Aviation Accident Summaries

Aviation Accident Summary NYC06FA156

Philipsburg, PA, USA

Aircraft #1

N56246

Piper PA-28R-200

Analysis

The airplane was cleared for the full instrument landing system (ILS) runway 16 approach. After crossing the locator outer marker (LOM), the airplane turned outbound, executed a course reversal, and then proceeded inbound in the general direction of the LOM, but never became established during the procedure turn. The airplane passed abeam the LOM about 1/2 mile to the northeast, and then conducted one "S" turn in about a mile, crossing over the final approach course twice before radar contact was lost. The last recorded target was at an altitude of 2,700 feet, and located about 1/2 mile west of the approach end of the runway. The airplane impacted trees about 228 feet below the decision altitude of 2,325 feet, and came to rest in a wooded area on a heading of 160 degrees. Examination of the wreckage revealed the NAV 1 radio was tuned to the localizer frequency, but the automatic direction finder was not tuned to the LOM. In addition, no preimpact failures or malfunctions were identified with either the airframe or engine. The pilot had approximately 625 total hours of flight experience, of which 45 hours were under simulated instrument conditions, and 107 hours were under actual instrument conditions. At the time of the accident, the airplane had been aloft approximately 4 hours 19 minutes, had about 41 minutes of fuel remaining, and it was unlikely the pilot would have been able to reach his filed alternate airport approximately 100 nautical miles away. The pilot was advised, 1 hour before the flight, of decreasing ceilings to 400 feet with 2 miles. Interpolation of weather data revealed that the weather at the arrival airport was about 200 feet overcast with 2.5 miles of visibility in light rain.

Factual Information

HISTORY OF FLIGHT On June 26, 2006, at 0302 eastern daylight time, a Piper PA-28R-200, N56246, was destroyed when it impacted trees and terrain during an instrument approach to Mid-State Airport (PSB), Philipsburg, Pennsylvania. The certificated commercial pilot was fatally injured. The pilot-rated passenger in the right front seat and two passengers were seriously injured. The flight originated at Springfield Robertson County Airport (M91), Springfield, Tennessee, on June 25, 2006, at 2243 eastern daylight time. Instrument meteorological conditions (IMC) prevailed and an instrument flight rules (IFR) flight plan was filed for the personal flight conducted under 14 CFR Part 91. At 2146, the pilot obtained a weather briefing from the Louisville Automated Flight Service Station. The forecast was for IMC conditions in the vicinity of the destination airport, and the pilot discussed the ceilings, visibility, and winds at length with the briefer. The briefer advised the pilot of decreasing ceilings to 400 feet overcast with 2 miles of visibility with light rain and mist. The pilot also obtained NOTAMS, and filed an IFR flight plan with Pittsburgh International Airport (PIT) as his alternate destination. The pilot filed an en route time of 4 hours at a cruising speed of 130 knots, and stated he had 5 hours of fuel endurance. The briefing was concluded at 2205. The instrument landing system (ILS) runway 16 approach at Mid-State Airport had an inbound course of 165 degrees. The minimum altitude outside the final approach fix, PORTS locator outer marker (LOM) was 4,000 feet. The PORTS LOM was 6 miles from the airport. The decision altitude for the approach was 2,325 feet which corresponded to 377 feet above the landing threshold. A review of voice communication data provided by the Federal Aviation Administration (FAA) revealed that the airplane was cleared directly to PORTS LOM, and then for the ILS runway 16 approach. After a brief discussion with the controller, the pilot clarified that he would perform the "full approach," rather than receive radar vectors to the final approach course. The pilot was issued a frequency change by the controller, radar services were terminated, and no further transmissions were received from the airplane. Radar data from the FAA was plotted to scale over the ILS runway 16 instrument approach procedure. A target identified as the accident airplane approached the airport from the south, and descended toward the PORTS LOM on an approximate track of 040 degrees. The airplane crossed PORTS LOM, and flew northwest along the eastern edge of the 345-degree outbound localizer course. About 3.5 miles northwest of PORTS LOM, the airplane performed a course reversal over the localizer course, instead of on the western side, as depicted by the procedure turn barb. After course reversal, the airplane flew inbound approximately parallel to the 165-degree final approach course, about 1/2 mile east of the course. The airplane continued approximately parallel to the inbound course, passed abeam PORTS LOM, and did not intercept the localizer course until it was 1/4 mile inside the final approach fix. Over the next mile, an "S" turn was completed, and then the airplane flew away from the localizer course on an approximate track of 200 degrees. The airplane then tracked south, and paralleled the localizer course until the radar target was lost about 1/2 mile west of the approach end of the runway, at 2,700 feet. The airport elevation was 1,948 feet. In a telephone interview, the pilot-rated passenger said that he worked at the departure airport, and was well acquainted with the pilot who invited him along for the flight. He said he had taken instrument flight training, but was not an instrument-rated pilot. The passenger said that the pilot arrived at the airport in the afternoon, and spent the day giving flight instruction in the local area. About 2200, they departed with the two other passengers on the cross-country flight. Prior to departure, the pilot mentioned that they might encounter "some weather" along the way. The airplane reached the Pittsburgh, Pennsylvania, area in clear weather, but the observation at Philipsburg was "500 to 600 foot ceiling," so the passenger suggested that they land at Pittsburgh. The pilot said, "We really need to get these guys to Phillipsburg," and elected to continue the flight. About 20 minutes from Philipsburg, the airplane encountered instrument meteorological conditions and "heavy rain." When asked about the pilot's demeanor, the passenger said, "He looked a little nervous, he was a little nervous about the approach. He mentioned [his nervousness] too." The passenger said that when the airplane entered the procedure turn he noticed ground lights, but then "nothing after that." He said that he then felt some turbulence, "like a micro-burst" during the approach. When asked about the conduct of the approach, the passenger said that the airplane appeared to be on course and on glide path until "we hit the turbulence and everything." When asked about the fuel state at that point, he said, "The fuel state wasn't the best. We had about 30 minutes left in the procedure turn, and I'm not sure that 30 minutes would have helped us. Pittsburgh was our alternate, and I'm not sure that 30 minutes would have gotten us back there." According to National Aeronautical Charting Office publications, the distance from Mid-State Airport to Pittsburgh International Airport was about 100 nautical miles. According to the Pilot's Operating Manual, the airplane's fuel capacity was 48 gallons. Fuel consumption rates were listed at 10.15 gallons-per-hour (GPH) at 75 percent power, 9.16 GPH at 65 percent power, and 8.0 gallons per hour at 55 percent power. When asked about the performance and handling of the airplane, the passenger stated that it was "good" and performed "normally" throughout the flight. The accident occurred during the hours of darkness approximately 40 degrees, 53 minutes north latitude, and 78 degrees, 06 minutes west longitude. PERSONNEL INFORMATION According to FAA records, the pilot held a commercial pilot certificate with a rating for airplane single engine land, multi-engine land, and instrument airplane. He additionally held a flight instructor certificate with a rating for airplane single engine, and a ground instructor certificate with a rating for advanced ground instructor. The pilot's most recent second-class medical certificate was issued January 24, 2006. He reported 535 total hours of flight experience on that date. Examination of the pilot's logbook revealed that he had logged 625 total hours of flight experience, 614 hours of which were in single engine airplanes. He logged 152 total hours of instrument flight experience, 107 hours of which were in actual instrument meteorological conditions. The pilot logged 80 total hours of night flying experience. AIRCRAFT INFORMATION Examination of aircraft records revealed that the airplane was a 1973 model, and had accumulated approximately 5,400 total hours of operation. The airplane's most recent annual inspection was completed April 1, 2006, at 5,396.7 aircraft hours. METEOROLOGICAL INFORMATION At 0243, the weather reported at State College Airport (SCE), State College, Pennsylvania, 11 miles east of Mid-State Airport at 1,239 feet elevation, included broken clouds at 900 feet, an overcast ceiling at 1,400 feet, and 2.5 miles of visibility in light rain. The winds were calm. According to FAA records, the pilot did not obtain any weather updates after the initial briefing, and he advised the air traffic controller that he had the weather information at PSB before the approach was initiated. AIDS TO NAVIGATION On June 28, 2006 the FAA performed a flight check inspection of the ILS or LOC RWY 16 approach at Mid-State Airport, Philipsburg, Pennsylvania. The flight check results were "Satisfactory." WRECKAGE AND IMPACT INFORMATION The airplane was examined at the scene on June 27, 2006, and all major components were accounted for at the scene. The airplane came to rest on mountainous, heavily wooded terrain in the Moshannon State Forest, at an elevation of 1,937 feet. The wreckage path was oriented 160 degrees and was 210 feet in length. It was divided into one-foot increments called wreckage points (WP). The initial impact point (WP zero) was in a tree about 60 feet above the ground. Trees along the wreckage path were broken off at progressively lower heights toward the main wreckage. Broken and angularly cut branches were strewn along the entire wreckage path. The inboard section of the left wing, with main landing gear attached, was located at WP 82, about 10 feet right of centerline. The landing gear was down and locked. The inboard section of the right wing with main landing gear attached, was located at WP 92, about 45 feet right of centerline. Both wings displayed deep, concave dents that were perpendicular to the leading edge. The wing tips, ailerons, and flaps from both wings were scattered between WP 25 and WP 60. The right stabilator half was located at WP 85, 45 feet right of centerline. The initial ground scar was about 10 feet prior to the main wreckage, which was located at WP 210. The cockpit and cabin area was destroyed, came to rest inverted, and was oriented about 240 degrees. The door was separated from the right side of the airframe, and the cockpit and cabin were torn along that side. Rescue personnel also cut the fuselage in several areas. The empennage and tail section were torn, twisted, and bent about 90 degrees from the fuselage, but remained attached by cables. The left stabilator half, vertical fin, and rudder were all attached. Control cable continuity was established from the cockpit to the control surfaces in the tail, and out to the breaks in the wings. All cable breaks were "broomstrawed," and appeared to have failed in overload. The three-bladed propeller was separated from the engine, and entangled in the main wreckage. Two of the three blades exhibited leading edge gouging, and "S" bending at the tips. One blade appeared unbent. All three blades displayed chordwise scratching. The engine was separated from the airframe, transported to a Pennsylvania Bureau of Forestry garage, and examined on June 27, 2006. The engine's crankshaft was rotated through the accessory drive, and continuity was established through the accessory section to the powertrain and valvetrain. The number one cylinder was impact damaged in the area of the exhaust valve, which prevented the valve from fully closing. The damaged metal was cut away, the valve was freed, and compression was established on all cylinders using the thumb method. The magnetos were removed, rotated by hand, and spark was produced at all ignition leads. Fuel was present in the engine-driven fuel pump, fuel servo, and the fuel manifold valve. The fuel pump was actuated by hand and pumped fuel. The vacuum pump was rotated by hand and produced pressures at both ports. Examination of the instrument panel revealed that the NAV 1 radio was tuned to the localizer frequency of 108.5. The automatic direction finder was tuned to 653. The published frequency for the LOM was 275. MEDICAL AND PATHOLOGICAL INFORMATION The FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed the toxicological testing for the pilot. The Mount Nittany Medical Center, State College, Pennsylvania, performed an autopsy on the pilot. ADDITIONAL INFORMATION The wreckage was released to a representative of the owner's insurance company on December 28, 2006.

Probable Cause and Findings

The pilot's failure to comply with the published instrument approach procedure, which resulted in controlled flight into trees. Factors in the accident were the low cloud ceiling, and dark night conditions.

 

Source: NTSB Aviation Accident Database

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