Aviation Accident Summaries

Aviation Accident Summary CEN17FA258

Waterford, OH, USA

Aircraft #1

N793MA

PIPER PA 28-181

Analysis

The private pilot and the passenger were making an instrument flight rules personal cross-country flight in the airplane. Radar data showed that the airplane was in cruise flight about 7,000 ft mean sea level (msl) until the pilot began a descent toward the initial approach fix for the GPS approach to the destination airport. Cloud tops in the area were about 6,200 to 6,900 ft msl; thus, the airplane likely entered clouds (instrument meteorological conditions) as it descended. The final 2.5 minutes of the radar data revealed erratic turns left and right, which were consistent with the pilot becoming spatially disorientated while descending in instrument meteorological conditions. The last radar point recorded the airplane about 2,950 ft msl or about 2,100 ft above ground level (agl); the reported cloud base at the destination airport was 1,200 ft agl. A witness reported that low overcast clouds were present as he heard the airplane fly overhead. The witness saw the airplane exit the clouds in a steep angle of descent with the engine operating at high power. The airplane disappeared behind a tree line and a few seconds later impacted a reservoir. The deviation from the intended flight path, erratic maneuvering, and steep descent in instrument meteorological conditions are consistent with spatial disorientation. A postaccident examination of the airplane and engine did not reveal any mechanical malfunctions or failures that would have precluded normal operation. The engine and propeller exhibited signatures consistent with high engine power at impact. The vacuum pump remained intact and did not exhibit any preimpact anomalies. Although the pilot held an instrument rating, his total instrument flight experience could not be determined. The pilot's autopsy revealed severe coronary artery disease that put him at risk of an acute coronary event; however, it is unlikely that symptoms of shortness of breath, chest pain, palpitations, or fainting would lead to the type of airplane performance findings present in this case. Therefore, it is unlikely the pilot's heart disease contributed to the accident.  Although the coroner's toxicology testing identified ethanol, the fact that it was absent on two other tests of liver and brain tissue indicates it was from sources other than ingestion and did not contribute to the accident. There is no evidence of a medical condition or substance that contributed to this accident.

Factual Information

HISTORY OF FLIGHTOn July 8, 2017, at 0942 eastern daylight time, a Piper PA-28-181 airplane, N793MA, impacted the Muskingum River Fly Ash Reservoir near Waterford, Ohio. The private pilot and the passenger were fatally injured, and the airplane was destroyed. The airplane was registered to and operated the pilot under the provisions of Title 14 Code of Federal Regulations Part 91 as a personal flight. Instrument meteorological conditions prevailed at the time of the accident, and the cross-country flight was operated on an instrument flight rules (IFR) flight plan. The airplane departed Logansport/Cass County Airport (GGP), Logansport, Indiana, at 0758 and was en route to Mid-Ohio Valley Regional Airport (PKB), Parkersburg, West Virginia. According to air traffic control and radar information, the airplane was in cruise flight about 7,000 ft mean sea level (msl) until the initial descent to PKB began at 0933. The airplane began a steady descent and proceeded toward OWAVE, the initial approach fix for the RNAV (GPS) RWY 21 approach to PKB. The final 2.5 minutes of the radar data revealed several sharp turns left and right (figure 1). The last radar point recorded the airplane at 0942 at 2,950 ft msl, about 2,100 ft above ground level (agl), which was 0.5 miles northeast of the accident site. The accident site is marked with the yellow pin in figure 1. Figure 1 – Flight Path A witness, who was 0.78 nautical mile southwest of the accident site (as shown in figure 1), reported that low overcast clouds were present as he heard the airplane fly overhead. The airplane then exited the clouds in a steep angle of descent with the engine operating at "full rpm, full power." The airplane disappeared behind a tree line; he heard a thud sound, and the engine noise stopped. Only a few seconds elapsed between the airplane descending out of the clouds and the thud sound. PERSONNEL INFORMATIONRemnants of a pilot logbook were recovered from the reservoir but were not legible. According to the application for his most recent medical certificate on March 28, 2016, the pilot's total flight experience was 1,100 hours. His instrument flight experience is unknown. The pilot's flight instructor provided copies of his logbook, which showed that the pilot and flight instructor flew 7 flights in the accident airplane from April 2015 to March 2017. The flights totaled 7.95 hours and included 17 instrument approaches: 12 instrument landing system (ILS), 4 very-high omnidirectional range (VOR), and 1 GPS approach. The pilot's most recent logged instrument flight was on March 11, 2017, during which he completed 2 ILS and 1 VOR approach. AIRCRAFT INFORMATIONThe pilot's flight instructor reported that he flew the airplane on July 26, 2016, from Indianapolis to GGP. He stated that the autopilot worked in the wings-level roll mode but would not hold a heading. The instructor did not report if the autopilot was placarded inoperative or if any subsequent maintenance had been performed to fix the issue. The airplane maintenance logbooks did not contain any entries regarding the autopilot. METEOROLOGICAL INFORMATIONThe weather conditions near the accident location included overcast ceilings between 1,200 and 1,500 ft agl (2,000 to 2,300 ft msl). The cloud tops across the region were 6,200 ft to 6,900 ft msl. An area forecast for southwestern Ohio forecasted overcast clouds at 2,000 ft msl and overcast clouds at 5,000 ft msl with cloud tops to 10,000 ft msl. An AIRMET for IFR conditions was active for the accident location at the accident time. AIRPORT INFORMATIONThe pilot's flight instructor reported that he flew the airplane on July 26, 2016, from Indianapolis to GGP. He stated that the autopilot worked in the wings-level roll mode but would not hold a heading. The instructor did not report if the autopilot was placarded inoperative or if any subsequent maintenance had been performed to fix the issue. The airplane maintenance logbooks did not contain any entries regarding the autopilot. WRECKAGE AND IMPACT INFORMATIONThe accident site was in the Muskingum River Fly Ash Reservoir, and the wreckage was submerged in about 5 ft of water. The wreckage debris field was generally oriented west to east. A fuel sheen was observed on top of the water near the wreckage. The wreckage was recovered by divers and pulled to the shore. A postaccident examination of the wreckage revealed that the airplane had separated into three main sections. The largest section, shown in figure 2, consisted of the engine, fuselage, and empennage. The next section consisted of most of the right wing, and the last section consisted of a small section of the left wing. Figure 2 – Airplane wreckage with the reservoir in the background Several small pieces of airplane debris were also recovered from other areas of the reservoir. No electronic devices were found with the wreckage. A distinct needle impact mark on the face of the airspeed indicator was observed near 153 kts indication, which was just below the redline. The altimeter barometric pressure was set to 29.98 inches of mercury. The other instruments were significantly damage during the accident sequence, and their final positions were unreliable. The vacuum pump remained attached to the engine, and no external damage was noted. The pump was partially disassembled, and the composite drive assembly, carbon rotor, and carbon vanes were intact. The electric auxiliary vacuum pump was not found with the recovered wreckage. The propeller remained attached to the engine crankshaft flange. The propeller spinner was crushed. One propeller blade remained intact, was curled aft about 100°, and exhibited longitudinal twisting. The other blade was twisted, curled aft about 90°, and was fractured about 1 ft from the tip; the separated tip was not found. The postaccident examination of the engine and airframe did not reveal any preimpact anomalies that would have precluded normal operation. MEDICAL AND PATHOLOGICAL INFORMATIONThe Montgomery County Coroner's Office, Dayton, Ohio, completed an autopsy on the pilot, and the cause of death was multiple blunt force injuries. Significant coronary artery disease was identified with 95% atherosclerotic stenosis of the left anterior descending coronary artery and 10% atherosclerotic stenosis of the left circumflex and right coronary arteries. The remainder of the examination of the heart was unremarkable; there was no evidence of previous ischemia. Toxicology testing performed by the Montgomery County Coroner's Office identified but did not quantify ethanol in the pilot's liver. Toxicology testing performed by the Federal Aviation Administration (FAA) Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, identified irbesartan and metoprolol in muscle and metoprolol and pravastatin in liver, none of which are considered impairing. No ethanol was found in liver or brain tissue. Irbesartan is a prescription medication used alone or in combination with other medications to treat high blood pressure. It is also used to treat kidney disease caused by diabetes in patients with type 2 diabetes and high blood pressure. Pravastatin is a prescription medication used together with diet, weight-loss, and exercise to reduce low-density lipoprotein cholesterol and triglycerides in the blood and to increase the amount of high-density lipoprotein cholesterol in the blood. Metoprolol is a prescription medication used alone or in combination with other medications to treat high blood pressure. It also is used to prevent angina (chest pain) and to improve survival after a heart attack. Metoprolol also is used in combination with other medications to treat heart failure.

Probable Cause and Findings

The pilot's loss of airplane control due to spatial disorientation in instrument meteorological conditions.

 

Source: NTSB Aviation Accident Database

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