Aviation Accident Summaries

Aviation Accident Summary WPR09FA116

Hagerman, ID, USA

Aircraft #1

N8810P

PIPER PA-24-260

Analysis

The student pilot departed in his recently purchased airplane on a night cross-country flight without an endorsement for operation of a complex airplane or instructor's approval. Recorded radar data revealed that about thirty minutes into the flight the airplane made a 180-degree turn back toward the departure airport, followed 14 minutes later by a second 180-turn back toward the destination airport. The second turn resulted in a loss of altitude of 2,000 feet in 23 seconds, or a rate of descent of 5,217 feet per minute. Radar data further revealed that about 55 minutes later while on a heading of south at 9,400 feet, the airplane made a right hand 180-degree turn to a heading or north. During the turn the airplane descended 4,600 feet in 47 seconds, or a rate of descent of 5,872 feet per minute. While reversing course it is more than likely that the pilot became spatially disoriented, evidenced by the last 6 radar returns that showed the airplane had descended rapidly in a tight right hand turn. The area surrounding the accident site was sparsely populated, with minimal ground light sources and a lack of visual cues. During the uncontrolled descent the airplane broke apart in flight. The major components that separated were the outboard sections of both left and right wings, the outboard sections of both left and right stabilators, and the airplane's empennage. No preimpact anomalies were found during the wreckage examination and all fractures were consistent with overload. The in-flight breakup resulted from aerodynamic forces induced by the pilot's recovery attempts that exceeded the airframe's structural limitations. The pilot had a history of anxiety and depression treated with a prescription antidepressant for two years prior to the accident, and he was experiencing substantial stress within a week of the accident. His toxicology results were consistent with the use of a over-the-counter sleep aid within the days prior to the accident. The pilot's mental condition may have contributed to the inappropriate decision to fly cross-country at night in a complex airplane he had just purchased. The pilot had denied treatment for anxiety and depression on his application for Federal Aviation Administration Airman Medical Certificate.

Factual Information

HISTORY OF FLIGHT On February 15, 2009, about 2045 mountain standard time, a Piper PA-24-260, N8810P, was destroyed following an airframe in-flight breakup while maneuvering near Hagerman, Idaho. The student pilot, the sole occupant, was killed. The airplane was registered to, and operated by a private individual. Visual meteorological conditions (VFR) prevailed at the time of the accident, and no flight plan was filed. The personal cross-country flight was operated in accordance with 14 Code of Federal Regulations Part 91. The flight departed the Caldwell Industrial Airport (EUL), Caldwell, Idaho, about 1900, and was destined for the Bountiful Skypark Airport (BTF), Bountiful, Utah. According to a written statement submitted to and in a telephone conversation with the Safety Board investigator-in-charge (IIC), a friend (the second airplane's pilot) of the accident pilot reported that he agreed to fly the accident pilot from BTF to EUL (266 nautical miles) in his airplane, a Cherokee 140, in order for the accident pilot could pick up his recently purchased airplane, N8810P. The friend stated that he also agreed to fly N8810P back to BTF for the accident pilot, but only after being checked out by the seller of the airplane; the accident pilot would then return in the Cherokee. The friend stated that while preparing for the checkout the accident pilot said, "Look. I'm fine flying this airplane back. I've more than enough time in it, and all of it more current than your time. I'll just fly it and you fly the Cherokee." The friend reported, "Well, it was [his] airplane at this point. I finally relented and said fine." The friend revealed that prior to departing EUL he briefed the accident pilot on the weather, since during the flight earlier in the afternoon from BTF to EUL they had encountered an overcast layer in the Mountain Home, Idaho area, located about 58 nautical miles (nm) southeast of EUL. The friend stated that he also advised the accident pilot to stay below 7,000 feet mean sea level (msl) while transitioning the Mountain Home area. The friend reported that after departing EUL and passing Mountain Home, the accident pilot radioed him stating, "I need to get the door closed. I'm freezing in here. I'm going to set down at Twin Falls." The friend stated that at this time he didn't think the accident pilot was near Twin Falls, but that he was just past Mountain Home. The friend added that both of them were subsequently in contact with the Twin Falls (TWF), Idaho air traffic control tower. The controller was advised of the accident pilot's problem with the door and that he would be landing at Twin Falls. Subsequently, the friend added that after he learned from the accident pilot that he had resolved the door issue, he relayed the information to the controller and advised him that they were both proceeding to Salt Lake City. The friend reported that he then switched over to the air-to-air frequency, related to the accident pilot how good the weather was in the Twin Falls area, and to be sure to climb up to at least 10,000 feet msl to cross over the mountains on the way to BTF. The friend reported that there were no further en route communications with the accident pilot. The friend stated that he had stayed at 7,500 feet msl until past Mountain Home, climbed up to 9,000 feet until Glen's Ferry, and then went up to 9,500 feet west of Buhl and Twin Falls. He said that while around Glen's Ferry, he noted how good the visibility was. The friend reported that he continued to BTF in visual flight rule (VFR) conditions, and that there were no weather problems along the route of flight. Radar data supplied by the 84th RADES/OLAD, McChord Air Force Base, Washington, tracked the accident airplane from EUL southeast to a location about one-quarter mile northeast of the accident site. At 1931:00, about 30 minutes after takeoff and about 58 nautical miles (nm) southeast of EUL, the track made a 180-degree left turn back to the northwest in the direction of EUL at an altitude of 7,400 feet msl. At 1944:12, after having traveled about halfway back toward EUL at 7,900 feet msl, the track made another 180-degree left turn back to the southeast. During the turn the track revealed that the airplane lost 2,000 feet in 23 seconds; the IIC calculated a descent rate during the turn of 5,217 feet per minute (fpm). About 20 minutes later at 2004:46, when the airplane was about 1 nm southeast of the Mountain Home Municipal Airport (U76), Mountain Home, Idaho, it began two left-hand orbits over the city before proceeding southeast. About 24 minutes later when the airplane was about 30 nm southeast of U76 at 8,200 feet msl, the track made a 90-degree left turn to the northeast, followed 33 seconds later by a right 90-degree right turn back to the southeast at 8,500 feet msl. The track indicated that 42 seconds later at 2038:36, the airplane turned further right to a heading of south at 9,000 feet msl, and 46 seconds later at 2039:22 at 9,400 feet msl, the track revealed a southwesterly heading. The track then revealed that in the 14 seconds between 2039:36 to 2039:50, the airplane made a right hand descending turn to a northerly heading from 9,200 feet msl to 7,600 feet msl; the IIC calculated a descent rate during the turn of 6,857 fpm. Twenty seconds later at 2040:10, the last radar return indicated the airplane's track was toward the northeast at 4,800 feet msl, about 1,500 feet above ground level (agl). The airplane wreckage was located the next morning about 11 nm west of Hagerman, Idaho, and about 68 nm southeast of the departure airport. The area surrounding the wreckage site was sparsely populated with minimal light sources. There were no reported witnesses to the accident. PERSONNEL INFORMATION The student pilot, age 41, possessed a second-class Federal Aviation Administration (FAA) airman medical certificate with no limitations, issued September 18, 2007. A review of the student pilot's logbook revealed that he had accumulated a total flight time of 67.9 hours, 4.3 hours of night time (all dual instruction), 13.3 hours of cross-country time, of which 2.5 hours were solo, and no night cross-country flight time. The last entry in the pilot's logbook, which occurred about 6 months prior to the accident, denoted "Introduction to complex airplane," which was conducted in a Piper PA-28-200. Further, the logbook revealed no endorsements for complex aircraft operations or for the solo cross-country accident flight. The pilot recorded no flight time in the same make and model as the accident airplane. AIRCRAFT INFORMATION N8810P, a 1965 Piper PA-24-260 Comanche, serial number 24-4166, was an all-metal airplane with semi-monocoque fuselage and empennage construction. The airplane was configured for a maximum seating of four occupants and a maximum gross weight of 3,100 pounds. The airplane was powered by a 260-horsepower, six-cylinder, horizontally opposed, air cooled, fuel injected, Lycoming IO-540-D4A5, serial number RL-1784-48, engine. The airplane's propeller was a two-bladed Hartzell HC-C2YK-1BF model. The airplane was equipped with wing flaps, a constant speed propeller, and a retractable tricycle landing gear. The airplane's most recent annual inspection was conducted on December 16, 2008, at a total time of 4,389.84 hours. The engine had accumulated a total time of 775.34 hours since its most recent major overhaul. METEOROLOGY At 2053, the weather reporting facility at the Twin Falls Airport (TWF), Twin Falls, Idaho, located 35 nautical miles southeast of the accident site, reported wind 020 degrees at 3 knots, visibility 10 statue miles, few clouds at 7,000 feet, temperature 1 degree Celsius, dew point -4 degrees Celsius, and an altimeter setting of 29.87 inches of Mercury. At 2055, the weather reporting facility at Mountain Home Air Force Base (MUO), Mountain Home, Idaho, located 33 nautical miles northwest of the accident site, reported wind 120 degrees at 16 knots, visibility 10 statue miles, broken clouds at 9,000 feet, temperature 2 degrees Celsius, dew point -3 degrees Celsius, and an altimeter setting of 29.87 inches of Mercury. At 2053, the weather reporting facility at the Jerome Airport (JER), Jerome, Idaho, located 30 nm east-southeast of the accident site, reported wind 030 degrees at 18 knots, visibility 10 statute miles, overcast clouds at 7,500 feet, temperature 3 degrees Celsius, dew point 6 degrees Celsius, and an altimeter setting of 29.88 inches of Mercury. According to the U.S. Naval Observatory, Department of Astronomical Applications, sunset occurred at 1812, and the end of civil twilight occurred at 1841. Moonrise did not occur until 0139 the following day. COMMUNICATIONS About 1 hour after departing EUL, from 2000 to 2021, and while orbiting the city of Mountain Home, the accident pilot was in contact with the Twin Falls air traffic control tower. The conversation focused on the pilot having trouble getting the cabin door closed. The controller was subsequently notified that the pilot had been successful in closing the door and was proceeding to his destination. (Refer to the transcribed report attached.) WRECKAGE AND IMPACT INFORMATION An on-site examination of the wreckage revealed that the airplane experienced an in-flight breakup. All of the airplane's structural components were located at the accident site. Airframe components were found scattered throughout a rectangular area over a measured distance of 4,670 feet long by 450 feet wide on a west to east orientation. The energy path was on a measured magnetic heading of 100 degrees. The main wreckage consisted of the fuselage with attached cockpit and engine assembly, the cabin area with all four seats, the inboard section of both wings, and the aft fuselage extending aft to, but not including the tail section. All three landing gear and the inboard sections of both flaps were observed in the retracted position. The wreckage came to rest inverted and oriented on a measured magnetic heading of 060 degrees. All components located west of the main wreckage site consisted primarily of the outboard sections of both left and right wings, the outboard sections of both left and right stabilators, and the airplane's empennage. The left outboard wing section was located about 4,670 west of the main wreckage and observed to be bent and twisted, with the aileron separated at all attach points. The right outboard wing section was located about 2,790 feet from the main wreckage area, and exhibited a lateral crease through its top midsection, with the aileron observed separated at all attach points. The right outboard stabilator was found about 4,403 feet from the main wreckage and exhibited deformation where it had separated from its mating surface. The associated trim tab remained attached to the stabilator. The airplane's left outboard stabilator, located about 3,883 from the main wreckage, was observed bent and twisted, and exhibited a 45-degree crease on its underside from its mid-span outboard to its leading edge. The stabilator's associated trim tab was separated at all attach points. The airplane's tail section, which was found about 1,443 feet from the primary wreckage, was intact with the exception of its left and right outboard stabilator sections. The top of the rudder's right hand side exhibited a downward oriented crease of about 45 degrees. The rudder remained attached to the vertical stabilizer at all attach points. The inboard sections of both the left and right stabilator trim tabs remained attached to their associated stabilators. The tail cone remained attached at the associated vertical stabilizer and horizontal stabilator attach points. The tail cone was observed intact, with the exception of where it had separated from the aft fuselage. The airframe and engine were recovered from the accident site and transported to a facility for further examination. The airplane was reconstructed, and all components were accounted for. The inboard 75 1/2 inches of both left and right wings remained attached to the fuselage at their respective attach points. The left and right main fuel tanks, and their associated left and right auxiliary fuel tanks were breached. Examination of the flight control system revealed that the control cables either remained attached to their respective attach fittings or had separated in a manner consistent with tension overload. In addition, several control cables were cut by the retrievers during recovery of the aircraft wreckage. The cabin area was destroyed. All four seats were identified and intact. The cabin door was destroyed and not observed. The left seat pilot's control yoke was separated from its control column, while the right seat pilot's control yoke remained attached to its associated control column. The throttle, mixture, and propeller controls were all observed in the full forward position. The entire top of the aft fuselage, from the aft cabin bulkhead to the tail cone, was deformed by downward crushing. The remainder of the fuselage sustained deformation as a result of bending and crushing in the vertical plane. Examination of the engine included partial disassembly. Engine continuity was established by rotating the crankshaft and achieving thumb compression on cylinders 2, 3, 4 and 6. The number 1 and 5 cylinder's push rods were bent. Both magnetos were removed and produced spark at all leads when rotated by hand. A visual examination of the fuel servo screen, the fuel injectors, and the fuel flow divider were observed free of debris. The examination of the engine assembly and accessories revealed no evidence of a pre-impact mechanical malfunction. The propeller remained attached to the engine at the propeller flange, and both propeller blades remained attached to their respective propeller hubs. One propeller blade was bent rearward approximately 90 degrees at a point 12 inches from the propeller hub. The other blade was relatively straight. TESTS AND REASEARCH Segments of the left wing spar, right wing spar, left stabilator and right stabilator were sent to the National Transportation Safety Board's Materials Laboratory in Washington, D.C., for examination and analysis by a Safety Board mechanical engineer. An examination of the left wing spar segments revealed two fracture zones, with both fracture faces oriented in a slant plane consistent with an overload event, and a slight upward bend to the upper spar cap. The examination further revealed two fracture zones to the right wing spar segments, both fracture faces oriented in a slant plane consistent with an overload event, and an upward bend to the upper spar cap. An examination of the left stabilator segments revealed fracture faces on a slant plane, consistent with an overload event, and a distinctive downward bend to the spar and attached skin. Examination of the right stabilator segments revealed fracture faces on a slant plane, consistent with an overload event, and a distinctive downward bend to the spar and attached skin. (Refer to the attached NTSB Materials Laboratory Factual Report No. 09-041.) A Garmin 496 Global Positioning System (GPS) unit was recovered from the airplane's wreckage and sent to the Safety Board's Vehicle Recorder Division for examination. The results of the examination by a recorder specialist revealed that the unit had sustained extreme damage due to impact forces, was irreparable, and that no data could be recovered from the component. PATHOLOGICAL AND TOXICOLOGICAL INFORMATION Medical records obtained on the pilot document that the student pilot’s only application for an Airman Medical and Student Pilot Certificate, dated September 18, 2007, had indicated a diagnosis of high blood pressure treated with enalapril. The application noted no other conditions or medications, and indicated “no” in response to “Mental disorders of any sort: depression, anxiety, etc.” Review of the student pilot’s personal medical records revealed a history of treatment with bupropion for anxiety and depression since March, 2007. A physician’s note 5 days prior to the accident noted that the student pilot was “upset …, very antsy, jittery, stressed … very an

Probable Cause and Findings

The student pilot's spatial disorientation, which resulted in a loss of aircraft control and subsequent in-flight breakup. Contributing to the accident was the pilot's mental condition which could have contributed to the inappropriate decision to fly the night time cross-country flight.

 

Source: NTSB Aviation Accident Database

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