Aviation Accident Summaries

Aviation Accident Summary BFO94FA017

RAVENNA, OH, USA

Aircraft #1

N8467H

PIPER PA-28RT-201

Analysis

During the takeoff climb in instrument meteorological conditions at night, the pilot became spatially disoriented. Prior to takeoff, and during the last flight prior to the accident, the pilot was made aware of an attitude indicator inaccuracy in the accident airplane. A witness to the accident stated that he heard the airplane's engine at high RPM then go to Low RPM. He stated he heard the engine do this a few times over the airport area. He stated that he saw the airplane come out of the cloud base and then bank into a 60-degree left turn. The airplane impacted trees and then a paint hangar before coming to rest on the ground. An IFR flight plan was filed for the cross country personal flight. Witness reports indicated the cloud base was anywhere between 200 to 700 feet above the ground around the time of the accident. Post accident examination of the airframe and engine did not reveal any anomalies.

Factual Information

HISTORY OF FLIGHT On Wednesday, November 24, 1993, at 1802 eastern daylight time, a Piper PA-28RT-201, operated by the Wright-Patterson Air Force Base Aero Club near Dayton, Ohio, collided with trees and a paint shop hangar at the Portage County Airport under undetermined circumstances. The pilot was fatally injured and the airplane was destroyed. The instrument flight rules (IFR) cross country personal flight was cleared for departure from the Portage County Airport at 1800 and was destined for the Wright-Patterson Air Force Base airport. The flight was operating under 14 CFR Part 91. According to a friend, (who was also a flight student of the pilot), on the day of the accident, the pilot flew from Wright- Patterson Air Force Base to Ohio State University (OSU) airport and arrived at 1530. The friend also stated that the purpose of that day's flights were to take him from the OSU airport and drop him off at the Portage County airport in Ravenna, Ohio, for personal reasons. The friend stated that he preflighted the airplane while the pilot filed an IFR flight plan and received a weather forecast. In addition, the pilot also performed a preflight inspection of the airplane. The friend stated that they departed the OSU airport at 1615 and the flight to Portage County airport was uneventful. He stated that he sat in the left seat for the flight and received instrument flight instruction en route to the airport. The friend stated that while in cruise flight, "...we noticed that by following the attitude indicator we seemed to maintain a slight turn according to the [directional gyro]. We assumed there was a slight error in the attitude indicator. At one point the attitude indicator showed a slight (less than approx 10 deg) bank to the right while the turn and bank coordinator indicated about the same degree of bank to the left. [The pilot] explained that the turn and bank coordinator was more sensitive and to follow it. I did this and our heading stabilized." The friend stated that during the approach to the airport, they observed that the base of the clouds were about 4,000 feet above the ground and there was a "fine rain" falling. He stated they landed at the Portage County Airport at 1715 and parked the airplane at Chinn Aviation. The friend stated that the weather had deteriorated considerably since they landed and he had asked the pilot if he wanted to stay the night. He said the pilot told him to go home and that he was going to fly back to Dayton, Ohio, in about fifteen minutes. The friend stated that the pilot and he debriefed the flight and then the pilot called a Flight Service Station to get a weather outlook. He stated that when he left the pilot, "He was happy and affable, and totally in control." The owner of Chinn Aviation stated that N8467H did not receive any fuel. He stated that he closed his facility at 1750 and the pilot was in his airplane. Mr. Chinn stated that he left his facility and did not see N8467H take off. According to the transcript of radio communications from the Akron-Canton Clearance position at the Akron-Canton Air Traffic Control tower, the pilot requested and received an IFR clearance to the Wright-Patterson Air Force Base from the Portage County Airport. At 1759:04, N8467H was cleared for takeoff from runway 09 and was told, once airborne, to "...contact departure." When the Akron-Canton Departure controller was not contacted by the pilot of N8467H, he asked the clearance controller to query the pilot over the clearance delivery frequency. At 1805:19, the clearance delivery controller transmitted to the pilot of N8467H and inquired about his position, however, there was no response. The clearance delivery controller did note that she saw "...on the ARDRW radar scope a splat at the 29G [Portage County] Airport and [then] it disappeared." A witness located in a hangar at the airport stated, "...I heard a low flying aircraft. At first I thought it was a 'buzz job.' After several zooms, I became concerned that it might be someone in trouble. It sounded like low-level, high power aerobatics over my building. After about 1/2 to 1 minute, [I heard] 3 or 4 loud zooms, [then] I heard [an] impact." Another witness, located in a home about 400 yards from the accident site stated, "...I noticed that the sound of this particular airplane in the area was loud, indicating that the aircraft was very close to the house in which I was staying. Based on the sound of the plane, and being familiar with the airport and several types of aircraft, I could almost surely state that the aircraft was going in a north-east to south-east turning pattern." He stated that he heard the sound of the impact and ran to the accident site. The witness also stated that the airport runway lights were on when he got to the accident site. Another witness, the owner of a maintenance shop at the airport, located about 100 feet from where the airplane impacted the paint hangar stated, "I heard the airplane's engine sound like it was looking for the airport. The engine was running wide open, dead off, wide open, dead off. I went outside and could not see [the airplane] because the clouds were so low. When I did see [the airplane], I saw the landing light then the airplane as it came out of the clouds...on a northerly heading....The plane was in at least a 60-degree nose down left turn at a very high speed. The airplane went in and it looked like the left wing hit the building....This happened about 6:05 pm." The accident occurred during the hours of darkness at 41 degrees 12.37 minutes north latitude and 81 degrees 15.07 west longitude. PERSONNEL INFORMATION The pilot held a commercial flight certificate with single and multi-engine land ratings. He also held a single engine land instrument rating and a single engine land instrument instructor rating. According to the Wright-Patterson Air Force Base Aero Club records, at the time of the accident the pilot had accrued about 2,800 total flying hours and was instrument proficient. The pilot's personal log book was not recovered. According to a witness and rescue personnel at the accident site, the pilot was found in the airplane's right front seat. METEOROLOGICAL INFORMATION N8467H landed at the Portage County Airport during the hours of daylight at 1715. At that time, the base of the clouds were reported to be 4,000 feet above the ground. Approximately 15 to 30 minutes later, witnesses reported that the weather deteriorated and the base of the clouds were reported to be about 500 feet above the ground. N8467H departed the airport during the hours of darkness, about 1800. A witness located in his hangar at the time of the accident, stated that he took-off in his airplane from the Portage County Airport about an hour after the accident. He stated that the base of the clouds were about 700 feet above the ground. Another witness who saw the airplane impact the hangar stated that he thought the base of the clouds were about 200 to 500 feet above the ground with precipitation falling. The owner of Chinn Aviation stated that he had two airplanes flying in the area around 1715. He stated that both airplanes had landed before 1730 and the pilots of both airplanes stated that they did not encounter any icing conditions or freezing precipitation. He stated that at 1730, the temperature was about 40-degrees fahrenheit and the base of the clouds were at 500 feet above the ground. The Akron, Ohio, National Weather Service Station, located about 20 nautical miles southwest of the accident site, recorded a weather observation about 1810. The report stated that there was a scattered cloud layer at 1,000 feet above the ground and a base of the clouds at 3,700 feet above the ground, with rain and fog. The visibility was 5 miles; the temperature was 43 degrees fahrenheit; the dew point was 41 degrees fahrenheit, and; the wind was from a magnetic heading of 020-degrees at a velocity of 12 knots. The altimeter setting was 30.19 inches of mercury. Another weather observation facility located 27 nautical miles east of the accident site observed the weather close to the time of the accident. That facility measured a cloud base at 600 feet above the ground, a visibility of two and one half miles with light rain falling, and a three degree temperature and dew point spread. A third National Weather Service in Cleveland, Ohio, located about 30 nautical miles northwest of the accident site, recorded a weather observation near the time of the accident. The weather observation measured the cloud base at 500 feet above the ground, the visibility was 7 miles with light rain and fog falling, and a two degree temperature and dew point spread. WRECKAGE AND IMPACT INFORMATION The airplane wreckage was strewn along a path about 193 feet from the initial tree strikes, on a magnetic bearing of 270 degrees. Examination of the accident site revealed several broken tree limbs and a rust colored paint hangar substantially damaged with ground markings leading from the paint hangar to the fuselage's final resting spot. The airplane's left wing tip was found beneath the broken tree limbs. A portion of the outboard section of the left wing was found lodged through the side of the most northeasterly corner of the paint hangar and another portion of the left wing, including the left main gear, was found broken away from the fuselage wrapped around the paint hangar's door support beam. The outboard section of the right wing was lodged in the roof of the paint hangar and the inboard section of the right wing remained attached to the fuselage. The right main gear remained with the inboard section of the right wing and was in the extended position. Airplane debris was found along the entire wreckage path. The engine was broken away from its mounts at the firewall and found along the wreckage path. The fuselage and empennage came to rest just short of a row of hangars. Witnesses stated that there was aviation fuel spewed throughout the wreckage. All airplane structure was accounted for throughout the wreckage path. The flap handle and markings on the flap handle detent in the cockpit indicated that the flaps were extended 10-degrees. The elevator trim tab was in the neutral position and the rudder trim position was not determined. The cockpit instruments were destroyed. The attitude indicator was dismantled at the accident site. No markings were noted inside the attitude indicator's gyro casing. The airspeed indicator was at zero and no markings were observed on the instrument's face card. The airspeed indicator's case was intact and capable of holding pressure. Markings on the altimeter's face card and pointers provided some indication of its reading at the time the glass was broken. The marks were inconsistent and indicated the altimeter read either 2,280 feet or 1,170 feet mean sea level. (See attached Materials Directorate report for further instrument inspection detail.) The engine was examined at the accident site on November 25, 1993, and then disassembled at the Textron Lycoming facility in Williamsport, Pennsylvania. The examination revealed no anomalies. Fuel samples were taken from the engine driven fuel pump, the fuel manifold, the filters, and the fuel injector. No contaminates were found. The vacuum pump was examined and dismantled with no anomalies noted. The vacuum pump system, including the filter was, damaged. The propeller was examined at the accident site. Chordwise scratches were noted on both propeller blades. One propeller blade was bent forward and rust colored paint was observed along the leading edge. The other propeller blade was bent aft. The propeller was shipped to the McCauley Accessory Division in Vandalia, Ohio, and inspected. The examination could not determine the blade angle at impact. All impact signature marks were outside the normal pitch range. The McCauley Memorandum reported, "...overall propeller damage and significant blade bending, especially the smooth forward bending of the No. 2 blade, is indicative of high power." MEDICAL AND PATHOLOGICAL INFORMATION The autopsy was performed by Dr. Anand Arora at the Robinson Memorial Hospital in Ravenna, Ohio, on November 25, 1993. The autopsy revealed no evidence of physical incapacitation or impairment prior to the accident. The toxicological examination was performed by Dr. Barry Levine at the Armed Forces Institute of Pathology in Washington, D.C., on December 8, 1993. The toxicology results were negative for all screened volatiles and drugs. ADDITIONAL INFORMATION According to the Wright-Patterson Air Force Base Aero club regulation 215-12, section 4-5, paragraph L, "Takeoff minimums will be no lower than authorized landing minimums at the departure airport from which the aircraft is operationally capable of flying." For runway 09 at the Portage County Airport, the published VOR-A minimum descent altitude was 603 feet above the ground. The airplane wreckage was released to Lieutenant Colonel Gillespie, Chief of the Flight Safety Division at the Wright-Patterson Air Force Base near Dayton, Ohio, on January 25, 1994.

Probable Cause and Findings

THE PILOT ATTEMPTED TO FLY THE AIRPLANE WITH KNOWN DEFICIENCIES IN THE ATTITUDE INDICATOR AND BECAME SPATIALLY DISORIENTED DURING THE TAKEOFF CLIMB. FACTORS IN THE ACCIDENT WERE THE LOW CEILING, NIGHT CONDITIONS, AND AN INACCURATE ATTITUDE INDICATOR.

 

Source: NTSB Aviation Accident Database

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