RANDOLPH, NH, USA
N4591J
Piper PA-28R-180
The non-instrument rated pilot departed on a flight at night over mountainous terrain. After the airplane failed to arrive at the destination, a search was initiated. The airplane was located the next day on Mt. Randolph approximately 2,000 feet to the southeast of the peak, and 500 feet below it. The airplane sustained an in-flight separation. According to Flight Service records, the pilot obtained a weather briefing over the telephone that forecasted scattered clouds at 5,000 feet, and scattered to broken clouds at 10,000 feet through early morning. The last radio contact with the airplane was when the pilot reported that he was encountering haze at 7,500 feet. A satellite infrared image showed overcast clouds across New Hampshire about the time of the accident. Examination of the wreckage revealed all fracture surfaces were consistent with overload. According to a witness, the airport was in a 'black hole,' surrounded by mountainous terrain with few ground lights for reference. In the last 7 years the pilot logged 0.4 hours of simulated instrument, and 4.7 hours of night. According to the Instrument Flying Handbook, illusions in flight can be created by motion and certain visual scenes. Illusions may lead the pilot to maneuver the aircraft into a dangerous attitude.
HISTORY OF FLIGHT On December 27, 1998, about 1940 eastern standard time, a Piper PA-28R-180, N4591J, was destroyed during an in-flight breakup, and subsequent collision with terrain near Randolph, New Hampshire. The certificated private pilot and passenger sustained fatal injuries. Visual meteorological conditions prevailed for the personal flight that originated from Berlin Muni Airport, Berlin, New Hampshire, destined for Central Jersey Regional Airport, Manville, New Jersey. The flight was conducted under 14 CFR Part 91, and a visual flight rules (VFR) flight plan was filed and activated. At 1707, Bangor Automated Flight Service Station (AFSS) received a call from an individual requesting a weather briefing, and using the call-sign N4591J. The briefer indicated to the caller that there were no weather advisories for the route of flight. Also, the briefer advised the caller that the lowest ceilings for his intended route would be 10,000 feet in the Worcester, Massachusetts, area. While providing initial weather information to the caller, the briefer stated the weather "looks excellent." The briefer continued by giving the caller the current weather at Berlin, which included, winds calm, clear below 12,000 feet, 10 miles of visibility, temperature 26 degrees Fahrenheit, and an altimeter of 30.21 inches of mercury. After providing the caller with current conditions, the briefer advised him that northern New Hampshire, and northern Vermont were forecasting scattered clouds at 5,000 feet, and scattered to broken clouds at 10,000 feet through early morning. The briefer added that Concord, New Hampshire, after 1900, was forecasting 5,000 feet scattered to broken, and 10,000 feet broken to overcast, adding the comment, "so that's good." The briefer then provided the next day's forecast, and while providing that information, he added, "I would recommend tonight instead of tomorrow." The caller then filed a flight fight plan for a 1935 departure. About 1930, an individual using the call-sign N4591J contacted Bangor Radio, and activated a VFR flight plan. Then, about 1935, Bangor received another transmission from N4591J. The person reported he was at 7,500 feet msl, and encountering haze. The briefer advised the individual that radar indicated high clouds with possible snow aloft. The briefer added that in "the area" ceilings were 9,000 to 11,000 feet broken to overcast, changing to scattered to broken in southern New Hampshire. The individual then asked what altitude would be required to get out of the haze, and the brief reiterate the information already provide. No other transmissions were received from N4591J after acknowledging the requested information from Bangor. After the airplane failed to arrive at Central Jersey, the Federal Aviation Administration (FAA) issued an alert notice. The first of two emergency locator transmitter signals was received at 2049, and an Army National Guard helicopter identified the wreckage about 1200, the day after the accident. The accident happened during the hours of darkness. The wreckage was located 44 degrees, 23.147 minutes north latitude, 71 degrees 19.215 minutes west longitude, and at an elevation of 2,860 feet. PERSONNEL INFORMATION The pilot held a private pilot certificate with a single engine land rating, with no instrument rating. His last FAA third class medical was dated January 1, 1998. A review of the pilot's logbook revealed a total of 526.7 hours of flight experience. In addition, the pilot logged a total of 343.8 hours of cross country flight, 141.6 hours of night, 3.6 of simulate instrument, and 17.1 hours in the accident airplane's make and model. In addition, from November 1991 to December 1998, the pilot logged a total of 25 flights. During that time frame, his logbook reflected a total of 0.4 hours of simulated instrument, and 4.7 hours of night. METEOROLOGICAL INFORMATION Examination of the NEXRAD National Mosaic Reflectivity Image for 1900, December 27, 1998, revealed an area of precipitation to the south of Berlin. Examination of the GOES 8 infrared image for 1900, on December 27, 1998, revealed overcast clouds across Vermont and New Hampshire. Moon angle at the time of the accident was 52 degrees above the horizon. Illumination was 68 percent. WRECKAGE AND IMPACT INFORMATION The main wreckage, which comprised the fuselage, left wing inboard section, right wing inboard section, and the empennage, minus the left and right stabilators, was located on Mt. Randolph, approximately 2,000 feet to the southeast of the peak, and 500 feet below it. The debris path was orientated northeast to southwest, with the outboard section of the right wing marking the start. A fragment of the right aileron attached to the inboard aileron hinge, and the right half of the horizontal stabilator were found approximately 500 feet southwest of the start of the debris path. Both of these items were located within 250 feet of one another. Approximately 400 feet further to the southwest, the vertical stabilizer, a section of the right flap, a section of the left aileron, and the outboard section of the left wing were located within 200 feet of one another. The left half of the horizontal stabilator was not located. On December 29, 1999, the wreckage was examined at the accident site. The fuselage was in one complete section, and crushed along its vertical axis. On the aft left side of the fuselage was a vertical brown scrape mark consistent with a tree impact. The right side of the carry-through spar was crushed forward. The top cap for the right wing's spar was bent, but connected. The lower spar cap was fractured, and displayed 45-degree shear planes consistent with overload. The left side of the carry-through spar was not deformed. The left wing's main spar was completely separated from the carry-through spar. The fracture surfaces displayed 45-degree shear planes, and were consistent with overload. The left wing's forward attachment point was connected, and the aft was separated. The right wing separated into two major sections. The outboard section of the right wing, including the wing tip, measured 54 inches. The inboard section measured 94 inches. The inboard section of the right wing displayed damage consistent with impact, and was severely deformed on the outboard 40 inches. The leading edge on this section also exhibited damage consistent with impact. The outboard 24 inches of the main spar top cap in this section was separated from the bottom cap, and bent forward. The lower cap was bent aft. Impact, and multiple breaks at various locations were observed on the main spar in this section. The right main landing gear remained attached to the wing, and was in the up position The right wing's flap was fractured into two pieces at the middle hinge. The leading edge of the separated flap section exhibited damage consistent with impact. Only the inboard hinge and approximately 5 inches of the right aileron were identified. The left wing also separated into two major sections. The inboard section measured 94 inches, and the outboard section measured 54 inches. This was the same as the right wing. The leading edge of the outboard section sustained little impact damage. The upper, and lower skin surfaces of this section separated along a rivet line with about 50 percent of the rivet holes exhibiting span-wise elongation. The false spar was bent rearward at a 30-degree angle, and the top two stringers, aft of the false spar, were bent up and aft. The left inboard wing section was bowed upward from the leading edge to the trailing edge, with the apex of the bow mid-chord on the underside of the wing. The pitot tube remained intact. Approximately 4 inches of the outboard section of the aileron, including the counterweight, remained attached to the outboard aileron hinge. Most of the left aileron was found separated from the left wing. The inboard hinge, along with a 1 foot by 2 foot section of the lower wing's skin remained attached to the separated portion of the left aileron. In addition, the outboard end of the separated aileron was not damaged. The inboard section of the left wing was crushed outboard of the fuel tank. The flap remained attached to the left wing, and was damaged on the inboard end. The flap's outboard hinge mount doubler was bent upward. The left main landing gear remained attached to the wing, and was in the up position. The aft left wing attachment was intact, but bent up. The forward one had separated, and the fracture surfaces displayed 45 degree shear planes. The lower skin near the lap joint exhibited upward bending, and the rivets were pulled out consistent with tension at various locations. The left wing's main spar separated at the fuselage, and where the false spar attaches. On the outboard end of the inboard section, the upper cap of the left main spar was crushed downward, and consistent with impact. The inboard end of the main spar's upper cap exhibited upward deformation, and the associated wing skin in this area was bent upward. Examination of the empennage section revealed that the horizontal, and vertical section of the tail had separated. The main spar for the vertical stabilizer had separated approximately four inches from its base. The skin on the right side of the base showed evidence consistent with tension, and the other side consistent with compression. The vertical stabilizer's forward attachment rivets were bent up, and left. The right side of the vertical stabilizer exhibited impact damage 27 inches from its base, and centered. The top of the rudder was separated at the hinge, and exhibited damage consistent with impact. The rivet line forward of the rudder on the vertical stabilizer that runs vertically was separated starting at the base, and moving upward approximately 20 inches. The rivets were torn out, and the holes were elongated in the aft direction. The rudder separated into two sections. The majority of the rudder was still attached to the empennage, and bent lengthwise 180-degree. The top 18 inches of the rudder remained attached to the vertical stabilizer, and was found along the debris path. Between the stabilator attachment hinges, approximately 13 inches of the stabilator spar remained attached to the empennage. The spar was bent downward, and the skin structure on the upper surface was consistent with tension while the lower surface was consistent with compression. The stabilator control rod was pulled out through the main spar of the stabilator in a forward direction. None of the stops on the stabilator or rudder displayed repeated impact marks. The rudder torque tube was bent left 90 degrees, and 30 degrees aft. The engine, and propeller were examined at the main wreckage site on December 29, 1998. When the engine's crankshaft was rotated, compression was obtained on all four cylinders, the accessory gears rotated, and the magneto leads produced spark. Fuel was observed in the line that connected the engine to the airframe, and the propeller displayed cord-wise scratching, leading edge gouges, and "S" bending. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was preformed on both the pilot, and passenger on December 29, 1998 at the Medical Examiners Office in Concord, New Hampshire. A toxicological test was performed on the pilot by the Federal Aviation Administrations Toxicology and Accident Research Laboratory, Oklahoma City, Oklahoma on March 4, 1999. TESTS AND RESEARCH On February 3, 1999, the wreckage was reexamined at a hangar facility in Biddeford, Maine, by a Safety Board Structures Group. In the structures group chairman's factual report he stated, "There was no evidence of any in-flight or post crash fire. All fracture surfaces examined exhibited overload failures." ADDITIONAL INFORMATION According to a witness who had flown out of Berlin at night, the airport was in a "black hole," surrounded by mountainous terrain with few ground lights for reference. The FAA Advisory Curricular titled, "Instrument Flying Handbook" provides the following information regarding illusions. "In general an illusion or false impression occurs when information provided by our sensory organs is misinterpreted or inadequate. Many illusions in flight can be created by complex motions and certain visual scenes that we encounter under adverse weather conditions and at night. Some illusions may lead to spatial disorientation or the inability to determine accurately the attitude or motion of the aircraft in relation to the Earth's surface.... The disoriented pilot may maneuver the aircraft into a dangerous attitude in an attempt to correct this illusory movement.... The sensations which lead to illusions during instrument flight conditions are normal perceptions experienced by normal individuals. These undesirable sensations cannot be completely prevented, but they can and must be ignored or sufficiently suppressed by developing absolute reliance upon what the flight instruments are telling us about the attitude of our aircraft.... Practice and experience in instrument flying are necessary to aid us in discounting or overcoming false sensations. As additional proficiency in instrument flying is acquired, we become less susceptible to these false sensations and their effects." According to the Aeronautical Information Manual "VFR flight operations may be conducted at night in mountainous terrain with the application of sound judgment and common sense.... Continuous visual contact with the surface and obstructions is a major concern and flight operations under an overcast or in the vicinity of clouds should be approached with extreme caution." The wreckage was released to a representative of the owner's insurance company on February 20, 1999.
The pilot's continued VFR flight into instrument meteorological conditions which led to spatial disorientation and loss of aircraft control. Also causal was the pilot exceeded the design limits of the aircraft which resulted in an in-flight separation. Contributing to the accident were the mountainous terrain, night conditions and the pilot's lack of instrument time.
Source: NTSB Aviation Accident Database
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