Aviation Accident Summaries

Aviation Accident Summary ERA16FA001

Westminster, SC, USA

Aircraft #1




Nearing the conclusion of a cross-country, instrument flight rules flight in instrument meteorological conditions, the private pilot was entering a procedure turn in advance of conducting an instrument approach to the destination airport. The pilot reported to air traffic control that he was outbound on the procedure turn but did not subsequently report when the airplane was inbound. Shortly thereafter, a military flight on the frequency reported hearing a "mayday" call and that the airplane was "going down." No further communications were received from the accident airplane. Radar and GPS data showed the airplane in a right, rapidly descending spiral. Witness statements and the distribution of the wreckage indicated that the airplane experienced an in-flight breakup. A postaccident examination of the airframe and engine revealed no evidence of mechanical malfunctions or failures that would have precluded normal operation. Fractures to the right wing and stabilator were consistent with overstress and likely occurred during an attempted recovery from the descending spiral. The pilot's autopsy revealed severe atherosclerosis in the vasculature of the brain and heart. There was near-total occlusion of the right frontal and middle cerebral arteries. In the heart, the left anterior descending coronary had 80% occlusion, while both the right and circumflex coronary arteries showed 40% atheromatous occlusion. In addition, the myocardium displayed indications that the pilot had experienced a previous heart attack. The pilot's wife was unaware of a previous heart attack or heart condition, and the pilot had not reported any heart issues to the Federal Aviation Administration. The pilot had very low levels of pseudoephedrine in his system at the time of the accident. Although his use of this powerful vasoconstrictor may have further increased his risk of an acute cardio- or cerebro-vascular event, given the low levels, it is unlikely that any direct psychoactive effect of the drug contributed to the accident. Finally, the pilot had 0.06 ug/ml of chlorpheniramine, a sedating antihistamine, in his postmortem blood. Although the pilot lost control of the airplane, there was no evidence of impaired behavior or decision-making before the loss of control. Therefore, it is unlikely that the sedating effects of the chlorpheniramine contributed to this accident. Given the circumstances of the accident and pilot's cardiac conditions, it is possible that he became acutely incapacitated by a sudden cardio- or cerebro-vascular event and that could have resulted in the loss of airplane control. Because the pilot suffered fatal blunt force injuries within a few minutes after symptoms began, no findings indicating the acute event would be expected to be visible on autopsy, and none were found; thus, it could not be determined whether the loss of control was the result of incapacitation or if there was another reason that the airplane departed controlled flight and the pilot was unable to regain control.

Factual Information

HISTORY OF FLIGHT On October 2, 2015, about 1512 eastern daylight time, a Piper PA-32R-301, N782TM, was destroyed when it collided with terrain following an in-flight breakup near Westminster, South Carolina. The private pilot and three passengers were fatally injured. The airplane was registered to Smith Family Aviation, LLC, and operated by the pilot under the provisions of 14 Code of Federal Regulations Part 91 as a personal flight. Day instrument meteorological conditions prevailed at the time of the accident, and an instrument flight rules (IFR) flight plan was filed. The flight originated from Warsaw Municipal Airport (ASW), Warsaw, Indiana, about 1151, and was destined for Oconee County Regional Airport (CEU), Clemson, South Carolina. According air traffic control information provided by the Federal Aviation Administration (FAA), the en route portion of the flight was uneventful. Due to other traffic landing at CEU and prevailing weather, the pilot was told to expect to hold at the ZEYLM intersection before executing the RNAV runway 7 approach at CEU. At 1504, Atlanta Center coordinated with Greer approach control for the flight to hold at ZEYLM at 6,000 ft mean sea level (msl). Recorded radar data showed that the airplane approached ZEYLM at 6,000 ft on a southeasterly heading. GPS data indicated the airplane track passed over ZEYLM at 1508:08. After passing ZEYLM, the airplane began a turn to the right, consistent with the published holding pattern on the approach chart; however, it continued to turn a full 180° toward the opposite direction. At 1509:19, the flight was cleared for the approach and the pilot reported that he was "outbound now" and would report when the airplane was established on the procedure turn inbound. About 1510:06, at 5,991 ft GPS altitude, the airplane entered an increasingly tightening, descending right turn, and within 16 seconds, its ground speed increased from 150 knots to 212 knots. At 1510:56, the pilot of a military flight, call sign "Blackbird 89," reported hearing a "mayday" call that an airplane was "going down." The controller subsequently queried the pilot when he did not report inbound on the approach; no response was received. Radar data showed the flight in a right, descending spiral until radar contact was lost over Lake Hartwell, on the Georgia/South Carolina border, about 2,200 ft msl. The last recorded GPS point was at 1510:44 in the vicinity of the main wreckage location. Local residents reported hearing and seeing the airplane before the accident. One witness heard a loud "boom," followed by white pieces of debris falling into the lake. Another witness saw the airplane descending vertically, in a spiral motion, until it disappeared behind a tree line. Another witness reported that the engine was running until ground impact. Several witnesses reported the event to 911, and the wreckage was located by first responders shortly thereafter. PERSONNEL INFORMATION The pilot, age 71, held a private pilot certificate with airplane single-engine land and instrument airplane ratings. He reported 1,448 hours total flight time on his most recent application for an FAA third-class medical certificate, dated October 17, 2013. A review of the pilot's logbook revealed that the last entry was made on September 21, 2015. At that time, he had logged 1,736.4 total hours, including 1,677.9 hours as pilot-in-command, 125.2 hours actual instrument time, and 59.3 hours simulated instrument time. He logged 148.6 hours during the previous 12 months, including 27.6 hours actual instrument time and 23 instrument approaches. During the 24 months prior to the accident, all of his logged flight time was in the accident airplane. His most recent flight review was completed on August 28, 2015 in the accident airplane. The flight review included three instrument approaches and holding. The pilot's son, age 44, was seated in the right cockpit seat. He held an FAA student pilot certificate, dated October 17, 2013. At that time, he reported 40 hours of total flight time and 32 hours in the last 6 months. No pilot logbook was found, and no determination could be made of his total flight experience or experience in the accident airplane. AIRCRAFT INFORMATION The six-seat, low-wing, retractable-gear airplane was manufactured in 1984. It was powered by a 300-hp Lycoming IO-540-K1G5D reciprocating engine, which drove a Hartzell three-bladed, constant-speed propeller. According to the maintenance logbooks, the most recent annual inspection of the airframe and engine was completed on October 28, 2014. At that time, the airframe total time was 4,817.5 hours. At the time of the accident, the airplane had accrued about 135 since the annual inspection. METEOROLOGICAL INFORMATION CEU, located about 14 nautical miles northeast of the accident site, was the closest official weather station. The 1454weather observation included wind from 040° at 10 knots, visibility 10 statute miles, light rain, broken clouds at 1,800 ft, overcast ceiling at 2,300 ft, temperature 17°C, dew point 14°C, and altimeter setting 29.81 inches of mercury. WRECKAGE AND IMPACT INFORMATION The main wreckage, which comprised the cabin, cockpit, engine, propeller, left wing, the inboard half of the right wing, and the separated right wing flap, was found inverted in a wooded area about 50 yards north of the shoreline of Lake Hartwell. Downward, vertical scraping damage was observed on adjacent trees. There was no fire. The Federal Bureau of Investigation Evidence Response Team (ERT) assisted investigators in searching for missing sections of the airframe. Numerous pieces of wreckage were found in a wooded area south of the lake. The center of this debris field was about 2,000 ft south the main wreckage, and was about 1,400 ft long and about 500 ft wide. The pieces of wreckage found in this area included the right stabilator outboard section, three sections of the right aileron, right wing tip trailing edge, right wing fuel tank skin with fuel filler port and cap attached, sections of right wing and empennage skin, aft empennage skin with airplane data plate attached, and a tail cone fairing. Following the land search, the ERT provided resources to search Lake Hartwell for parts of the wreckage still unaccounted for. On December 2, 2015, ERT personnel located the outboard half of the right wing and the left stabilator in the lake. The left stabilator was found in two separate sections. The vertical stabilizer and rudder were not located. The wreckage was transported to a storage facility for additional examination. The left wing was still attached to the fuselage. The left main landing gear was extended and locked. The upper wing skin exhibited upward compression buckling, while the bottom skin exhibited stretching with rebound buckling noted between the skin fasteners. The aileron and flap were in place and secure. The left flap was in the retracted position and the flap linkage was in place. The aileron pushrod was in place and connected to the bellcrank. The aileron control cable was connected to the bellcrank and continuous to the aileron control wheel chain. The aileron balance cable was secure to the left aileron bellcrank and continuous to the right wing. The wing tip was in place; however, the wing tip lighting components were separated. The right wing was in two primary sections, inboard and outboard, along with several small pieces of wing skin, skin reinforcement channels, fuel cell pieces, and other small parts. The inboard section measured about 8.5 ft in length and was secured to the fuselage. The right main landing gear was extended and locked. Compression buckling of the upper wing skin was evident, and the main spar showed a permanent upward and aft deformation. All fracture surfaces exhibited overstress signatures; no evidence of fatigue or corrosion was observed. The separated outboard wing section was about 6.75 ft in length and was recovered from Lake Hartwell . The flap was separated and intact; it was located adjacent to the main wreckage. The right aileron was in three pieces and all pieces were found on land, south of the lake. The aileron bellcrank was connected to the outboard section and was bent in the inboard direction. The aileron control cable was connected to the bellcrank and was continuous for about 4.5 ft outboard of the fuselage, in the area of the wing separation. The remaining position of the control cable was continuous to the aileron control wheel chain. The cable separation displayed broomstraw signatures. The aileron balance cable was secured to the aileron bellcrank and continuous to about 3.7 ft from the fuselage. The balance cable separation displayed broomstraw signatures. The remaining portion of the balance cable was continuous to the left side of the aileron bellcrank. The empennage assembly was separated from the aft fuselage. The right side of the stabilator was fragmented and the tip was separated. The left side of the stabilator was mostly intact; however, the tip assembly was separated. About two-thirds of the stabilator trim tab was recovered with the left side, and the remaining portion was recovered with the right side. The trim drum was attached to the trim tab and stabilator hinge assembly. The trim drum inner shaft was extended about 2 threads, consistent with a pitch trim setting of about 50% nose down. Both trim cables were pulled and displayed broomstraw separation signatures. The left side of the stabilator main spar structure displayed permanent rearward deformation and most of the skin was separated. Both stabilator hinge points were in place and free to move, although travel was restricted because of impact damage. The stabilator stop bolts were in place, secure, and displayed no damage. The stabilator balance tube was attached to the spar and the balance weights were in place. The upper control cable was secure and continuous for about 14 inches. The remaining portion of the cable was continuous to the control column T-bar attach point. The cable was cut just forward of the rear seats to facilitate recovery. The lower stabilator control cable attach point was separated from the balance tube. The attach fitting and cable were secure and found in the aft pulley. The cable was continuous for about 18 inches, where it was separated and showed broomstraw signatures. The remaining portion of the cable was continuous and secure to the control column T-bar attach point. The cable was cut just forward of the aft seats to facilitate recovery. The bridle cable was secure in the attach clamps; however, it was separated between the clamps and the servo. A portion of the cable was wrapped around the pitch servo, which was free to rotate. The electric trim servo had a portion of the trim cable wrapped around the capstan, which was free to rotate. The vertical stabilizer and rudder were separated and were not located. The right-side rudder control cable was separated just forward of the rudder bellcrank attach point and was continuous to the rudder pedals in the cockpit; however, it was cut immediately forward of the aft seats to facilitate recovery. The left-side rudder control cable attach point in the cockpit was broken from the rudder bar, and the control cable was not located. The left side rudder attach bracket was found under the floorboards of the forward fuselage section. The forward fuselage was mostly intact but displayed substantial impact damage, mostly to the forward section. The engine displayed impact damage and was offset to the left side. The aft fuselage was cut immediately aft of the center rear facing seats to facilitate recovery. The empennage assembly was separated and fragmented. The aft fuselage displayed compression impact damage on the right side immediately forward of the vertical stabilizer attach point in a rounded shape, consistent in size with the wing leading edge. This location was immediately forward of the horizontal stabilator. The aft fuselage also showed rotational compression wrinkling. All seats were in place and secure. Some impact displacement of the lower seat frames and seat backs was noted. The left rear and left front seat belts were cut during extrication of the occupants. The right front and right rear seats belts were unbuckled. The center seats were not occupied. No shoulder belts were fastened to any of the lap belts. The control column T-bar displayed impact damage, and the aileron chain was displaced from the sprockets. Both aileron control cables were secure to the chain. The left side was continuous to the aileron bellcrank and the right side was continuous to about 4.5 ft outboard of the fuselage. The aileron balance cable was continuous from the left side aileron bellcrank through the fuselage to about 3.7 ft from the fuselage. The aileron control cables were free to move and the balance bridle cable was still in place around the roll servo, which also was also free to move. The flap jackscrew was fully extended and displayed 32 threads, consistent with a flap setting of 0° (fully retracted). The fuel selector valve was positioned on the left tank and the linkage was secure. The fuel sump filter was free of contaminants. The auto gear extension mechanism was in place and connected. The instrument panel incurred substantial impact damage. The gear selector switch was in the down position. The flap selector was in the up (retracted) position. The magneto switch was in the left position. Examination of the engine revealed only superficial impact-related mechanical damage. The engine was removed from the airframe for further examination. The crankshaft was free to rotate, and rotation of the accessory drives was noted. Compression and suction were verified on all cylinders. Examination of the fuel servo filter, fuel manifold, and fuel pump revealed no anomalies. Rotation of the single-drive dual magneto verified spark to all leads. The vacuum pump was removed; the drive was intact and the pump was free to rotate. The pump was disassembled and the vanes and rotor were intact. The propeller was in place and secure to the engine. Soft, sandy soil was packed into the spinner as well as the front of the engine. Two of the three blades showed a gradual aft bend and the third blade showed a slight aft bend. There was leading edge surface erosion on the blades. The spinner displayed rotational compression, pushing the spinner into the leading edges of the propeller blades. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on the pilot at the request of the Oconee County, South Carolina Coroner. The cause of death was blunt force trauma with resultant multi-organ damage, and the manner of death was accident. Severe atherosclerosis was observed in the vasculature of the brain and heart. There was near-total occlusion of the right frontal and middle cerebral arteries. In the heart, the left anterior descending coronary had 80% occlusion, while both the right and circumflex coronary arteries showed 40% atheromatous occlusion. In addition, the myocardium demonstrated a pale area of fibrosis (scar) extending from the right sub endocardial ventricular septum to the left sub endocardial ventricular septum without acute hemorrhage. On microscopic evaluation, the myocardium demonstrated areas of sub endocardial fibrosis with entrapped, mummified, myocardial fibers and the coronary arteries showed severe atherosclerotic occlusion with near-total obliteration of artery lumens. The pilot reported hay fever, childhood asthma, orthopedic injuries, and kidney stones to the FAA. He reported that he was taking no medications at the time of his latest FAA medical exam, dated October 17, 2013. Toxicology testing on specimens from the pilot was performed by the FAA's Bioaeronautical Research Sciences Laboratory, Oklahoma City, Oklahoma. Testing identified chlorpheniramine (0.06 ug/ml) and pseudoephedrine in peripheral blood. Both chlorpheniramine and pseudoephedrine, as well as ephedrine, were detected in the urine. Chlorpheniramine is a sedating antihistamine available over-the-counter in a variety of cold and allergy products. Therapeutic levels are considered between 0.01 and 0.04 ug

Probable Cause and Findings

The pilot's loss of airplane control for reasons that could not be determined based on the available information.


Source: NTSB Aviation Accident Database

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