Aviation Accident Summaries

Aviation Accident Summary ERA16FA032

Cornelia, GA, USA

Aircraft #1

N57WV

PIPER PA 28-180

Analysis

The private pilot was conducting a visual flight rules (VFR) personal cross-country flight at night with two passengers on board. The pilot landed the airplane along his route to refuel. The airport manager reported that the airport's automated weather observation system was reporting 300 to 400 ft overcast ceilings. Further, one of the passengers sent a text message to someone waiting at their destination airport stating that they had to circle around the intermediary airport a couple of times to find a runway because it was "awful cloudy" and there was a "low ceiling." After refueling, the pilot departed despite the instrument meteorological conditions (IMC) that prevailed at both the intermediary airport and the destination airport. Although the pilot was instrument-rated, there was no evidence that he maintained his currency. Further, the pilot did not file and instrument flight rules flight plan. Radar data revealed that, as the airplane crossed over the destination airport, it began a left turn before disappearing from radar. Residents who lived near the airport reported hearing a "whirling" noise, followed by a loud crash. They stated that, when they went outside to see what happened, there was heavy fog and mist. At no time during the flight was the pilot communicating with air traffic control or receiving radar services. The wreckage was located about 0.25 mile from the destination airport. Forward-to-aft crushing signatures to the wreckage, damage to adjacent trees, and the lack of a linear wreckage debris path was consistent with a near-vertical, nose-low attitude at impact. An examination of the airframe and engine did not reveal any evidence of a preimpact anomaly or malfunction that would have precluded normal operation. The conditions that existed during the flight, including dark night lighting conditions, low ceilings, and restricted visibility, were conducive to the development of spatial disorientation. Further, the airplane's near-vertical descent was consistent with the pilot's loss of control due to spatial disorientation. The pilot's decision to initiate the VFR flight into known IMC directly led to the accident.

Factual Information

HISTORY OF FLIGHTOn November 4, 2015, about 2355, eastern standard time, a Piper PA-28-180 airplane, N57WV, impacted wooded terrain following a loss of control during approach to Habersham County Airport (AJR), Cornelia, Georgia. The private pilot and two passengers were fatally injured, and the airplane was destroyed. The airplane was registered to and operated by the pilot, and was being conducted as a 14 Code of Federal Regulations Part 91 personal flight. Night instrument meteorological conditions existed at the airport at the time of the accident, and no flight plan was filed. The flight originated from Hazlehurst Airport (AZE), Hazlehurst, Georgia, about 2300 and was destined for AJR. According to a witness who was waiting for the airplane to arrive at AJR, the flight originated from Treasure Coast International Airport (FPR), Fort Pierce, Florida, earlier that evening. The witness received a text message from one of the passengers, which stated that the flight had just landed at AZE to refuel and that they had to circle around the airport a couple of times to find the runway because it was "awful cloudy" and there was a "low ceiling." According to the AZE airport manager, he heard the airplane depart about 2300 and noted that the AWOS was reporting 300 to 400 ft overcast. Another witness, who was waiting for the airplane to arrive at AJR, reported that he According to information from the Federal Aviation Administration (FAA), the pilot was not receiving radar services nor was he communicating with air traffic control at any time during the accident flight. Radar data obtained from the FAA, and correlated to the accident flight, revealed that as the airplane crossed over AJR, it began a left turn before disappearing from radar. Witnesses who lived near the airport reported hearing an airplane flying overhead and shortly afterward hearing a "whirling" noise, followed by a loud crash. They went outside to see if they could determine where the noise had come from but were not able to due to the heavy fog and mist in the area. They searched the area that night, located the airplane in a ravine, and notified the local authorities. PERSONNEL INFORMATIONThe pilot held a private pilot certificate with airplane single-engine land and instrument ratings and an FAA third-class medical certificate issued October 12, 2015, with the limitation that he must possess glasses for near vision. At the time of his medical examination, the pilot reported 800 total hours of flight experience, 0 hours of which were in the previous 6 months. A review of the pilot's logbook revealed that the last entry was dated April 28, 2012. The total time entered was 732.3 flight hours. He had a total actual instrument time of 6.4 hours and a total simulated instrument flight time of 78.9 hours. On March 27, 2012, the pilot completed an instrument proficiency check. No other pilot records were found during the investigation. AIRCRAFT INFORMATIONThe airplane was manufactured in 1968. It was powered by a Lycoming O-360-A4A-series engine and equipped with a Sensenich propeller. Review of a maintenance work order excerpt revealed that the airplane was last inspected in accordance with an annual inspection on August 18, 2015, at a tachometer time of 1,328 hours. The tachometer was destroyed; therefore, the time at the time of the accident could not be determined. The airplane's maintenance logbooks were not located during the wreckage examination. A review of the fueling records revealed that the pilot refueled the airplane with 23.8 gallons of 100 low lead fuel before departing from AZE. The airplane was equipped with a J.P. Instruments engine data monitor, which was sent to the National Transportation Safety Board's recorder laboratory for data readout. The data revealed no anomalies with the engine's operation. METEOROLOGICAL INFORMATIONThe 2355 AJR recorded weather included winds from 080° at 3 knots, 3 statute miles visibility, light rain, overcast clouds at 300 ft, temperature and dew point 16°C, and an altimeter setting of 30.30 inches of mercury (inHg). The 2355 recorded weather at Toccoa Airport, Toccoa, Georgia, located 14 nautical miles southwest from AJR, included calm wind, 2 statute miles visibility, overcast ceiling at 200 ft, temperature and dew point 17°C, and an altimeter setting of 30.29 inHg. The 2255 AZE recorded weather included winds from 110° at 4 knots, 7 statute miles visibility, an overcast ceiling at 600 ft, temperature and dew point 23°C, and an altimeter setting of 30.21 inHg. Lockheed Martin Flight Services reported that the pilot had not contacted it for weather information. There was also no record that the pilot used the Direct User Access Terminal Service for weather information and flight plan processing. AIRPORT INFORMATIONThe airplane was manufactured in 1968. It was powered by a Lycoming O-360-A4A-series engine and equipped with a Sensenich propeller. Review of a maintenance work order excerpt revealed that the airplane was last inspected in accordance with an annual inspection on August 18, 2015, at a tachometer time of 1,328 hours. The tachometer was destroyed; therefore, the time at the time of the accident could not be determined. The airplane's maintenance logbooks were not located during the wreckage examination. A review of the fueling records revealed that the pilot refueled the airplane with 23.8 gallons of 100 low lead fuel before departing from AZE. The airplane was equipped with a J.P. Instruments engine data monitor, which was sent to the National Transportation Safety Board's recorder laboratory for data readout. The data revealed no anomalies with the engine's operation. WRECKAGE AND IMPACT INFORMATIONThe wreckage site was in a wooded area about 0.25 mile from AJR on a magnetic heading of 330°. Freshly broken tree branches were observed above the wreckage. The airplane was observed in a nose-down position the nose and cockpit were buried about 4 ft below the ground's surface. All flight control surfaces were located at the accident site and were still attached to the fuselage. Both wings were accordion crushed toward the ground, and the airplane's tail section remained above ground and was crushed downward. The airplane was removed and repositioned for examination. Control continuity was confirmed from the control yoke to the elevators and ailerons and from the rudder to the rudder pedals. Forward-to-aft crushing signatures were observed on the fuselage and both wings. Scraping damage, in a vertically down direction, was observed on adjacent trees. The wreckage debris path was not linear, and there was no evidence of fire. All the structural components of the airframe and engine were accounted for at the scene. The cockpit instrument panel was destroyed, and the flight and performance instruments were separated. The attitude indicator and directional gyro were disassembled, and the internal gyros were found intact with no rotational scaring. The stabilator and aileron control cables remained attached to the "T" bar assembly. The flap lever assembly was impact damaged, and the flap lever was found separated from its mounting point. The rudder pedal assembly was found separated from its mounts and was impact damaged. The rudder cables were found attached to their mounting points; however, the rudder bar assembly was destroyed by impact and separated from its mounts. The fuselage was found crushed aft and destroyed by impact. Eight ft of the inboard left wing remained attached to the fuselage and was found crushed aft from impact. The remainder of the wing was separated outboard of the left fuel tank and was impact damaged. The left aileron was separated from its mounts, and the left aileron balance weight was found separated from the aileron and was not located in the wreckage. The aileron drive cable was attached from the bellcrank to the "T" bar chain, and control continuity was established from the "T" bar chain to the aileron bellcrank. The balance cable was attached to the bellcrank and to the roll servo and the center board pulley. Control continuity was established on the balance cable from the bellcrank to the centerboard of the fuselage. The left wing bellcrank stops were found in place. The left fuel tank was breeched by impact, the fuel cap was found in place, and the fuel tank pickup screen was found clear of debris. The left main landing gear (MLG) was found attached to the wing, and the left flap was attached to the inboard and outboard hinge attachment points; however, the center hinge attachment point was separated. Impact damage was noted in this area of the wing. The right wing was found separated at the wing root from the fuselage, and the wing skin was crushed aft. The aileron cables were found separated at the wing root and had been cut during recovery. The aileron stops were found in place; however, the aileron bellcrank was found separated from its mount and protruding out from the bottom of the wing just outboard of the fuel tank. The outboard 5 ft of the wing was found separated from the remainder of the wing. The right MLG remained attached to the wing. The right aileron was found attached to the wing, and the aileron balance weight was found attached to the aileron. The right flap was impact damaged and remained attached to its hinge attachment points. The right fuel tank was breeched from impact, and the fuel cap was found in place. The fuel tank pickup screen was found to be clear of debris. Aileron control continuity was established from the wing root to the bellcrank. The right side of the stabilator was separated for recovery, and the stabilator trim tab remained attached. The left side of the stabilator and stabilator trim tab remained attached to its mounting points. The leading edge of the vertical stabilizer was found crushed aft. The rudder was impact damaged but remained attached to its mounts. Flight control continuity was established to the rudder, stabilator, and stabilator trim except where impact separated or cut for recovery, and no preimpact anomalies were noted. The engine was found buried about 4 ft below the ground's surface. Engine internal continuity was confirmed from the propeller flange to the rear accessory drives; full rotation of the crankshaft was not possible due to impact damage. The four top spark plugs were removed for examination, and the plug electrodes were brown colored and exhibited normal wear patterns. The bottom spark plug electrodes revealed the same wear patterns. The carburetor was fractured across the throttle bore and separated from the engine. The carburetor bowl was removed from the upper assembly, and about 1 ounce of red liquid was observed in the bowl. The liquid tested positive for water using water-finding paste. The brass carburetor floats were deformed, consistent with hydraulic crushing. The propeller remained attached to the crankshaft flange. The propeller spinner was separated. The spinner back plate and starter ring gear support were fragmented. Both propeller blades exhibited chord-wise scratches, leading edge gouges, and paint abrasion. Both blades were bent aft and twisted. ADDITIONAL INFORMATIONFAA Advisory Circular (AC) 60-4A, "Pilot's Spatial Disorientation," states, in part, the following: The attitude of an aircraft is generally determined by reference to the natural horizon or other visual references with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of disorientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is 'up.' The AC notes that a disoriented pilot may place an aircraft in a dangerous attitude and recommends that pilots "not attempt visual flight rules flight when there is a possibility of getting trapped in deteriorating weather." MEDICAL AND PATHOLOGICAL INFORMATIONThe Division of Forensics Sciences, Georgia Bureau of Investigation, Georgia, performed an autopsy of the pilot. The autopsy report noted the cause of death as "multiple injuries." Toxicology specimens were not collected at the time of the autopsy; therefore, postaccident toxicological testing was not performed.

Probable Cause and Findings

The pilot's decision to initiate the flight into known adverse weather conditions, which resulted in his spatial disorientation and loss of airplane control.

 

Source: NTSB Aviation Accident Database

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