Aviation Accident Summaries

Aviation Accident Summary CHI08FA054

Warrens, WI, USA

Aircraft #1

N1919H

Piper PA-32R-300

Analysis

The air traffic controller who was working the tower position at the departure airport reported that the accident airplane had landed at the airport. Within about 10 - 15 minutes, the pilot departed again. It was dark, and the weather was "just above" visual flight rule (VFR) minimums during the airplane's arrival and departure. The pilot did not file a flight plan. Radar track data indicated that the accident airplane flew about a 131-degree magnetic heading at about 2,500 feet mean sea level (msl) from the departure airport to the airspace near the accident site at the time associated with the accident. The radar track data indicated that the airplane was in a left, descending turn prior to being "lost" from radar contact, consistent with spatial disorientation. The post-crash inspection of the airplane revealed no preexisting anomalies. The accident site bordered an area of instrument flight rule (IFR) conditions, and was within the area with marginal VFR conditions at the time of the accident. Weather data obtained from a reporting station about 100 miles east-northeast of the accident site indicated multiple freezing levels, first at approximately 1,000 feet above ground level (agl) with temperatures below freezing to 1,500 feet, and the second freezing level at approximately 4,746 feet msl.

Factual Information

HISTORY OF FLIGHT On December 20, 2007, about 1800 central standard time, a Piper PA-32R-300, N1919H, operated by Wisconsin Aviation as a rental airplane, was destroyed when it impacted terrain about 7 miles north of Warrens, Wisconsin. The private pilot, the sole occupant, received fatal injuries. The 14 Code of Federal Regulations Part 91 personal flight departed the Chippewa Valley Regional Airport (EAU), Eau Claire, Wisconsin, about 1730 and was en route to the Watertown Municipal Airport (RYV), Watertown, Wisconsin. Night marginal visual flight rules conditions (MVFR) prevailed at the time of the accident, and no flight plan was filed. On an earlier flight, the pilot had departed in the accident airplane from RYV at about 1630 with a passenger on board. No flight plan was filed. A witness reported that the pilot landed at EAU and the passenger disembarked from the airplane. The witness reported he talked with the pilot around 1715 - 1730. He reported that the pilot did not request fuel and the pilot seemed to be in a hurry to depart. The air traffic controller who was working the tower position at EAU reported that N9119H landed at EAU, and within about 10 - 15 minutes, departed again. The tower controller reported that it was dark and the weather was "just above" visual flight rule (VFR) minimums during the airplane's arrival and departure. Radar track data indicated that an airplane transmitting a 1200 transponder code flew about a 131-degree magnetic heading at about 2,500 feet mean sea level (msl) from EAU to the airspace near the accident site at a time associated with the time of the accident. The radar track data indicated that the airplane was in a left, descending turn prior to being "lost" from radar contact. A witness who lived near the accident site reported that she heard an airplane flying at a low altitude near her home about 1800. She reported that there was ground fog when she heard the airplane. PERSONNEL INFORMAION The pilot, age 26, held a private pilot certificate with single engine land and instrument airplane ratings. He held a third-class medical certificate that was issued on April 19, 2005. He had a total of about 456 flight hours. AIRCRAFT INFORMATION The airplane was a Piper PA-32R-300, serial number 32R-7780202, manufactured in 1977. It seated 6 and had maximum gross weight of 3,400 pounds. The last annual maintenance inspection was conducted on July 12, 2007. It had flown 127 hours since the last inspection, and it had a total of 9,416 flight hours at the time of the accident. The engine was a 300-horsepower Lycoming IO-540-K1G5D engine with a Hartzell three-bladed propeller. The engine had 137 hours flight time since the last overhaul. METEOROLOGICAL INFORMATION The National Weather Service (NWS) Weather Depiction Chart for 1600 indicated that the accident site bordered an area of instrument flight rules (IFR) conditions, and was within the area depicted by MVFR conditions. At 1656, the surface weather observation at EAU was: Winds 150 degrees at 6 knots, visibility 6 miles, haze, overcast 2,000 feet above ground level (agl), temperature 2 degrees Celsius (C), dew point - 2 degrees C, altimeter 29.85 inches of Mercury (Hg). At 1756, the surface weather observation at EAU was: Wind 120 degrees at 7 knots, visibility 6 miles, haze, overcast 1,800 feet agl, temperature 2 degrees C, dew point - 2 degrees C, altimeter 29.86 inches of Hg. At 1827, the special weather observation at EAU was: Wind 140 degrees at 8 knots, visibility 5 miles, haze, overcast 1,400 feet agl, temperature 2 degrees C, dew point - 2 degrees C, altimeter 29.86 inches of Hg. At 1755, the surface weather observation at Volk Field Airport (VOK), Camp Douglas, Wisconsin, located about 19 miles south-southeast of the accident site, was: Wind 150 degrees at 4 knots, visibility 1.5 miles, light drizzle and mist, ceiling overcast 900 feet agl, temperature 1 degrees C, dew point 1 degrees C, altimeter 29.86 inches of Hg. At 1855, the surface weather observation at VOK, was: Wind 130 degrees at 4 knots, visibility 1.75 miles, mist, ceiling overcast 1,100 feet agl, temperature 1 degrees C, dew point 1 degrees C, altimeter 29.89 inches of Hg. The closest upper air sounding was from the NWS Green Bay, Wisconsin, located about 100 miles east-northeast of the accident site at an elevation of 702 feet above mean sea level (msl). The sounding indicated multiple freezing levels, first at approximately 1,000 feet agl with temperatures below freezing to 1,500 feet, and the second freezing level at approximately 4,746 feet msl. The sounding indicated a relative humidity of 75 percent or more from the surface up to approximately 3,000 feet msl, and between 11,000 to 17,000 feet msl in a stable atmosphere. The astronomical data for VOK indicated the following: Beginning of civil twilight: 0659 Sunrise: 0732 Sunset: 1626 End of civil twilight: 1659 Elevation of Sun at 1820: more than 15 degrees below the horizon Moonrise: 1319 Elevation of Moon at 1820: 50.5 degrees above the horizon Azimuth of Moon: 112 degrees Percent illuminated: 87 percent Phase of Moon: Waxing gibbous WRECKAGE AND IMPACT INFORMATION The airplane impacted a peat bog located about 60 nautical miles (nm) on a 130-degree bearing from EAU, and about 97 nm from RYV. The airplane wreckage was localized at the impact point on a heading of about 100 degrees magnetic. There was no wreckage debris path, and there was no post impact fire. The wreckage was moved to a maintenance hangar in Oshkosh, Wisconsin, for inspection. The fuselage was fragmented during impact and during the recovery process. The control 'T' bar was in place and both stabilator cables were attached. Both stabilator cables were separated just aft of the T bar and were "broomstrawed." Both rudder cables were attached to the rudder bar but were separated in the forward cockpit. Both separations were broomstrawed. The flap handle was in the down (flap retracted) position. The fuel selector position was on the right tank. The inspection of the artificial horizon indicator revealed that the pendulous vanes were free to rotate with no internal scoring or rotational signatures. The inspection of the directional gyro revealed that the pendulous vanes were free to rotate with no internal scoring or rotational signatures. Twelve instrument light bulbs were recovered. All bulbs exhibited stretched and broken filaments. An auxiliary vacuum warning light was recovered and there was no stretching of either the vacuum "Off" or auxiliary "On" bulbs. The three annunciator lights were recovered for the "ALT", "VAC", and "Oil". Both the ALT and VAC bulbs were stretched and broken. The OIL light was intact and showed no stretching. The left wing separated from the fuselage and exhibited leading edge compression damage and fragmentation. Both fuel tanks were ruptured and contained no fuel. The aileron cables were still attached to the aileron bellcrank, which was broken from its mount. The aileron cable was traced to the forward fuselage and the separations were consistent with overload. The landing gear was in the retracted position. The right wing separated from the fuselage and exhibited leading edge compression damage and fragmentation. Both fuel tanks were ruptured and contained no fuel. The aileron cables were still attached to the aileron bellcrank, which was broken from its mount. The aileron cable was traced to the forward fuselage and the separations were consistent with overload. The landing gear was in the retracted position. The engine inspection revealed continuity of the drive train when the crankshaft was rotated. Thumb compression and suction were confirmed to all cylinders. Spark was confirmed to all ignition leads. The engine driven fuel pump exhibited suction and compression when the arm was cycled. The fuel servo incurred impact damage and was separated from the mounting flange and throttle plate. Fuel was found in the fuel flow divider. The vacuum pump was intact with no damage. The drive and coupling were intact, free to rotate, and provided vacuum when rotated by hand. Disassembly showed the rotor and vanes were intact with minimal wear. The propeller governor, starter, and alternator were separated from their mounts and were not recovered during the wreckage recovery from the peat bog. The propeller and spinner were still attached to the engine. The spinner was crushed in a spiral shape. All three propeller blades were loose in the hub. The propeller marked "A" had its blade tip broken off. There were nicks and abrasion to the leading edge. It exhibited blade twist to toward low pitch, and it was bent aft and had multiple bends. Blade "B" exhibited blade twist toward low pitch. The blade tip showed bending and slight tip curl. Blade "C" was bent aft with blade twist toward low pitch. It exhibited no chordwise scratching or gouges. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot was conducted on December 23, 2007, in Madison, Wisconsin, at the University of Wisconsin, School of Medicine and Public Health. A Forensic Toxicology Fatal Accident Report was prepared by the FAA Civil Aeromedical Institute. The results of the tests indicated the following: Carbon monoxide and cyanide: Not preformed No Ethanol detected in urine 13.574 (ug/ml, ug/g) morphine detected in urine 0.379 (ug/ml, ug/g) morphine detected in liver 0.07 (ug/ml, ug/g) codeine detected in urine Zolpidem detected in urine Zolpidem detected in liver Diphenhydramine present in urine Diphenhydramine detected in liver The National Transportation Safety Board's Medical Officer noted the following information that was contained in the autopsy report: 1. Under “Final Anatomic Diagnoses” is noted, in part, “Massive blunt force injury--- Reported treatment for heroin addiction--- Intravascular crystals noted in lung---” 2. Under “Initial External Examination” is noted, in part, "--- A prescription container--- for “Suboxone” made out to [the pilot] is recovered from the remains---" ADDITIONAL INFORMATION A pilot reported that he had flown the accident airplane the day prior to the accident. The pilot reported that he had flown the airplane from RYV to the South St. Paul Downtown Airport, St. Paul, Minnesota, and back to RYV on an IFR flight plan. He reported that the airplane's radio, navigation system, GPS, instruments, and autopilot were all working normally.

Probable Cause and Findings

The decision by the pilot to fly into known adverse weather, and the pilot's failure to maintain control of the airplane due to spatial disorientation. Contributing factors include the clouds and the night conditions.

 

Source: NTSB Aviation Accident Database

Get all the details on your iPhone or iPad with:

Aviation Accidents App

In-Depth Access to Aviation Accident Reports