Dennisville, NJ, USA
N4499T
PIPER PA-28R-200
The non-instrument-rated private pilot/owner of the airplane had longstanding arrangements for the trip to his destination, which was about 500 miles east of where he lived and based his airplane. He originally planned to depart on Thursday morning, but instrument meteorological conditions (IMC) at the airport prevented him from leaving on Thursday or Friday. On Saturday morning, IMC still prevailed. Several witnesses observed the pilot and his son at the fuel dock, and all assumed that he would then taxi back to his hangar since the ceilings were between 200 and 400 feet above ground level. Instead, the airplane departed and disappeared from view into the overcast clouds. The pilot initially squawked the visual flight rules (VFR) code of 1200 on his transponder, but then contacted an air traffic controller for flight advisories. The controller assigned a discrete transponder code, and instructed the pilot to maintain VFR. For the next 7 minutes, multiple witnesses on and near the airport heard the airplane in their vicinity. All reported that it sounded like the airplane was continuously changing speed, direction, or both. Several witnesses then heard the airplane impact the ground. Airplane components were found in two locations: at the main wreckage site and along a debris path that consisted of the outboard portions of the left wing and left stabilator. Physical evidence indicated that the wing failed in the positive direction due to airloads and not due to any preseparation mechanical deficiencies. No other evidence of any preimpact component deficiencies or failures was discovered and examination of the wreckage and ground scars indicated that the engine was developing power at impact. Discussions with the pilot's wife revealed that he occasionally flew into or through clouds, albeit usually for short durations, in order to begin or complete his flights. In the case of the accident flight, the pilot had already delayed his departure 2 days, so he was highly motivated to begin the trip. Although the departure airport conditions were IMC, the pilot was aware that the forecast called for improved conditions towards his destination. In addition to his prior VFR operations into IMC, he did not hold a valid medical certificate and no current record of a required transponder inspection was located. Ground-based radar and onboard global positioning system (GPS) data revealed that the airplane flew a ground track that included about eight 360-degree turns and three 180-degree turns, and that its altitude varied continuously between 200 feet and 1,600 feet above mean sea level. The GPS and radar data clearly indicated that the pilot became disoriented and was unable to methodically and safely extract himself from his predicament. FAA guidance regarding VFR flight into IMC cautioned pilots to minimize attitude changes and obtain appropriate assistance, including use of the autopilot.
HISTORY OF FLIGHT On November 14, 2009, about 1050 eastern standard time, a Piper PA-28R-200, N4499T, was substantially damaged when it impacted terrain about 10 minutes after takeoff from Woodbine Airport (OBI), Woodbine, New Jersey. The certificated, non-instrument-rated private pilot/owner, and the passenger were fatally injured. The personal flight was operated under the provisions of 14 Code of Federal Regulations Part 91. Instrument meteorological conditions (IMC) prevailed, and no flight plan was filed for the flight to Monroe County Airport (BMG), Bloomington, Indiana. According to several witnesses, the pilot originally planned to depart for BMG on Thursday, November 12, but weather conditions caused him to delay his departure. The following day, he came to the airport, and again due to inclement weather, the pilot decided not to depart for BMG. While at the airport, the pilot requested assistance from the airport manager, who also had conducted the pilot's most recent flight review, in using an Internet-based flight planning tool. Later that day, the pilot met a flying companion in a local restaurant; the two spoke of the pilot's planned flight, and how the existing weather conditions had again delayed the flight. During that conversation, the companion cautioned the pilot "not to take any chances," and to wait for the weather to improve. On the morning of the accident, IMC prevailed, but the forecast called for conditions to improve as the day progressed. The recorded weather conditions at OBI reported an overcast ceiling at 300 feet above ground level (agl) for the period from 1000 to 1200; that ceiling was below the minimum values for the published instrument approach procedures into OBI. Several other pilots, including some who were instrument-rated, were either in the airport office, or elsewhere on the airport, waiting for conditions to improve so that they could fly. About 1015, those witnesses observed the pilot and the passenger at the fuel dock, fueling the airplane. The witnesses universally reported that a solid overcast ceiling was present at approximately 200 to 300 feet agl, that "there were no holes" in the ceiling, and that "there was no sun" shining anywhere that they could see. All witnesses who observed the pilot fueling the airplane stated that they "assumed," due to the low ceiling, that the pilot would return his airplane to the hangar after fueling was completed. The OBI fueling records indicated that the pilot completed the purchase of 20.7 gallons of fuel at 1030. Shortly thereafter, several witnesses saw and/or heard the airplane operating on the ground near the threshold of runway 31. About 1040, the pilot utilized the Unicom frequency to broadcast his intention to depart, and he began his takeoff roll on runway 31. Several persons, some of whom knew the pilot, and who also knew that he was not instrument-rated, watched the airplane take off, and climb into the overcast. One witness stated that the airplane entered the overcast "between the end of the runway and the railroad tracks," which crossed the extended runway centerline approximately 1/3 mile beyond the runway end. Three witnesses in a maintenance hangar at OBI had access to a radio that could receive aviation frequencies, and after the airplane took off, they changed the frequency on the radio to 124.6 megahertz (MHz), which was the frequency for Atlantic City approach control. They heard the pilot request traffic "advisories," and although they could not hear the controller, understood that the controller had assigned the airplane a discrete transponder code. Witnesses on and near the airport reported that they heard, and occasionally saw, for a period of between 5 and 10 minutes, an airplane flying in their vicinity. All witnesses reported that the sound varied in a way that gave them the impression that the airplane was continuously changing speed and direction, as if it was climbing, descending and circling. One witness, who was in his backyard with his daughter, stated that he was familiar with how airplanes typically sounded, but "this one was different." The continued variation in sound gave him the impression that the airplane was performing aerobatics, and he questioned the pilot's judgment for performing aerobatics in the clouds. He then saw the airplane fly over his neighbor's house. He said that he "never saw a plane that low before," and he sent his daughter inside for her safety. Another witness at the airport saw the airplane emerge from the overcast, headed away from him to the west, and disappear below the treeline. He then saw the airplane re-emerge, and climb back up into the overcast. All witnesses reported that their sightings of the airplane were very brief, each lasting only a few seconds. Another witness and his wife were sitting in their kitchen, and heard the airplane apparently circling. They then heard a "bang" or a "clunk," which was followed by a "hard thud." Another witness heard the airplane strike tree branches. Most witnesses only reported a single sound of impact, which some described as a "thump." Two residents, who lived in separate homes approximately 1/2 mile from the accident site, ran into the woods behind their homes in search of the airplane. They located the main wreckage, checked the airplane occupants for vital signs, found none, and notified authorities via a mobile telephone. According to the New Jersey State Police, the first 911 call was placed at 1059. PERSONNEL INFORMATION Federal Aviation Administration (FAA) records indicated that the pilot held a private pilot certificate, with an airplane single engine land rating, that was obtained in 2004. His most recent FAA third-class medical certificate was issued in September 2007, and was valid through September 2009. On that application he reported 300 total hours of flight experience. Examination of the pilot's personal flight time log indicated that as of the date of the accident, he had approximately 395 total hours of flight experience, including 308 hours in the accident airplane. His most recent flight review was completed in December 2008. AIRCRAFT INFORMATION According to FAA and Piper Aircraft documentation, the airplane was a four-place, low-wing monoplane of all-metal construction, with retractable, tricycle-style landing gear. The design utilized an all-moving tailplane known as a stabilator. Each wing was equipped with an integral "wet wing" fuel tank that had a usable fuel capacity of 24 gallons. The three-bladed constant-speed propeller was driven by a Lycoming IO-360 series piston engine. The airplane was manufactured in 1972, and was registered to the pilot in 2005. A review of maintenance records indicated that the most recent annual inspection was completed on September 12, 2009, and at that time, the airplane had accumulated a total time in service of 2,378 hours. The engine had the same amount of time in service, and at the time the inspection was completed, it had accumulated 887 hours since its most recent major overhaul. The propeller had accumulated a total time in service of 335 hours at the time of the annual inspection. The airplane maintenance records indicated that Piper Service Bulletin (SB) "1181" was complied with in 2006. Review of Piper Service Letter (SL) and SB information revealed that no such SL or SB was applicable to the accident airplane model. Piper SB 1161, issued in March 2006, did apply to the airplane. That SB specified inspection of a wing rib located at wing span station 49.25 for cracking, with 100-hour visual, and 500-hour dye penetrant repetitive inspection intervals. That SB was considered mandatory by Piper, but there was no corresponding FAA Airworthiness Directive (AD). The 2006 maintenance records entry stated "no cracks found." No subsequent maintenance entries that referenced either SB 1161 or SB "1181" were located. A review of maintenance records indicated that the vacuum pump and the artificial horizon in the airplane at the time of the accident had been installed in the airplane since at least 2006. An FAA inspector's review of the maintenance records indicated that there was "no evidence that a current inspection of the Altimeter and Transponder was accomplished" in accordance with applicable regulations. METEOROLOGICAL INFORMATION The OBI recorded weather observations at 5 minute intervals during the period from 1000 to 1200 reported an overcast ceiling at 300 feet agl. During that same period, the reported visibility ranged from 1 3/4 miles to 3 miles, and the temperature and dew point remained constant at 14 degrees C, with the exception of the first two dew point readings of 13 degrees C. Examination of other weather data indicated that the region was blanketed by a layer of stratus clouds that was approximately 3,000 feet thick, and pilot reports (PIREPs) corroborated those observations. COMMUNICATIONS Review of the FAA Atlantic City air traffic control (ATC) audio and radar tracking data indicated that the pilot first contacted Atlantic City approach about 1046. At that point the airplane had just taken off from OBI, was turning to the west, and was broadcasting the visual flight rules (VFR) code of 1200 on its transponder. The controller acknowledged the radio call, and the pilot then stated "nine nine tango is departing OBI. Destination is bravo gulf bravo mike gulf Indiana Bloomington. Request advisories inflight please." The controller assigned a discrete transponder code to the flight, and the pilot acknowledged. About 1 minute later, the controller broadcast "Cherokee nine nine tango you're radar contact a mile west of the Woodbine airport. Atlantic City altimeter is 29.95, maintain VFR at all times, proceed on course," and the pilot responded with only "nine tango." About 1053, the controller queried the pilot "how do you read?" and then stated "radar contact lost." The controller repeated those calls about 20 seconds later. Finally, about 1056, the controller asked the pilot of another aircraft to try to contact the flight; that pilot made two radio calls but did not elicit a response from the pilot of N4499T. No other radio transmissions from the airplane were recorded. AIRPORT INFORMATION The departure airport (OBI) was a non-towered airport equipped with two runways. Runway 1/19 was 3,304 feet long, runway 13/31 was 3,073 feet long, and the two runways intersected near the approach ends of 13 and 19. A fuel sample was obtained from the OBI pump where the pre-accident refueling of the airplane was accomplished. The sample was free of contaminants. WRECKAGE AND IMPACT INFORMATION The accident site and wreckage were examined in detail beginning the day after the accident. The wreckage consisted of two basic groups of debris; left wing and left stabilator fragments in a loose cluster, and the remainder of the airplane at the main wreckage site. The overall debris field was oriented on a magnetic heading of about 015 degrees, and measured about 1260 feet in length. The left wingtip was the first item in the debris field. The outboard 7-foot section (approximate parting stations WS100 at leading edge, WS130 at trailing edge) of the left wing was next; it was located about 160 feet beyond the wingtip. The outboard 3-foot segment of the left stabilator was located about 400 feet beyond the left wingtip, and was the last item in that grouping, which also included portions of the left aileron. The main wreckage was situated about 3,500 feet southwest of the OBI runway 1 threshold. The outboard wing section skin and spar damage was consistent with deflection of the wing in the positive (with respect to the airplane axis system) direction, and the aileron displayed similar deformation. No corrosion, fretting, or other indications of pre-separation or pre-impact failure were observed on the spar cap or web fracture surfaces of the wing or aileron. The only crush or impact damage to the wing section was near the wingtip, primarily in a spanwise direction from outboard to inboard. The damage to the left outboard stabilator was consistent with deflection in the positive direction. The main wreckage was tightly contained, and consisted of the entire airplane, with the exception of the outboard portions of the left wing and left stabilator. The ground impact point was demarcated by a 2-foot-deep crater with an east-west dimension of approximately 10 feet, and a north-south dimension of 5 feet. Most of the main wreckage was adjacent to the northern and eastern boundaries of the crater. Most structural components exhibited significant disruption and deformation. The upper-aft fuselage and tailcone/empennage was separated from the rest of the airplane. The lower fuselage and cockpit area were found inverted. The aft seats had been removed prior to the flight, and were subsequently found in the pilot's hangar. Most of the cockpit instruments were damaged and unreadable. The tachometer registered a time of 2,387.15 hours. The artificial horizon and the directional gyro were removed and retained for further examination. The frequencies set into the top-most navigation/communication radio could not be determined. The communication radio below that radio was set to 122.00 MHz. The autopilot mode selector was set to "HDG," but the operational status of the unit could not be determined. The engine controls were all found in their full forward positions. The flap handle was impact damaged and displaced upward, and the pre-impact flap position could not be determined. The remainder of the switch and control positions were deemed to be unreliable. The landing gear was found in the retracted position. Both wing fuel tanks were highly fragmented, and were devoid of fuel. The entire right wing was located with the main wreckage, and exhibited extensive crush and deformation damage. The outboard section of the right wing was fracture-separated outboard of the main landing gear. The forward and aft wing-to-fuselage attach points were fractured. The aileron and flap remained attached to the right wing. The aileron balance weight was separated from the aileron, but was found adjacent to the wing. The inboard section of the left wing, including the left flap, was also located with the main wreckage, and exhibited extensive crush and deformation damage. No corrosion, fretting or other indications of pre-impact failure were observed on the spar cap or web fracture surfaces of the inboard section of the left wing. The main portion of the empennage, including the vertical stabilizer and rudder, was entangled with the left inboard wing section. The center section of the stabilator remained attached at both hinge points. The balance tube remained attached to the stabilator, but was displaced aft of its design location. The right outboard end of the stabilator was separated and found adjacent to the rest of the empennage. All four stabilator stop bolts were undamaged and secure, with head heights of approximately 3/8 inch above their mounting pad surface. All rudder hinges remained securely attached and undamaged. Both rudder stop bolts were undamaged and secure, with head heights of approximately 3/8 inch above the hinge plate. All aerodynamic control surfaces were found at the accident site, and control continuity from the cockpit controls to the aerodynamic surfaces was confirmed. The stabilator pitch trim drum showed 16 threads of extension, which was consistent with a full airplane nose up setting, and a tab deflection of 12 degrees tab down. According to a representative of the airplane manufacturer, the as-found position "may not reflect the actual trim setting prior to impact." The engine remained partially attached to the engine mount and firewall. The lower engine case was cracked. The intake and exhaust tubes were partially crushed and bent. The muffler, one magneto and some other components were separated from the engine. The internal surfaces of the muffler and other exhaust tubing were light gray/white, which was consistent with normal operation. The fuel distribution block and the engine-driven fuel pump contained fuel that appeared uncontaminated. The vacuum pump was removed and retained for further exa
The non-instrument-rated pilot's decision to depart into known instrument meteorological conditions, which resulted in his spatial disorientation and overcontrol of the airplane and the subsequent in-flight structural failure. Contributing to the accident was the pilot's failure to use all available resources, including the autopilot and the air traffic controller.
Source: NTSB Aviation Accident Database
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