Aviation Accident Summaries

Aviation Accident Summary ATL05FA041

Bradley, SC, USA

Aircraft #1

N2823H

Piper PA-28-181

Analysis

The private pilot was on a visual flight rules (VFR) night flight over a sparsely populated area; the airplane crashed about 9 miles from the departure airport. Wreckage and impact information was consistent with a steep-angle, high-speed descent. No evidence of mechanical malfunction was observed. Weather conditions included mid to high-level cloud coverage with ceilings broken at 2,200 feet above ground level and overcast at 3,400 feet above ground level. Moon phase was a waning crescent with 11 percent of visible disk illuminated. Review of these data by a Safety Board senior meteorologist revealed that the moon was below the horizon at the time of the accident and would have been obscured by the mid to high-level cloud cover. According to FAA advisory circular (AC) 60-4A "Pilot's Spatial Disorientation," "Surface references and the natural horizon may at times become obscured, although visibility may be above visual flight rule minimums. Lack of natural horizon or surface reference is common ... especially at night in extremely sparsely populated areas or in low visibility conditions. A sloping cloud formation, an obscured horizon, a dark scene spread with ground lights and stars, and certain geometric patterns of ground lights can provide inaccurate visual information for aligning the aircraft correctly with the actual horizon. The disoriented pilot may place the aircraft in a dangerous attitude."

Factual Information

HISTORY OF FLIGHT On January 7, 2005, at 1856 eastern standard time, a Piper PA-28-181, N2823H, registered to pending applicant Cherokee One, LLC, and operated by the private pilot, collided with trees and the ground in Bradley, South Carolina. The personal flight was operated under the provisions of Title 14 CFR Part 91 with no flight plan filed. Visual meteorological conditions prevailed. The private pilot and the three passengers received fatal injuries, and the airplane was destroyed. The flight departed McCormick County Airport (S19), McCormick, South Carolina, at an undetermined time on January 7, 2005. According to flight service station records, the pilot telephoned the Anderson, South Carolina, automated flight service station (AFSS) for a weather briefing at 1739 and requested a standard weather briefing for a 1-hour-15-minute flight from S19 to Marlboro County Jetport (BBP), Bennettsville, South Carolina, with an estimated departure time of 2000. The pilot also requested wind information for 3,000 and 6,000 feet. The briefer told the pilot that the satellite imagery was showing cloud cover over the entire route. The briefer stated that the current reported conditions at Greenwood County Airport (GRD), South Carolina, were visibility 10 statute miles with overcast clouds at 3,800 feet, and at Columbia, South Carolina, ceilings were broken at 4,000 feet. The briefer stated that the forecast for Columbia was ceilings broken at 2,000 feet, and, by 2100, conditions at Florence, South Carolina, were forecast to include clouds at 2,000 feet with mist, and that conditions there were expected to deteriorate after 2200. The pilot did not file a flight plan to BBP, and, according to information provided by family members, the accident flight was instead en route to GRD. No known radio communication or radar contact was made with the flight. When the airplane failed to arrive at GRD, friends and family became concerned and initiated a search. Witnesses in residences near the accident site reported the downed airplane to the local 911 operator at 1856. One witness reported the airplane sounded "as if in distress ... [with] the engine idling high." The wreckage was found in a wooded area 9.14 nautical miles north northeast of S19. PERSONNEL INFORMATION The pilot held a private pilot certificate for airplane single-engine land issued March 6, 1999, and a third-class airman medical certificate issued September 27, 2004, with no limitations. The pilot's logbook was not recovered for examination. On the pilot's March 6, 1999, application for his private pilot certificate, he reported 55.5 total flight hours with 7.3 hours night instruction received, and on his September 27, 2004, application for the medical certificate, he reported 150 total civilian flight hours. AIRCRAFT INFORMATION The four-seat, low-wing, fixed-gear airplane, serial number (S/N) 28-7990474, was manufactured in 1979. It was powered by a Lycoming O-360-A4M 180-hp engine, S/N L-29497-36A, and equipped with a Sensenich model 76EM8S5-0-62, S/N 19917K, fixed-pitch propeller. Review of copies of maintenance logbook records showed an annual inspection was completed November 24, 2004, at a recorded tachometer reading of 5173.1 hours, airframe total time of 5713.1 hours, and engine time since major overhaul of 642.1 hours. The tachometer and the Hobbs hour-meter were observed at the accident site, however, damage precluded determining the current readings. METEOROLOGICAL INFORMATION A review of recorded data from the GRD automated weather observation station, elevation 631 feet, revealed at 1816 conditions were winds calm, visibility 10 statute miles, cloud conditions broken at 2,200 feet above ground level and overcast at 3,400 feet above ground level. The GOES-12 infrared satellite image at 1832 depicted a region of mid- to high-level cloud cover extending over an area that included the accident site. No convective clouds were identified in the immediate vicinity. On the day of the accident, official sunset was at 1736, end of civil twilight was at 1804, moonset was at 1434 with an elevation more than 15 degrees below the horizon, and moonrise would be 0548 on January 8, 2005. Moon phase was a waning crescent with 11 percent of visible disk illuminated. Review of these data by a Safety Board senior meteorologist revealed the moon was below the horizon at the time of the accident and would have been obscured by the mid- to high-level cloud cover. WRECKAGE AND IMPACT INFORMATION Wreckage debris and broken tree limbs were scattered about 175 feet along an approximate 235-degree magnetic heading from a cluster of scraped and broken trees. A separated section of the outboard left wing and an outboard section of the left aileron were lodged in one of the damaged trees at the beginning of the debris path. A crater approximately 3 feet deep, 20 feet long, and 10 feet wide was observed on the ground approximately 90 feet southwest of the initial cluster of broken trees, and the fuselage and empennage were located approximately 40 feet southwest of the crater. The fuel tanks were breached, and fuel odor was detected in the general area where some fuel tank pieces were found. From the northeast side of the debris path looking southwest toward the main wreckage, the tree in which the outboard section of the left aileron was lodged showed scrapes and damage higher than the break and scrape damage in the other trees. Examination of the left wing revealed a separated section was on the ground at the base of a tree with the left flap attached; the main wing spar and the flap were bent, and the fuel filler cap was secure in its port. An approximate 6-foot section of aileron cable with a turnbuckle intact was found with this section of the left wing; the separated cable ends showed a splayed appearance of the individual cable strands. The composite left wingtip cap was found separated and in a tree. The left inboard section of aileron was found attached at the inboard hinge to another separated section of the left wing. The left aileron bellcrank was not located. The Greenwood County Sheriff's Department retrieved the outboard section of the left aileron from the tree and submitted it for examination. Sheriff's department personnel reported that the components were crushed around the tree and that it was difficult to separate them from the tree. Examination revealed the outboard section of the left aileron was attached to a separated section of the outboard left wing at the outboard hinge and both showed semi-circular, fore-to-aft accordion crush damage and tree bark debris. Examination of the right wing revealed an outboard section was separated and on the ground with the composite wingtip cap attached and a section of the right aileron attached at the outboard and middle hinges. Sections of the main wing spar were bent and separated. The fuel filler cap was absent from the port and found within the debris path. The right aileron bellcrank was attached, both arms were bent inboard, and the stops were in place. An approximate 6-foot section of balance cable and an approximate 2-inch section of the control cable were attached to the bellcrank; the separated cable ends showed a splayed appearance of the individual cable strands. The inboard section of the right aileron was separated inboard of the rivet line. An inboard section of the right flap about 2.5 feet long was found separated with the inboard bracket attached. The outboard section of the right flap was found separated and showed semi-circular fore-to-aft crush damage. The empennage was attached to the fuselage with the vertical fin attached by a section of aircraft skin. The rudder was attached to the vertical fin at all attach points, and the rudder control cables were attached to the rudder horn. Rudder control continuity was established from the rudder to the cockpit rudder bar. The stabilator structure with the trailing edge was attached, most of the left side skin was attached, most of the right side skin was separated and found in the debris path, the balance weight was attached, and the stabilator trim tab was attached. The stabliator control cables were attached to the balance weight. Stabilator control continuity was established from the balance weight tube assembly to the cockpit t-bar. The stabilator trim tab arm assembly was attached to the tab and bent, and the trim control cable was observed on its drum. The fuselage was on its left side. The cabin, cabin roof, and cabin floor showed crush damage, the cabin door was separated, and the seats showed deformation. The instrument panel was crushed with most instruments and avionics separated from their mounts. A separated section of a control yoke was found near the impact crater. Separated rudder pedals were observed within the debris field. The engine primer control was found separated and in the "in" and "locked" detent. The engine start and magneto switch was found separated with the key absent and the orientation of the keyhole in the "both" position. The attitude indicator and the directional gyro were found crushed and separated; disassembly of each revealed their respective rotors and rotor housings displayed circumferential scoring. The engine was separated from the firewall with sections of the engine mount bent and attached. Dirt and debris were found embedded around the propeller, spinner, and the cylinder fins. The propeller remained attached to the crankshaft, the spinner was crushed onto the propeller hub, and both propeller blades displayed chordwise gouges across the leading edge and forward face. One propeller blade exhibited an s-shaped bend and was twisted from root to tip, and the other propeller blade was bent and twisted from approximately mid-span to tip. Tree branches 2- and 3-inches in diameter were found within the debris path severed cleanly in a diagonal linear pattern. Crush damage was observed to the No. 1 cylinder exhaust valve pushrod. The exhaust system was crushed. The starter and ring were crushed, deformed, and impacted with dirt and debris. The alternator was not attached, and its rotor was found separated with dirt embedded. The engine sump and the accessory case were crushed with case pieces and the accessories separated, and accessory drive gears were exposed. Separated pieces of both magnetos, the ignition harness, the top of the vacuum pump, the vacuum system air filter, and the oil filter were found in the debris field. The vacuum pump drive coupling was observed intact at the separated base of the pump. The oil pump and the engine-driven fuel pump were found attached to a separated section of accessory case. The carburetor was separated, and the throttle, mixture, and heat controls were damaged. The air box was crushed with dirt embedded in the air filter element. The oil filler cap was secure it its port. Examination revealed the accessory drive gears turned when the propeller was turned by hand. The propeller was removed to facilitate further examination, and compression developed on all cylinders when the propeller flange was turned by hand. Movement was observed on all valves except for the No. 1 cylinder exhaust valve. The bent pushrod for the No. 1 cylinder exhaust valve was removed, and the valve lifter for the No. 1 exhaust valve was then observed to move when the propeller flange was turned. The top and bottom spark plugs for each cylinder were removed for examination. The No. 1 cylinder top plug was damaged with part of the electrode missing; the other plug electrodes showed light gray-colored deposits and the wear on each was consistent with the "normal" condition on the Champion AV-27 illustrated comparison card for massive electrode plugs. Oil residue was observed on the Nos. 1 and 3 cylinder top and bottom plugs. Examination of the crushed muffler components revealed no observed evidence of corrosion or pitting. Disassembly examination of the carburetor revealed both internal floats were shattered, the needle valve showed no abnormalities, the bowl appeared clean and free of contaminants, and the inlet port at the screen was free of debris. The fuel finger screen was free of debris. The damaged and exposed oil filter element showed clean, green-colored oil residue and no evidence of metallic contaminants. Disassembly of the oil pump showed green-colored oil residue present and the internal gears were intact. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot on January 8, 2005, by Newberry Pathology Associates, P.A., Newberry, South Carolina, as authorized by the Greenwood County Coroner. The autopsy findings included "multiple blunt force injuries," and the report listed the specific injuries. The cause of death was reported as two of the listed injuries. Forensic toxicology was performed on specimens from the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated no ethanol was detected in the liver or the muscle, and no drugs were detected in the liver. ADDITIONAL INFORMATION A Safety Board air traffic control specialist reviewed radar data from the Charlotte ARSR-1E, Raleigh ARSR-1A, and the Fort Fisher ARSR-4 sites for timeframes and locations that included the accident flight but found no associated primary or mode C targets. The specialist reported that radar coverage from these sites for low altitudes in the vicinity of S19 and the accident site is limited due to terrain interference. A review of satellite photographs provided by the Greenwood County Sheriff's Office showed the accident site was in wooded area a few hundred feet east of McCormick Highway, State Highway 10, near an eastern boundary of the Sumter National Forest. Review of map data from the Sumter National Forest, Long Cane Ranger District, showed areas of the Sumter National Forest spanned the direct flight path between S19 and GRD south of Bradley. The FAA Airplane Flying Handbook, FAA-H-8083-3, chapter 10, states the following about night flying: "Night flying requires that pilots be aware of, and operate within, their abilities and limitations ... . Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references." According to FAA advisory circular (AC) 60-4A "Pilot's Spatial Disorientation," "Surface references and the natural horizon may at times become obscured, although visibility may be above visual flight rule minimums. Lack of natural horizon or surface reference is common on over-water flights, at night, and especially at night in extremely sparsely populated areas or in low visibility conditions. A sloping cloud formation, an obscured horizon, a dark scene spread with ground lights and stars, and certain geometric patterns of ground lights can provide inaccurate visual information for aligning the aircraft correctly with the actual horizon. The disoriented pilot may place the aircraft in a dangerous attitude." The airplane wreckage was released March 14, 2005.

Probable Cause and Findings

The pilot's loss of control of the airplane due to spatial disorientation, which resulted in an uncontrolled descent and collision with trees and the ground. A factor was the dark night conditions.

 

Source: NTSB Aviation Accident Database

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