illusions in a Barany chair, a Vertigon, a GYRO, or a Virtual Reality Spatial Disorientation Demonstrator. •Before flying with less than 3 miles visibility, obtain training and maintain proficiency in airplane control by reference to instruments. •When flying at night or in reduced visibility, use the flight instruments. •If intending to fly at night, maintain night-flight currency. Include cross- country and local operations at different airports. •If only Visual Flight Rules-qualified, do not attempt visual flight when there is a possibility of getting trapped in deteriorating weather. •If you experience a vestibular illusion during flight, trust your instruments and disregard your sensory perceptions. MEDICAL AND PATHOLOGICAL INFORMATIONThe Mackinac County Medical Examiner, Saint Ignace, Michigan, conducted an autopsy on the pilot and determined that the cause of death was "trauma due to an airplane accident." No toxicology testing was conducted.

Probable Cause and Findings

The noninstrument-rated pilot's improper decision to depart in instrument meteorological conditions, which resulted in impact with terrain.

 

Source: NTSB Aviation Accident Database

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