Aviation Accident Summaries

Aviation Accident Summary IAD02FA043

OXFORD, CT, USA

Aircraft #1

N82284

Piper PA-34-200T

Analysis

After obtaining weather information, the pilot departed on a long cross country flight at night in instrument meteorological conditions. Approximately 2 hours after departure, the pilot was vectored by air traffic control (ATC) to intercept the localizer for the ILS RWY 36 approach at his destination airport. The pilot acknowledged that he had intercepted the localizer, and was cleared for the approach. Subsequently, ATC terminated radar services and approved a change in radio frequency. The pilot acknowledged the instructions, and there were no further communications with him. Data extracted from a handheld GPS unit revealed that during the last 4 minutes of the flight, the airplane made a series of left and right hand turns in the vicinity of the localizer course as it descended towards the airport. However, it was never established on the localizer course. The last recorded position calculated by the GPS occurred at 2118, was at an altitude of 779 feet msl, about 2,000 feet southeast of runway 36. The published decision altitude for the approach was 972 feet msl. A witness said that the airplane flew very low over her home, and sounded like "a motorcycle going full throttle...at a steady constant rate." Another witness said that the airplane flew over his home about 40-50 feet above the trees with the engines "running correctly." He then observed the airplane's landing lights illuminate the tree tops, then the woods, before it collided with terrain. Weather at the time of the accident included wind from 200 degrees at 6 knots gusting to 15 knots, visibility 2 statute miles, ceiling 300 feet overcast, temperature 52 degrees F, and dewpoint 51 degrees F.

Factual Information

HISTORY OF FLIGHT On April 12, 2002, at 2118 eastern daylight time, a Piper PA-34-200T, N82284, was destroyed when it collided with trees, then terrain, while executing an instrument approach to Waterbury -Oxford Airport (OXC), Oxford, Connecticut. The certificated private pilot was fatally injured. An instrument flight rules (IFR) flight plan was filed for the flight that originated at Grand Strand Airport (CRE), North Myrtle Beach, South Carolina, at 1807. Night instrument meteorological conditions prevailed for the personal flight conducted under 14 CFR Part 91. Prior to departure, the pilot obtained weather information and filed an IFR flight plan with the Anderson Automated Flight Service Station (AFSS), Anderson, South Carolina. He also purchased 62.9 gallons of fuel, which filled the tanks. A review of air traffic control (ATC) communications revealed that after the pilot arrived in the New York Terminal Radar Approach Control (TRACON) area, he received vectors to intercept the localizer course for the instrument landing system (ILS) RWY 36 approach at Waterbury-Oxford Airport. At 2102, the pilot advised the approach controller that he was established on the localizer, and five minutes later, he was cleared for the approach. At 2114, the approach controller advised the pilot that he was about 2 miles from the locater outer marker (LOM)/Clera intersection. At that time, the approach controller terminated radar services and approved a change radio frequency. The pilot acknowledged the radio call. At 2123, the approach controller attempted to contact the pilot, but there was no response. There were no further communications with the pilot. A witness, who was standing in his driveway, facing the airport, heard the airplane approach, and noted that it sounded "off course." When the witness looked up, the airplane flew over his home about 40-50 feet above the trees, then "continued to fly normally at the same altitude as if to land." The witness then observed the airplane's landing lights illuminate the tree tops and the woods, before it crashed. The witness also related that he built engines, and thought the airplane's engines sounded like they were "running correctly." A second witness was in his home when he heard the sound of a twin-engine airplane approach from the east. He said the engine rpm sounded "higher" than normal, when all of a sudden it dropped to a real low rpm for a few seconds. The rpm then increased "drastically" for 3 to 4 seconds, before it dropped slightly. The witness also said that "normally the sound of the plane drifts off, but this changed drastically." A third witness was in her home, located directly across the street from the accident site. She said the airplane flew very low over her home and sounded like "a motorcycle going full throttle overhead at a steady constant rate." Almost instantly, she heard a loud boom and saw an orange glow in the yard. A fourth witness was standing outside his office at the airport, when he heard the sound of a "jet engine revving loud." He said the "revving started to get faster (higher)", then he heard a crash. Radar data was requested from the Federal Aviation Administration (FAA). Due to a technical malfunction with the recording equipment, the data was not recovered for this flight. The accident occurred during the hours of darkness, approximately 41 degrees, 28 minutes north latitude, and 73 degrees, 7 minutes west longitude. PERSONNEL INFORMATION The pilot held a private pilot certificate with ratings for airplane single engine land, multi engine land, and instrument airplane. His most recent Federal Aviation Administration (FAA) third class medical certificate was issued on May 12, 2000. Examination of the pilot's logbook revealed that the last entry was logged on December 25, 2001. At that time, the pilot had accrued a total of 897.5 hours, of which, 341.2 hours were in multi-engine aircraft. He had a total of 119.7 hours at night, and 45.2 flight hours in actual instrument conditions. In the six months preceding the accident, the pilot wrote in the remarks section of his logbook that he had executed eight ILS RWY 36 approaches at the Waterbury-Oxford Airport. On a separate piece of paper, the pilot recorded two separate flights that occurred on March 30, 2002. The first flight was 1 hour in duration, and the pilot remarked that he had completed, "turns, ILS 36 circle to land RWY 18...3 landings." The second flight was 1.7 hours in duration, and the pilot remarked that he completed "turns, 3 landings day, 1 ILS 36." METEOROLOGICAL INFORMATION Weather reported at the Waterbury-Oxford Airport, at 2115, included winds from 200 degrees at 6 knots gusting to 15 knots, temperature 52 degrees F, dewpoint 51 degrees F, and altimeter setting 30.38 inches Hg. The visibility was 2 statute miles and the ceiling was 300 feet overcast. The published weather minimums for the ILS RWY 36 approach included a 300-foot ceiling and a 1-mile visibility. AIDS TO NAVIGATION The published inbound course for the ILS RWY 36 approach was 005 degrees, and the decision altitude was 972 feet msl (250 feet agl). The airport elevation was 727 feet msl. Runway 36 was a 5,000-foot-long and 100-foot-wide asphalt runway, which was equipped with a 4-light precision approach path indicator (PAPI) system, high intensity runway lights (HIRL) and runway end identifier lights (REIL). On April 13, 2002, FAA flight test personnel conducted an inspection of the ILS RWY 36 approach system, and found it "satisfactory". WRECKAGE AND IMPACT INFORMATION The airplane wreckage was examined at the site on April 13-14, 2002. All major components of the airplane were accounted for at the scene. The airplane came to rest upright, embedded in brush and mud, on a heading of 120 degrees, at a ground elevation of approximately 650 feet mean sea level (msl), about 2,000 feet southeast of runway 36. Initial tree impact scars started 176 feet from the main wreckage, and a 5- to 10-foot-wide swath was cut through the approximately 50-foot trees. Tree impact scars became progressively lower on the trees in the direction of the main wreckage, which was in a general direction of 295 degrees. The terrain also sloped down hill from the initial impact point to where the main wreckage came to rest. Several cut tree branches were found along the wreckage path. Examination of the branches revealed that the ends were cut at approximately 45-degree angles at the beginning of the wreckage path, and approximately 80-degree angles closer to the main wreckage. The surface of these cuts exhibited black paint transfer marks. The left aileron, left fuel tank, outboard section of the left wing, right engine propeller assembly, and right main landing gear were found scattered along the wreckage path. The cockpit, fuselage, and empennage, were consumed by fire. The right wing remained attached to the fuselage, and exhibited fire and impact damage. The fuel tank was melted, the aileron was separated, and the flap was partially attached and bent under the fuselage. The left wing main spar remained attached to the fuselage at the wing root. However, the wing structure was fragmented and separated due to impact damage. The tail control surfaces exhibited fire and impact damage, and remained attached to the fuselage by control cables. Flight control continuity was traced for each flight control surface. Some of the cables exhibited "broomstraw" separations. Examination of the flap handle and flap chain mechanism revealed that the flaps were extended 10 degrees. The rudder trim wheel and actuator were both found in the full-right position. However, the cables had severed through to approximately 1.5 inches of airframe structure in the tail. The pitch trim actuator was found set to 1/2 degree nose down. The right main landing gear and nose wheel were separated from the fuselage, and found under the fuselage. The nose wheel actuator was found extended. Both wing fuel filters were intact. The left wing filter bowl was empty. The filter was covered with soot, but was absent of debris. The right wing filter bowl contained light blue fuel, and the filter was absent of debris. The throttle, propeller, and mixture controls were all in the full forward position. The altimeter, airspeed indicator, turn coordinator, and directional gyro were found outside the main wreckage. The altimeter was fragmented, and the needles were missing. The altimeter setting was 30.37 inches HG. The airspeed indicator indicated 165 knots, and the miniature airplane in the turn coordinator was inverted with a 45 degree left wing down attitude. The inclinometer was broken. The directional gyro exhibited impact damage to the face plate. The unit was disassembled and the gyro housing was removed and examined. The gyro was intact, and there was no rotational scoring on the interior of the housing. The right engine was separated from the airframe and behind the right wing. The engine sustained impact damage, and was not exposed to fire or heat damage. The fuel pump was separated from the engine, but the coupler was intact. The interior section of the vacuum pump had separated from the engine and was not located. The base of the vacuum remained attached to the engine, and the coupler was intact. Both magnetos were separated from the right engine. Each magneto was rotated by hand, and spark was produced to all leads. The top spark plugs were removed and appeared gray in color. The right engine fuel manifold valve was intact. When the valve was disassembled, fuel was observed in the chamber, the diaphragm was intact, and the screen was absent of debris. Engine continuity and compression were established to each cylinder by manual rotation of the propeller flange. During the compression check, valve train continuity was confirmed to all but the #5 cylinder due to impact damage. The vacuum pump coupler was also observed to turn. The turbocharger remained attached to the engine by an oil return cable. The compressor was partially separated from its housing, and was full of mud. The impeller blades turned freely, and a few of the blades were bent opposite in the direction of rotation. The right propeller assembly was separated from the engine and located along the wreckage path. All three blades remained attached, but were loose in the hub. Examination of the propeller hub mounting bolts revealed that they were stripped, and three holes were elongated opposite the direction of rotation. One blade exhibited s-bending, leading edge damage, and chordwise scratching. The second blade was bent aft and twisted along the outboard section of the blade. A trailing edge section of the blade's tip was missing. The blade also exhibited leading edge damage and chordwise scratching. The third blade exhibited s-bending, leading edge damage and chordwise scratching. The outboard section of the blade was bent forward and the tip of the blade was missing. The left engine was lying inverted, inside the fuselage. The engine exhibited extensive impact and fire damage. The oil sump was partially melted away, and sections of the sump were down in the interior section of the engine. A section of the propeller hub was still attached to the flange, which was bent. The induction and throttle body exhibited extensive heat damage. The top section of the fuel manifold valve screen was melted away, and the remaining section of the diaphragm was peeled from its seat. The fuel screen was coated with a small amount of ash. Both magnetos and their respective harnesses were separated from the left engine. They sustained extensive heat damage, and could not be examined. The vacuum pump was separated from the engine, but the coupler remained intact. The fuel pump and coupler were separated from the engine, but the coupler was intact. The top six spark plugs were removed and appeared oil-soaked. The #1 and #2 plugs were filled with oil and mud. The engine could only be rotated about 45 degrees. When the engine was rotated, the vacuum pump coupler turned, and movement was observed to the accessory drive gears, and #3 cylinder valves. The turbocharger was separated from the engine and sustained fire damage. The compressor housing and impeller were melted away. The impeller could not be rotated. The left engine propeller assembly was found fragmented, under the fuselage. The hub was fractured and one blade remained attached. The second blade was separated, and embedded in the mud. The third blade was not located. The blade that remained in the hub was bent aft, and exhibited twisting, leading edge and trailing edge damage. The second blade was bent forward, and exhibited s-bending, chordwise scratching, and leading edge damage. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy was performed on April 13, 2002, by the State of Connecticut, Office of the Chief Medical Examiner, Farmington, Connecticut. Toxicological testing was performed by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. ADDITIONAL INFORMATION A handheld Garmin GPSMAP 295 was found at the accident site and sent to the manufacturer for examination. The unit was examined on June 10, 2002, under FAA supervision. Data was extracted and downloaded onto a map from Street Atlas USA, and the localizer course was superimposed over the map. The unit recorded the airplane's entire flight from North Myrtle Beach to Oxford. Examination of the last 4 minutes of the flight track revealed that when the airplane was approximately 1 3/4-miles south of the locater outer marker (LOM), it was at an altitude of 3,008 feet msl. The airplane then turned left, and passed abeam the LOM about 1 mile left of course at an altitude of 2,837 feet msl, before it turned right and appeared to momentarily intercept the localizer course. Then, the airplane turned left, and flew about 3/4-mile left of the localizer course, before it initiated another right hand turn back towards the localizer course. The airplane crossed over the localizer course at an altitude of 1,271 feet msl just south of the middle marker, then began a left hand turn back towards the airport just before the data ended. The last position calculated by the GPS receiver was 41 degrees 28 minutes north latitude, and 73 degrees, 7 minutes west longitude, at 2118:32. The altitude was 779 feet msl. The airplane wreckage was released to a representative of the owner's insurance company on April 14, 2002.

Probable Cause and Findings

The pilot's failure to follow the published instrument approach procedure. Factors were the night and low ceiling conditions.

 

Source: NTSB Aviation Accident Database

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