Wednesday, January 18, 2012

Inuvik, Northwest Territories, airport roof damaged in blizzard

 
 Parts of the Inuvik, N.W.T., airport seem to have been torn off during the high winds and snow in the region Tuesday. (Submitted photo)

 Parts of the roof at the Inuvik, N.W.T., airport were damaged in Tuesday’s blizzard.

 A large section of the roof peeled back like a sardine can. Airport manager Karen King said the damage is not causing the airport to shut down since it is just exterior damage.

"The airport's fully operational. It looks a lot worse, I think," said King.

Blizzard conditions wreaked havoc in the town, and winds reached up to 90 km/h in many parts of the Beaufort Delta.

The town's power flicked on and off. A metal tower on Inuvik's famous dome building snapped in half.

Tom Zubko, the owner of New North Networks which operates out of the dome, said that damage also looks worse than it is.

"It's one of those procrastination things — I have been meaning to take it off for a long time, and mother nature's done that for me now," said Zubko.

Donna-Lynn Baskin, who lives in Inuvik, said there was little to no visibility on the roads. She called the weather Inuvik’s worst blizzard in years.

She even narrowly missed colliding with something unusual which was in the middle of Mackenzie Road, the town’s main street – a hot tub.

“It was blowing down the street, when I came upon it I had to dodge and go down a side street to avoid it. It was just scuffling along, the wind was really pushing it, it was the whole hot tub unit…I was just glad not to hit it. It was white so it just sort of blended in, right now it's lodged in a snow bank in front of one of the local businesses,” she said.

Baskin said the winds were full of debris and that her home had been hit by flying shingles. She said there was so much snow blowing around that it was difficult to even see other cars on the road.

'I had to dodge and go down a side street to avoid it. It was just scuffling along, the wind was really pushing it, it was the whole hot tub unit.'—Donna-Lynn Baskin, Inuvik, N.W.T., resident

“The way the wind was gusting in some places - it was like someone had thrown white paint across the car windows,” she said.

Much of the same weather is expected today in the Beaufort Delta region. Schools and offices were closed, and health centres in many of the communities were open only for emergencies.

Gwich’in Tribal Council leader Richard Nerysoo is urging people in the region to be prepared to weather out the storm with enough fuel, water and food for several days.

Winds are expected to die down Wednesday afternoon.

Source:  http://www.cbc.ca

Smith Aerostar 601P, N700PS: Accident occurred January 16, 2012 in Philadelphia, Mississippi

NTSB Identification: ERA12FA146
 14 CFR Part 91: General Aviation
Accident occurred Monday, January 16, 2012 in Philadelphia, MS
Probable Cause Approval Date: 05/30/2013
Aircraft: Aerostar Aircraft Corporation PA-60-601P, registration: N700PS
Injuries: 1 Fatal.

NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On the day of the accident, a mechanic taxied the airplane onto the runway and performed a full power check of both engines, exercised both propellers, and checked each magneto drop with no discrepancies reported. Following the engine run, the mechanic taxied the airplane to the fuel ramp where the fuselage fuel tank was filled; after fueling, the fuselage tank had 41.5 gallons of usable fuel. The mechanic then taxied the airplane to the ramp where the engines were secured and the fuel selector switches were placed to the off position. The mechanic reported that, at that time, the left fuel tank had 4 to 5 gallons of fuel, while the right fuel tank had about 2 to 3 gallons of fuel; the unusable fuel amount for each wing tank is 3 gallons.

The pilot taxied the airplane to the approach end of runway 18 and was heard to apply takeoff power. A pilot-rated witness noted that, at the point of rotation, the airplane pitched up fairly quickly to about 20 degrees and rolled left to about 10 to 15 degrees of bank. The airplane continued rolling left to an inverted position and impacted the ground in a 40 degree nose-low attitude. A postcrash fire consumed most of the cockpit, cabin, both wings, and aft fuselage, including the vertical stabilizer, rudder, and fuselage fuel tank.

Postaccident inspection of the flight controls, which were extensively damaged by impact and fire, revealed no evidence of preimpact failure or malfunction. Although the flap actuators were noted to be asymmetrically extended and no witness marks were noted to confirm the flap position, a restrictor is located at each cylinder’s downline port by design to prevent a rapid asymmetric condition. Therefore, it is likely that the flap actuators changed positions following impact and loss of hydraulic system pressure and did not contribute to the left roll that preceded the accident.

Examination of the engines and propellers revealed no evidence of preimpact failure or malfunction that would have precluded normal operation. Postaccident examination of the fuselage fuel sump revealed the left fuel selector was in the crossfeed position, while the right fuel selector was likely positioned to the on position. (The as-found positions of the fuel selector knobs were unreliable due to postaccident damage.) The starting engines checklist indicates that the pilot is to move both fuel selectors from the on position to the crossfeed position, and back to the on position while listening for valve actuation/movement. The before takeoff checklist indicates that the pilot is to verify that the selectors are in the on position.

Although the left engine servo fuel injector did not meet flow tests during the postaccident investigation, this was attributed to postaccident heat damage. Calculations to determine engine rpm based on ground scars revealed that the left engine was operating just above idle, and the right engine was operating about 1,315 rpm, which is consistent with a left engine loss of power and the pilot reducing power on the right engine during the in-flight loss of control. Examination of both propellers determined that neither was feathered at impact.

Although the as-found position of the left fuel selector knob could be considered unreliable because of impact damage during the accident sequence, given that right wing fuel tank had no usable fuel, it is unlikely that the experienced pilot would have moved the left fuel selector to the crossfeed position in response to the engine power loss. It is more likely that the pilot failed to return the left fuel selector to the on position during the starting engines checklist and also failed to verify its position during the before takeoff checklist; thus, the left engine was being fed only from the right fuel tank, which had very little fuel. There was likely enough fuel in the right tank and lines for the pilot to taxi and takeoff before the left engine failed, causing the airplane to turn to the left, from which the pilot did not recover.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

The pilot’s failure to maintain directional control during takeoff following loss of power to the left engine due to fuel starvation. Contributing to the loss of control was the pilot’s failure to feather the left propeller following the loss of left engine power.

HISTORY OF FLIGHT

On January 16, 2012, about 1242 central standard time, an Aerostar Aircraft Corporation PA-60-601P, N700PS, registered to M & H Ventures LLC, experienced a loss of directional control during the initial takeoff and crashed in an open field near Philadelphia Municipal Airport (MPE), Philadelphia, Mississippi. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from MPE to Key Field Airport, Meridian, Mississippi. The airplane sustained substantial damage due to impact and a postcrash fire. The airline transport pilot, the sole occupant, was fatally injured. The flight was originating at the time of the accident.

A witness in an airplane waiting short of the runway for the accident pilot to depart watched the takeoff roll from runway 18 and reported the accident airplane became airborne just before the intersection of the ramp and runway. After becoming airborne, the witness noted the airplane immediately, “got squirrelly” and went to the left. The witness stated he taxied onto the runway and back taxied to the approach end of runway 18, where he initiated his takeoff roll; the wind at the time was from 160 degrees at 15 knots with gusts to 20 knots. After becoming airborne, he noted the airplane had crashed and reported the event on the airport UNICOM frequency.

Another witness saw the airplane while it was airborne and noted it rolled left and “it looked like the wind caught the wing.” The witness reported the airplane rolled onto its left side and pitched nose down impacting the ground.

Still another witness who was located northeast of the accident site reported hearing the airplane begin the takeoff roll. The witness walked outside the building and noticed the airplane, “…veering to the left like it was turning out…” then noticed the airplane rolling onto its left side and pitching nose down impacting the ground.

PERSONNEL INFORMATION

The pilot, age 48, held an airline transport pilot certificate with airplane multi-engine land rating, and also a commercial pilot certificate with airplane single engine land rating. At the airline transport level he was type rated in several transport category airplanes. He held a first class medical certificate with no limitations issued on July 27, 2011. On the application for his last medical certificate he listed having a total time of 6,200 hours.

In December 2011, the pilot undertook initial ground and flight training in the airplane. The training was conducted by a pilot who had 16,000 hours in Piper Aerostar airplanes.

The ground instruction consisted of 24 hours over the course of three full days, and the flight instruction consisted of 2.0 hours dual flight in the accident airplane, which occurred on December 15, 2011. The ground school consisted of systems instruction, while the flight training consisted of stalls, pitch and power demonstration, climbs, turns, flap demonstration, air velocity minimum control (VMCa), engine failures after takeoff, in the traffic pattern, and on final approach. Twelve takeoff’s and landings with and without flaps were performed, and go-arounds and aborted takeoff’s were also performed. The notes section of the flight review checklist indicates “Great Job-.”

AIRCRAFT INFORMATION

The airplane was manufactured in 1977 by Ted Smith Aerostar Corporation, as model PA-60-601P, and was designated serial number 61P-0427-157. It was certificated in the normal category and originally equipped with two turbocharger equipped Lycoming IO-540-S1A5 engines rated at 290 brake horsepower at 2,575 rpm, automatic controlled turbochargers installed in accordance with (IAW) supplemental type certificate (STC) SE60WE, and Hartzell constant speed full manual feathering HC-C3YR-2UF propellers with FC8468-8R propeller blades.

In December 1996, the airplane was modified by supplemental type certificate (STC) SA1658NM which removed the original engines and installed 350 horsepower Lycoming TIO-540-U2A engines; the same make and model propellers remained installed. The airplane type certificate holder reported that as a result of the engine change, flight testing confirmed there was no change to the airplane’s original Vmca, which is 97 miles-per-hour indicated airspeed.

The airplane’s fuel supply system in each wing consists of integral wet wing tanks located outboard of the engine nacelle. Each tank has a total capacity of 65 gallons, of which 62 gallons are considered usable. The airplane also has a bladder-type fuselage fuel tank located between the rear cabin bulkhead and the forward bulkhead of the baggage compartment, which has a total capacity of 43.5 gallons, of which 41.5 gallons are considered usable. An annunciator light labeled “LOW FUEL” installed in a group in the annunciator panel in the glare shield by design illuminates continuously when 12 gallons fuel remain in the fuselage tank. The light will remain on as fuel is depleted from the fuselage tank until it is serviced above 12 gallons. The airplane was not equipped with a crossfeed annunciator light when the airplane was manufactured and the maintenance records do not reflect a crossfeed annunciator light was installed after manufacture in accordance with Kit 764-493.

A multiple sump assembly installed below the fuselage fuel tank has a “center sump” which is the low point for the fuselage tank, and two wing sumps which are the low points for each wing tank. Each sump can be drained by depressing its respective drain valve located on the lower aft side of the fuselage just aft of the wing. Fuel from the left and right wings are supplied via lines and hoses to each respective wing sump through a flapper check valve installed on each respective wing sump. Flapper check valves are also installed on each side of the fuselage fuel sump; the check valves prevent back-flow of fuel from one tank to another. Fuel from the fuselage tank flows through flapper check valves into each respective wing fuel sump, then to the each respective engine through valves, hoses, auxiliary fuel pumps, servo fuel injector, flow divider, injector lines, and fuel injector nozzles.

Four electrically operated valves are installed on the fuel sump assembly, and are controlled from two fuel selector switches (one for each engine) mounted on the instrument panel. Each valve on the fuel sump assembly has two positions (open or closed) and the switches have three detent positions (off, on, and crossfeed). The left switch is mounted on the pilot’s lower panel, while the right switch is mounted on the co-pilot’s lower panel. For example, when either fuel selector is in the on position, fuel is supplied from its respective wing tank if fuel is available and also from the fuselage tank. With either fuel selector positioned to the crossfeed position, fuel is supplied to the engine from only the opposite wing tank and not the fuselage tank. If both fuel selectors are positioned to crossfeed at the same time, no fuel will be consumed from the fuselage tank; the left engine will only be supplied fuel from the right wing and the right engine will only be supplied fuel from the left wing.

The FAA Approved Airplane Flight Manual indicates that the crossfeed position is only to be used in level coordinated flight only, and double crossfeed is prohibited except in emergency when the “LOW FUEL” warning light on the annunciator panel is illuminated.

Review of the maintenance records that begin with an entry dated July 18, 1977, associated with an entry related to a production test flight, to the last entry dated January 16, 2012, revealed no entry indicating removal or replacement of either fuel selector switch, or fuel selector knob.

Further review of the maintenance records revealed the airplane was last inspected in accordance with an annual inspection on December 27, 2011. The logbook entry indicates the airplane total time at that time was 2,856.9 hours. The mechanic who signed off the repairs and approved the airplane for return to service indicated that during the annual inspection, calibration of the fuel quantity system was performed. The airplane had accumulated approximately 22 hours since the inspection at the time of the accident. The maintenance records also reflect an entry on the day of the accident indicating in part that the left engine servo fuel injector was reinstalled after being sent for “bench check and repair.” The entry also indicates that after installation of the servo fuel injector, the mechanic rigged and leak checked it. Additionally, the mechanic also removed and cleaned the fuel injector nozzles, and adjusted the idle speed and idle mixture settings.

The mechanic who signed off the installation of the left servo fuel injector reported that he determined that a full power, high speed taxi should be performed to verify that the left engine would meet all full power parameters. On the day of the accident about 0905, or about 3 hours 37 minutes before the accident, he performed a walk-around inspection then started both engines using the airplane’s checklist. At the time, he reported that the left wing fuel tank had 4 to 5 gallons fuel, the right tank had 2 to 3 gallons fuel, and the center tank had 18 gallons of fuel. He taxied the airplane to the turn-around for runway 18, then performed a preflight run-up. He cycled the propellers at 1,500 rpm, then performed a magneto check at 2,000 rpm noting a drop of 75 rpm when checking each magneto separately. He further reported that all engine parameters were in the “normal operating range.” He taxied into position, held the brakes and applied 30 inches manifold pressure, then released the brakes and smoothly increased power to 42 inches manifold pressure. He noted that the rpm was 2,500 and the fuel flow was 38 gallons-per-hour. He then reduced power and taxied to the ramp where he allowed the engines to cool for 4 minutes, then secured the engines. He then examined the engine nacelles for oil or fuel leaks, but did not report seeing any. Realizing the airplane needed fuel, he restarted the engines, taxied to the fuel pump, where a lineman filled the center fuel tank adding 22 gallons 100 low lead (100LL). He restarted the engines, taxied to his hangar, shut down the engines, and moved each fuel selector switch to the off position. He then towed the airplane inside the hangar.

The mechanic further stated that the accident pilot and another individual arrived at the airport about 1025, and then both departed the airport briefly. They returned to the airport, and he discussed the maintenance that was performed, and began installing a new mount on the pilot’s yoke for a Garmin 696 portable global positioning system (GPS) receiver. The mechanic towed the airplane to the ramp, and returned the tug to the hangar. He then went back to the airplane and met the pilot while he was performing his preflight inspection. The mechanic noted that the aileron trim was neutral, and he checked the fuel sump drains while being watched by the accident pilot. The mechanic left the airport before the accident flight departed and did not witness the accident.

The last entry in the airframe logbook was dated January 16, 2011; the sign off should have been January 16, 2012. The entry indicated that the airplane total time was approximately 2,879 hours.

METEOROLOGICAL INFORMATION

A surface observation weather report taken at Philadelphia Municipal Airport at 1245, or approximately 3 minutes after the accident indicates the wind was from 180 degrees at 14 knots with gusts to 20 knots. The visibility was 10 miles, and scattered clouds existed at 2,400 feet and 6,500 feet, while a ceiling of broken clouds existed at 9,000 feet. The temperature was 19 degrees Celsius, but the dew point reading was missing, and the altimeter setting was 30.24 inches of Mercury.

COMMUNICATIONS

According to the pilot of an airplane waiting to depart after the accident pilot departed, the accident pilot announced his takeoff from runway 18 on the common traffic advisory frequency (CTAF); the accident pilot did not make any distress call on the CTAF after becoming airborne.

AIRPORT INFORMATION

The Philadelphia Municipal Airport is a publically-owned airport which has one asphalt runway designated 18/36. The runway is 5,001 feet in length and 75 feet in width.

FLIGHT RECORDERS

The airplane was not equipped, nor was it required to be equipped, with a cockpit voice recorder (CVR) or flight data recorder (FDR). However, the airplane was equipped with components that are capable of recording and retaining non-volatile memory associated with flight, or fuel load. The components that have non-volatile memory, or are capable of retaining data consist of a Garmin GTN 750, Garmin 696 portable global positioning system (GPS) receiver, and a Shadin fuel flow indicator.

The Garmin GTN 750 records only data consisting of last frequencies, stored flight plans, and user settings, while the Garmin 696 GPS was downloaded but there was no track log recorded for the accident flight; it is a pilot/owner selectable option to enable or disable the recordings. The Shadin fuel flow gauge was downloaded indicated 41.4 gallons fuel remaining, 2.3 gallons of fuel used, and a full fuel load as being 165.5 gallons. Details of component analysis are available in the NTSB public docket for this accident.

WRECKAGE AND IMPACT INFORMATION

The airplane crashed in an open field; the main wreckage was located at 32 degrees 47 minutes 38.2 seconds North latitude and 089 degrees 07 minutes 25.0 seconds West longitude, or approximately 930 feet east of runway 18/36 centerline and at a point abeam runway 18/36, about 523 feet from the departure end of runway 18.

Examination of the accident site revealed craters associated with the leading edge of the left wing, both engines, and the top portion of the fuselage. The ground scar attributed to the left wing was oriented on a magnetic heading of 154 degrees magnetic, while the ground scar attributed to the top portion of the fuselage was oriented on a magnetic heading of 128 degrees. An energy path of dirt and debris was oriented on a magnetic heading of 120 degrees. Windscreen pieces were noted in the ground scar crater attributed to the upper portion of the fuselage, while the ground scar attributed to be from the leading edge of the left wing that extended several inches below the surface was at an angle of 40 degrees from the surrounding surface terrain. The upper portion of the clam shell door was partially embedded in the ground on the right side of the ground scar from the upper fuselage with the word “Aerostar” visible and oriented upright but nearly 180 degrees from the energy path orientation. Two parallel oriented ground scars attributed to the left and right propeller blades were noted. The distance between the two attributed from the left propeller measured 37 inches, while the distance between the two attributed from the right propeller measured 21.5 inches.

The front fuselage and right wing came to rest on a magnetic heading of 160 degrees magnetic. Extensive postaccident fire damage was noted to the cockpit, cabin, both wings, and empennage. The grass south of the main wreckage was also burned. Both engines remained attached to the wings and the propellers remained attached to the engines. All components necessary to sustain flight remained attached or were found in close proximity to the main wreckage. Examination of the flight controls for roll, pitch, and yaw revealed no evidence of preimpact failure or malfunction. The left flap actuator was extended approximately 3.375 inches while the right flap actuator was extended approximately 5.625 inches; both flap actuators were retained for further examination.

Examination of the cockpit revealed the left throttle, left propeller, and both mixture controls were full forward, while the right throttle was about ½ knob width less than full forward, and the right propeller control was about 1 knob width less than full forward. Both magneto switches were in the both position. The elevator trim indicator was off scale nose low, the rudder trim indicator was off scale nose left, and the flap indicator was off scale past full down. The flap selector was in the down position, while the landing gear selector handle was in the up position. The hour meter indicated 540.4. The 5 housings of the annunciator lights were separated from the attach point of the glare shield; the annunciator housings were retained for further examination. A Garmin 696 portable GPS receiver was tightly clamped to within 1 inch of the pilot’s yoke by a steel band clamp; the GPS receiver was retained for further examination. The left fuel pressure was off scale low, while the right fuel pressure was in the green arc near the upper red line limit. The cabin door pin of the lower door was near the green mark. Examination of the fuel pressure gauge revealed the left needle was indicating approximately 31 psi or just below the lower red line limit, while the right was indicating approximately 35 PSI or just above the lower red line limit.

Examination of the pilot’s instrument panel revealed the left fuel selector knob part number (P/N) MS91528-1K4B, was separated and was not located. The remaining portion of the aluminum knob which had a matching flat remained secured to the switch shaft key. The flat of the knob and switch shaft key remained aligned and were parallel to the “OFF” marking on the instrument panel. Further inspection of the back portion of the switch revealed several wires were separated from it, and the switch back was broken.

Examination of the co-pilot’s instrument panel revealed the right fuel selector knob P/N MS91528-1K4B was in the off position as first viewed. The portion of the knob in the area of the set screws was broken. Following removal of the knob, the remaining portion of the aluminum knob which had a matching flat remained secured to the switch shaft key. The flat of the knob and switch shaft key remained aligned and were parallel to the “OFF” marking on the instrument panel. The switch moved freely when the remaining portion of knob was moved by hand. Further examination of the right fuel selector knob revealed evidence of 2 holes associated with set screws. Proper placement of the knob correlated with the shaft and set screws revealed it was in the crossfeed position.

Examination of the fuel sump assembly revealed it exhibited extensive heat damage. The position indicator for the No. 1 valve was in the closed position, while the position indicators for the Nos. 3 and 4 valves were in the open positions. The No. 2 valve was destroyed by fire; therefore, the position could not be determined.

Examination of the left and right engines was performed by a representative of the engine manufacturer with Safety Board oversight. The examination of the left engine revealed crankshaft, camshaft, and valve train continuity. Suction and compression was noted in each cylinder during hand rotation of the crankshaft. The magnetos remained installed and noted to produce spark at all towers during rotation of each magneto using an electrical drill motor. Inspection of the air induction system revealed no obstructions. Inspection of the turbocharger components revealed no evidence of preimpact failure or malfunction. Slight heat damage was noted to the lower aft area of the engine; the servo fuel injector cover exhibited evidence of light heat damage. The propeller, propeller governor, servo fuel injector, flow divider, and engine-driven fuel pump were retained for further examination.

Examination of the right engine revealed crankshaft, camshaft, and valve train continuity. Suction and compression was noted in each cylinder during hand rotation of the crankshaft. The magnetos remained installed and noted to produce spark at all towers during rotation of each magneto using an electrical drill motor. Inspection of the air induction system revealed no obstructions. Inspection of the turbocharger components revealed no evidence of preimpact failure or malfunction. The propeller, propeller governor, servo fuel injector, flow divider, and engine-driven fuel pump were retained for further examination.

Examination of the left propeller revealed all blades were in the low pitch position. One propeller blade was loose in the propeller hub, which appeared to be intact with no evident impact damage. Cycling of the pitch change mechanism was not attempted and the air valve retained an air charge. The propeller faying flange, cylinder, piston, piston change rod, fork, spring and spring guides, feather stop, and start lock were unremarkable. The low pitch stop had an impression mark. None of the preload plates installed on the butt end of each propeller blade had impact marks; therefore, the position of the propeller blades at the moment of impact could not be determined. However, the propeller blades were not feathered at the moment of impact. Examination of the propeller blades revealed the No. 1 blade as marked was bent aft about 20 degrees at mid-blade; no blade twist or leading edge damage was noted. The No. 2 propeller blade was bent forward approximately 20 degrees at mid-blade; no blade twist or leading edge damage was noted, but rotational scoring was noted in the paint on the cambered side of the blade. The No. 3 propeller blade was bent aft approximately 20 degrees at mid-blade; no blade twist or leading edge damage was noted, but rotational scoring was noted in the paint on the cambered side of the blade. The pitch change knob of the No. 1 blade was fractured, while the pitch change knobs of the Nos. 2 and 3 blades were not fractured. No discrepancies were noted that would preclude normal operation; all damage noted was attributed to impact damage.

Examination of the right propeller revealed all blades were in the low pitch position. Cycling of the pitch change mechanism was not possible and the air valve was fractured and did not retain an air charge. The cylinder exhibited light gouges on the forward end due to contact by the spinner. The propeller faying flange, piston, spring, spring guides, feather stop, and start lock were unremarkable. The pitch change rod was bent, and the fork was cocked on the bent pitch change rod. The low pitch stop had an impression mark. The preload plate of the No. 1 propeller blade as marked exhibited an impact mark caused by fork contact at a low pitch position. The impact mark equated to a 2 degree blade angle. The No. 2 propeller blade had an impact mark on the preload plate at a low pitch position, while the No. 3 propeller blade had an impact mark on the preload plate of the caused by fork contact at a low pitch position. The impact mark equated to a 6 degree blade angle. Examination of the propeller blades revealed the No. 1 blade exhibited a 30 degree large radius aft bend at mid-blade, and the leading edge was twisted towards low pitch. Paint abrasion and rotational scoring was noted on the leading edge and cambered side of the blade; the pitch change knob was fractured. The No. 2 propeller blade exhibited a 20 degree large radius aft bend at mid-blade, and the leading edge was twisted towards low pitch. Paint abrasion and rotational scoring was noted on the leading edge and cambered side of the blade; the pitch change knob was fractured. The No. 3 propeller blade was bent mildly aft at mid-blade, and the pitch change knob was bent. No discrepancies were noted that would preclude normal operation; all damage noted was attributed to impact damage.

MEDICAL AND PATHOLOGICAL INFORMATION

A postmortem examination of the pilot was performed by the Mississippi State Medical Examiner’s Office, Jackson, Mississippi. The cause of death was listed as “multiple blunt traumatic injuries due to air craft crash, N700PS.”

Forensic toxicology was performed on specimens of the pilot by the FAA Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma. The toxicology report stated the specimens were unsuitable for carbon monoxide analysis, but the results were negative for cyanide, volatiles, and the drug screen.

TEST AND RESEARCH

As previously reported, the position indicators at the fuselage fuel sump were examined and the position indicator for the No. 1 valve was in the closed position, while the position indicators for the Nos. 3 and 4 shutoff valves were in the open positions. The No. 2 valve was destroyed by fire; therefore, the position could not be determined.

Per the airplane maintenance manual, the Nos. 1 and 3 valves are associated with the left engine, and the Nos. 2 and 4 valves are associated with the right engine. The as-found positions of the Nos. 1 and 3 valves at the fuel sump assembly equates to the left fuel selector being in the crossfeed position, or fuel to the left engine being supplied from the right fuel tank. Although the position of the No. 2 shutoff valve could not be determined, the maintenance manual also indicates that the only scenario in which the No. 4 shutoff valve would be in the open position (as viewed post accident), is when the right fuel selector is in the on position.

The airplane was fueled on the day of the accident at 0935. According to the individual who fueled the airplane, a total of 22.0 gallons of 100 low lead (100LL) fuel were added to the center fuel tank.

The pilot of an airplane (N252HM) fueled from the same source reported he did not notice any contamination in his fuel tanks as a result of the 10 gallons of 100LL fuel added to each wing fuel tank of his airplane. He also reported he did not experience any engine discrepancies related to fuel during his subsequent 1.0 hour flight after fueling.

Postaccident, a sample of fuel from the facility that fueled the airplane was submitted for analysis to Interek Caleb Brett, located in Romeoville, Illinois. The test results indicate that the submitted specimen meets the requirement of ASTM International (ASTM), ASTM D910 Aviation Gasoline specifications. A copy of the report is contained in the NTSB public docket for this case.

Bench testing of the left and right propeller governors was performed at a Federal Aviation Administration (FAA) certified repair station. Bench testing of the left and right propeller governors revealed no evidence of preimpact failure or malfunction.

Bench testing and examination of both servo fuel injectors (servo) and flow dividers was performed at a FAA certified repair station. The left servo was placed on a test bench as received, and was noted to flow 160 pounds-per-hour (PPH) at test points 1, 3, and 4. Specification at test points 1, 3, and 4 are 52.0 to 84.0 PPH, 84.0 to 96.0, and 212.0 to 237.0 PPH, respectively. Following bench testing, the servo was disassembled which revealed the regulator seat was loose in the body and was not sitting correctly. The seat assembly was removed and noted to be deformed when compared with an exemplar seat. An exemplar seat was installed and the unit was re-assembled then placed on the test bench. At test point 1, the unit flowed 1.0 PPH higher than specification, at test point 3 the unit flowed 3.0 PPH greater than specification, and at test point 4 the unit flowed within specification. Testing of the automatic mixture control (AMC) was performed and it tested satisfactory. Bench testing of the right servo revealed it flowed within limits at test points 1 and 4, however, the unit flowed 11 PPH higher than specification at test point 4. Testing of the AMC was performed and it tested satisfactory. Bench testing of the left and right flow dividers revealed both tested satisfactory. Disassembly inspection of each flow divider after flow testing revealed no discrepancies with the diaphragm, or spring. Each flow divider had a 2.0 PSI spring installed.

A representative of the servo fuel injector manufacturer was contacted to review the findings of the left fuel servo test results (160 PPH at test points 1, 3, and 4), and also the finding of the distortion of the seat assembly. The representative reported in his experience he has seen distortion of the seat in cases where there was a postcrash fire. The representative also indicated that the material of the seat melts just above 300 degrees. He stated that the as-found flow result of 160 PPH at test point 1 would have resulted in an excessively rich mixture that most likely would not sustain combustion, and the reduced fuel flow at test point 4 would have resulted in a lean mixture when attempting to obtain full power.

Bench testing of the left and right engine-driven fuel pumps was performed at a FAA certified repair station. At 2,575 rpm and 38 PSI (test standard), the left and right engine-driven fuel pumps flowed 47.8 and 46.35 gallons-per-hour (GPH), respectively. The specified fuel flow at that rpm and PSI setting is a minimum of 42.0 GPH. The left engine-driven fuel pump passed the 600 RPM test, while the right engine-driven fuel pump did not pass the 600 RPM test. Disassembly of the right engine-driven fuel pump revealed the valve poppet had a worn spot, which is why it failed the 600 RPM test.

According to the FAA Approved Airplane Flight Manual, the starting engines checklist indicates that both fuel selectors are to be moved to the on, crossfeed, then back to the on positions, with wording indicating to listen for actuation/movement of valve actuation. The before takeoff checklist indicates to verify that the fuel selectors are in the on position, and the “LOW FUEL” warning light is out.

As previously reported, at the beginning of the flight, the fuselage fuel tank was full, and the left wing fuel tank had 4 to 5 gallons fuel, while the right wing fuel tank had 2 to 3 gallons of fuel. The airplane flight manual indicates that the unusable fuel amount for each wing fuel tank is 3 gallons.

Examination of the left and right flap actuators, and also the five annunciator housings was performed by the NTSB Materials Laboratory located in Washington, D.C. The flap actuators were submitted in an attempt to determine each actuator position prior to impact, while the annunciator housings were submitted for filament testing and examination in an effort to determine whether any of the bulbs were illuminated at impact. The examination of the flap actuators revealed both exhibited signs of exposure to fire and thermal damage. No witness marks were noted; therefore, the pre-fire flap actuator position could not be determined. Each of the five annunciators housed two annunciator lights that were made up of two bulbs each, for a total of four bulbs per fixture. The annunciator lights bulb filaments for REQ OXY (oxygen required per altitude switch, GEAR (throttle below 20 inches manifold pressure and gear in the up position), A/P INT (autopilot interrupt when using control wheel steering with autopilot on), LOW FUEL (when fuel quantity in the fuselage tank falls below 12 gallons), HTR FAIL (heater overheat circuit breaker is off), AUX HYD (auxiliary hydraulic pump is pumping, DE-ICE (when boots are inflating), R ALT and L ALT (alternators are off line). No bulb filament stretching was noted for both bulbs of the gear, low fuel, auxiliary hydraulic, de-ice, right alternator, or left alternator. Stretching was noted to both bulb filaments for regulator oxygen, while stretching was noted to one bulb filament of autopilot interrupt and heater fail.

Calculations to determine left and right engine rpm at impact were performed using the measured distance for the left and right propeller blades (37 inches and 21.5 inches), respectively. The calculations took into account the estimated groundspeed of 70 knots, which is the VMCa speed of 84 knots minus the headwind component of 14 knots. The formula is to multiply the groundspeed by 1212, and divide that amount by the distance in inches between the propeller slash marks multiplied by the number of propeller blades. Using that formula, the calculations revealed that the left engine rpm was approximately 764, while the right engine rpm was approximately 1,315.

A search of the FAA Service Difficulty Reports for the P/N of the fuel selector switch (980223-001) and P/N of the knob (MS91528-1K4B) revealed no records.

The flight manual supplement indicates that following engine failure during takeoff with insufficient runway remaining, the propellers and throttles are to be advanced to high rpm and to 42 inches manifold pressure, then place the landing gear up, and flaps up. The next step indicates to verify inoperative engine, followed by feathering of the propeller. The next step is to maintain 100 knots calibrated airspeed (CAS) for obstacle clearance, then after obstacle clearance establish best rate of climb speed of 117 knots CAS. The airplane is then to be trimmed, and the suspect engine secured.

The Aerostar Model 601P FAA Approved Airplane Flight Manual indicates that with respect to the flaps, flow control valves are installed in the flap system to provide equal fluid flow to the left and right flap actuators thereby ensuring symmetrical flap extension and retraction. A restrictor is also located at each cylinder’s downline port to prevent a rapid asymmetric condition from occurring should the downline rupture when the flaps are extended.


 NTSB Identification: ERA12FA146 
 14 CFR Part 91: General Aviation
Accident occurred Monday, January 16, 2012 in Philadelphia, MS
Aircraft: Aerostar Aircraft Corporation PA-60-601P, registration: N700PS
Injuries: 1 Fatal.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators either traveled in support of this investigation or conducted a significant amount of investigative work without any travel, and used data obtained from various sources to prepare this aircraft accident report.

On January 16, 2012, about 1242 central standard time, an Aerostar Aircraft Corporation PA-60-601P, N700PS, registered to M & H Ventures LLC, experienced a loss of directional control during the initial takeoff and crashed in an open field near Philadelphia Municipal Airport (MPE), Philadelphia, Mississippi. Visual meteorological conditions prevailed at the time and no flight plan was filed for the 14 Code of Federal Regulations (CFR) Part 91 personal flight from MPE to Key Field Airport, Meridian, Mississippi. The airplane sustained substantial damage due to impact and a postcrash fire. The certificated airline transport pilot, the sole occupant, was fatally injured. The flight was originating at the time of the accident.

A witness in an airplane waiting short of the runway for the accident pilot to depart watched the takeoff roll from runway 18 and reported the accident airplane became airborne just before the intersection of the ramp and runway. After becoming airborne, the witness noted the airplane immediately, “got squirrelly” and went to the left. The witness stated he taxied onto the runway and back taxied to the approach end of runway 18, where he initiated his takeoff roll; the wind at the time was from 160 degrees at 15 knots with gusts to 20 knots. After becoming airborne, he noted the airplane had crashed and reported the event on the airport UNICOM frequency.

Another witness saw the airplane while it was airborne and noted it rolled left and “it looked like the wind caught the wing.” The witness reported the airplane rolled onto its left side and pitched nose down impacting the ground.

Still another witness who was located northeast of the accident site reported hearing the airplane begin the takeoff roll. The witness walked outside the building and noticed the airplane, “…veering to the left like it was turning out…” then noticed the airplane rolling onto its left side and pitching nose down impacting the ground.



Richard Howarth (pictured) the founder of HD Machines, LLC, in Meridian, Mississippi, was killed when his plane crashed just after take off Monday afternoon in Philadelphia, Mississippi. Howarth was 48.

Services for Richard Harper Howarth, Jr. will be held Saturday, January 21, 2012, at 2:00 p.m. at Saint Paul's Episcopal Church, with the Reverend Brian Ponder officiating.

Visitation will begin at noon in the church parish hall.

Burial will be at Magnolia Cemetery with Robert Barham Family Funeral Home in charge of the arrangements.

Mr. Howarth, 48, died Monday, January 16 in an airplane accident outside of Philadelphia, MS. He was an accomplished pilot, having served as a highly-decorated naval aviator during the Iraq War, and since 1995 as a pilot for Federal Express.

Following graduation in 1985 from Virginia Tech with a B.S. degree in Finance, Mr. Howarth worked in the commercial lending department at Chemical Bank in New York for one year. He then began a distinguished career in the U.S. Navy, receiving his wings at NAS Meridian, and later graduating from the Navy Fighter Weapons School (Top Gun). He graduated number one in officer commissioning class, received the Distinguished Naval Graduate Award and also graduated number one from Naval Air Training flight school.

Mr. Howarth flew an F-18 during Desert Storm, and led 44 combat missions during that conflict. He was awarded two Air Medals and two Navy Commendation medals with "V" for valor in combat. Upon retiring from active military duty, Mr. Howarth briefly flew commercially for ValuJet Airlines, and for Federal Express since 1995. While at FedEx, Mr. Howarth developed the MD-11 syllabus for training company pilots that is still in use today. He flew several aircraft for FedEx, and was selected to personally train the current cadre of pilot instructors for the company.

Mr. Howarth also founded a very successful vegetation management contract services company in 2004. As president of HD Machines, LLC in Meridian, he supervised all aspects of business operations covering thirteen states ranging from the Southeast to the Midwest.

Mr. Howarth is survived by his wife Cynthia Townsend Howarth; children Juliet Wells Howarth, Cythina Townsend Howarth, Jetson Dow Taylor and his wife Bryn, Brooke Taylor Kauerz, Jamison Clark Taylor and his wife Misty; father Richard Harper Howarth, Sr., mother-in-law Jane Temple Townsend; sisters Sara Howarth Marshall and her husband Tommy and Amelia Howarth Baker and her husband Clark; grandchildren Crosby Taylor, Jet Taylor, Evans Kauerz, Harper Kauerz, and Case Taylor; and nieces Ashley Marshall, Natalie Marshall and Emily Marshall.

The family request that memorials be made to Jacob's Well Recovery Center for Women, 45 Buford Lane, Poplarville, MS 39470 or The Richard H. Howarth, Jr. College Fund, 414 Highways 11 and 80, Meridian, MS 39301.

Family and friends may sign the online guest book at www.robertbarhamffh.com 


Aviat A-1C-180 Husky, Shell Aviation LLC, N62WY: Accident occurred December 03, 2011 in McKinney, Texas

http://registry.faa.gov/N62WY

NTSB Identification: CEN12LA125 
14 CFR Part 91: General Aviation
Accident occurred Saturday, December 03, 2011 in McKinney, TX
Probable Cause Approval Date: 05/30/2013
Aircraft: AVIAT AIRCRAFT INC A-1C-180, registration: N62WY
Injuries: 1 Serious.

NTSB investigators may not have traveled in support of this investigation and used data provided by various sources to prepare this aircraft accident report.

After returning from a short night flight, the airplane was parked on a ramp in front of a hangar to deplane the passenger and take another person on a flight. The engine was at idle power and the propeller was turning. The pilot stated that he leaned across the airplane and opened the right door so the passenger could exit. When he saw that she was exiting toward the front of the airplane, he put his arm out and told her to walk toward the rear after exiting. Once the pilot saw that the passenger was clear of the wing strut and walking away, he lowered his arm. A witness who was walking from the hangar toward the airplane saw that the passenger was walking toward the front of the aircraft. He yelled for her to stop, and a second later she hit the propeller from the rear and fell to the ground. He noticed that the pilot immediately shut the engine down and then called emergency services. FAA Advisory Circular (AC) 91-42D, "Hazards of Rotating Propeller and Helicopter Rotor Blade,” states that a propeller under power, even at slow idling speed, has sufficient force to inflict injuries. It cautions that the engine “should be shut down before boarding or deplaning passengers.” It further states that “when it is necessary to discharge a passenger from an aircraft on which an engine is running, never stop the aircraft with the propeller in the path of the passenger’s route from the aircraft.”

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

The passenger's inadvertent contact with a rotating propeller after exiting the parked airplane. Contributing to the accident were the dark night conditions and the deplaning of the passenger while the propeller was turning.


On December 3, 2011, about 2050 central daylight time, a passenger of a parked Aviat Aircraft Inc., Husky A-1C, N62WY, came into its rotating propeller after exiting the airplane on the ramp of the Aero Country Airport (T31), McKinney, Texas. The airplane was registered to Shell Aviation, LLC, McKinney, Texas, and was being flown by a private pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Dark night visual meteorological conditions (VMC) prevailed at the time of the accident. The passenger was seriously injured and the pilot, who was the only other person remaining on board, was not injured. The flight had originated from T31 and had just returned from flying in the local area to view holiday lights.

A witness who was with the group of people who were at the airport to fly in the airplane that night reported that he and the pilot pushed the airplane out of the hanger approximately 2030 in preparation for the flight. He stated that the weather was VFR with ceilings around 3500 ft and good visibility. Several minutes after the pilot had started the airplane, he walked the first passenger to the aircraft, made specific mention to her of the propeller and to be careful, then helped her enter the aircraft and fasten her seat belts. Once she was situated in the rear seat he walked away from the aircraft and back into the hanger. The airplane then took off to view the holiday lights. After 10-15 minutes passed, he saw the airplane taxi back onto the ramp and park facing toward the north. After a brief discussion with another person in the hangar, he saw the shadow of the passenger exiting the airplane. He then began walking toward the aircraft and noticed that the passenger was walking toward the front of the aircraft. He yelled for her to "STOP", and a second later she hit the propeller from the rear and fell to the ground. He noticed that the pilot immediately shut the engine down and then called emergency services.

According to the pilot (as he recalled the event in a written statement), after landing from the planned 20-minute flight, he stopped the airplane on the ramp with the engine running in anticipation of taking another passenger to view the holiday lights. He opened the door on the right side of the airplane expecting a friend to come out and assist his passenger in deplaning. After he opened the door, the passenger started to get out of the airplane. Upon noticing that she was exiting in front of the strut, the pilot leaned out of his seat and placed his right hand and arm in front of her to divert her away from the front of the airplane and the propeller. He continued to keep his arm extended and told the passenger that she should walk behind the airplane. Once he saw that the passenger was at least beyond where the strut was attached to the wing, and walking away, he dropped his right arm and returned to his normal seat position. The pilot then looked to the left side of the airplane and opened his window to ask who was next to go for a ride. The pilot then heard someone yell, "STOP," and he immediately shut down the engine and saw the passenger lying in front of the airplane.

The NTSB did not travel to the scene of the accident, however, after notification of the event, an FAA inspector responded to the accident scene. He reported that when he arrived, the airplane was hangared, the scene cleaned up, and the injured passenger had been taken to the hospital. Local law enforcement and emergency medical personnel had processed the scene prior to the arrival of the FAA inspector. Both the FAA inspector's statement of his observations and the law enforcement report of the event are included in the supporting docket for this report.

FAA Advisory Circular (AC) 91-42D "Hazards of Rotating Propeller and Helicopter Rotor Blade,” outlines safety considerations for pilots and passengers of aircraft with turning propellers or rotors. The AC is advisory in nature and not mandatory guidance. In part, the circular states that a propeller under power, even at slow idling speed, has sufficient force to inflict fatal injuries. On page 4 of the circular, it cautions that the engine “should be shut down before boarding or deplaning passengers”...”when it is necessary to discharge a passenger from an aircraft on which an engine is running, never stop the aircraft with the propeller in the path of the passenger’s route from the aircraft.” The Advisory Circular is included in the supporting docket for this report.


NTSB Identification: CEN12LA125
14 CFR Part 91: General Aviation
Accident occurred Saturday, December 03, 2011 in McKinney, TX
Aircraft: AVIAT AIRCRAFT INC A-1C-180, registration: N62WY
Injuries: 1 Serious.

This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed.

On December 3, 2011, about 2050 central daylight time, a passenger of a parked Aviat Aircraft Inc., Husky A-1C, N2364G, contacted its rotating propeller after exiting the airplane on the ramp of the Aero Country Airport (T31), McKinney, Texas. The airplane was registered to Shell Aviation, LLC, McKinney, Texas, and was being flown by a private pilot under the provisions of Title 14 Code of Federal Regulations Part 91. Dark night visual meteorological conditions prevailed at the time of the accident. The passenger was seriously injured and the pilot, who was the only other person remaining on board, was not injured. The flight had originated from T31 and had just returned from flying in the local area to view holiday lights from the air.

According to the pilot (as he recalls the event), after landing from the planned 20-minute flight, he stopped the airplane on the ramp with the engine running in anticipation of taking another passenger to view the holiday lights. He opened the door on the right side of the airplane expecting a friend to come out and assist his passenger in deplaning. After he opened the door, the passenger started to get out of the airplane. Upon noticing that she was exiting in front of the strut, the pilot leaned out of his seat and placed his right hand and arm in front of her to divert her away from the front of the airplane and the propeller. He continued to keep his arm extended and told the passenger that she should walk behind the airplane. Once he saw that the passenger was at least beyond where the strut was attached to the wing, and walking away, he dropped his right arm and returned to his normal seat position. The pilot then looked to the left side of the airplane and opened his window to ask who was next to go for a ride.

The pilot then heard someone yell, "STOP STOP," and he immediately shut down the engine and saw the passenger lying in front of the airplane.

 

Controller in Near Plane Crash Raises ‘Professionalism’ Concern

Jan. 18 (Bloomberg) -- An air-traffic controller who caused a near mid-air collision in June near Gulfport, Mississippi, had been repeatedly disciplined and was described by another controller as “unsafe,” according to a government report.

The tower also was not properly staffed, and the incident was not logged in after it occurred, as required by the Federal Aviation Administration, the U.S. National Transportation Safety Board said in a report released today.

“The investigation revealed a number of deficiencies within the ATC facility that contributed to this incident,” the NTSB said.

The NTSB last May added “professionalism” of pilots and air-traffic controllers to its list of most-wanted safety enhancements. “There have been a disturbing number of individual incidents of non-compliant behavior, intentional misconduct or lack of commitment to essential tasks,” the safety board said on its website last year.

A JetLink Embraer SA ERJ 145 regional jet operated for United Continental Holdings Inc. came within about 300 feet of a privately owned Cessna 172 propeller plane shortly after they took off at almost the same time from different runways at Gulfport-Biloxi International Airport on June 19, the NTSB said. The two planes were carrying 55 people.

‘That Was Close’

“Wow, that was close,” the captain said he told the co- pilot afterward, according to the NTSB report.

The incident was caused by controller Robert Beck, who cleared both planes to take off at about the same time, according to NTSB documents released today.

Another controller told investigators that he saw the planes accelerating for takeoff and tried to warn Beck, who didn’t react, according to the report.

“We take reports like these very seriously,” Doug Church, a spokesman for the National Air Traffic Controllers Association, said in an e-mail. “We welcome the examination of this incident by federal officials and plan to work with the FAA to continue to improve the safety of our aviation system.”

An FAA manager at the airport tower, Ron Burrus, told investigators “it was a miracle that no one died,” according to the documents.

Beck “had a history of discipline problems that included absence without leave,” according to a manager cited in the report.

Controller Dennis Hilton, who also worked at the tower, said he rated Beck’s performance as a controller as “D-,” the NTSB said.

“Mr. Hilton stated that he considered Mr. Beck unsafe and that he avoided working with him when possible,” the NTSB documents said.

The NTSB is investigating cases in which air-traffic controllers fell asleep while on duty last year. The FAA last year reported it had discovered nine instances in which controllers fell asleep or didn’t respond to radio calls from pilots.

 You can read the NTSB incident report by clicking here.

Source: http://www.businessweek.com

NTSB: Near collision over Gulfport "operational error". Cessna 172, N54120 and Embraer ERJ145. Incident occurred June 19, 2011 in Gulfport, MS.

GULFPORT, MS (WLOX) -  The NTSB says "operational error" by an air traffic controller in Gulfport nearly led to a mid-air collision.

An incident report from the NTSB says the incident took place on June 19, 2011.  

The report describes how a small private plane and a 55 passenger regional jet heading to Houston got permission to take off within 16 seconds of each other.  

According to the NTSB findings, the Cessna 172 was on runway 18 and about to liftoff, when the air traffic controller told the 55 passenger regional jet it could roll down runway 14.  

So, how did two planes get take off clearance just 16 seconds apart?  The air traffic controller told investigators, "that from previous experience, he anticipated that the Cessna departing runway 18 would take 3 to 5 minutes to get airborne and the ERJ145 would depart well in advance of the Cessna."  

However, within seconds, the two aircraft were airborne.  And they reportedly passed in front of each other just 300 feet above the airfield.

The NTSB report says, "The Gulfport control tower local controller cleared two aircraft for takeoff from runways with intersecting departure flight paths without ensuring the first aircraft had passed the flight path intersection prior to clearing the second aircraft for takeoff."  

According to the NTSB, "The investigation revealed a number of deficiencies within the ATC facility that contributed to this incident."

Because of the near mid-air collision, managers in the Gulfport control tower will no longer let the air traffic controller work the local control position. 

You can read the NTSB incident report by clicking here.

Nobody on either plane was injured.

NTSB Identification: OPS11IA673A
Scheduled 14 CFR Part 121: Air Carrier operation of EXPRESSJET AIRLINES INC
Incident occurred Sunday, June 19, 2011 in Gulfport, MS
Probable Cause Approval Date: 01/18/2012
Aircraft: EMBRAER EMB-145EP, registration: N13929
Injuries: 55 Uninjured.

N54120, a Cessna 172, called ready for takeoff on runway 18. The tower local controller (LC) cleared the Cessna for takeoff on runway 18. Sixteen seconds later, (Jet Link) BTA2555/Embraer ERJ145 called ready for takeoff for runway 14. The LC cleared the ERJ145 for takeoff. The departure flight path of runway 18 intersects runway 14. The local controller was working the LC position combined with Ground Control (GC), Clearance Delivery (CD)/Flight Data (FD) and Controller-In-Charge (CIC) positions. The Cessna was airborne crossing taxiway Charlie when the ERJ145 passed through the intersecting flight paths airborne in front of the Cessna. Both aircraft were estimated to be at 300 feet. No traffic was issued to either aircraft by the LC. Closest proximity was estimated to be 0 feet vertically and 300 feet laterally. According to FAA Order 7110.65, Air Traffic Control, paragraph 3-9-8, Intersecting Runway Separation:

a. Issue traffic information to each aircraft operating on intersecting runways.
b. Separate departing aircraft from an aircraft using an intersecting runway, or runways when the flight paths intersect, by ensuring that the departure does not begin takeoff roll until one of the following exists:
1. The preceding aircraft has departed and passed the intersection, has crossed the departure runway, or is turning to avert any conflict.

The National Transportation Safety Board determines the probable cause(s) of this incident as follows:
the Gulfport control tower local controller cleared two aircraft for takeoff from runways with intersecting departure flight paths without ensuring the first aircraft had passed the flight path intersection prior to clearing the second aircraft for takeoff.

Jacksonville, Florida: What's that Extra Plane Noise? Offshore Group Conducts Drills


JACKSONVILLE, Fla. -- With an international airport, two military bases and plenty of smaller airports, the skies over Jacksonville are accustomed to air traffic, but extra noise has been filling the skies lately.

The USS Enterprise and the Enterprise Carrier Strike Group are offshore conducting exercises in preparation for the final deployment of the world's first nuclear aircraft carrier, scheduled for later this year.

The drills will continue into the first week of February, according to Navy Public Affairs Officer LCDR Mike Kafka.

Chief Mass Communication Specialist Stephen M. White with USS Enterprise Public Affairs explained the carrier left its homeport in Norfolk, Virginia, on Jan. 11, to participate in a Composite Unit Training Exercise (COMPTUEX) and Joint Task Force Exercise (JTFEX).

COMPTUEX is designed to hone warfare skills and maintain unit proficiency.

"It's the final exercise to ensure Enterprise is combat ready," said Capt. William C. Hamilton, Jr., Enterprise commanding officer. "We're looking forward to working with the full strike group conducting combat exercises across the full spectrum of battle spaces."

That spectrum for the next few weeks includes Jacksonville's airspace, leading to unusual jet noises in the area from the more than 4,500 sailors and Marines involved.

JTFEX tests the group's ability to operate with coalition forces in a hostile environment.

"By the end of COMPTUEX and JTFEX, we will have a combat-ready strike group that will be ready to execute the Navy's mission anywhere in the world," said Rear Adm. Walter E. Carter, Jr., commander, Enterprise Carrier Strike Group.

The strike group consists of the USS Enterprise, Carrier Air Wing 1, Destroyer Squadron 2, guided missile cruiser USS Vicksburg, and three guided missile destroyers: USS Porter, USS James E. Williams and USS Nitze.

First Coast News

Red River, Wisconsin: Local, state and federal agencies practice for air disaster.




RED RIVER - Tens of people are dead and many more injured after a plane crashes onto the ice on the bay of Green Bay - sort of.

A simulated crash of a flight from Austin Straubel International Airport Wednesday is to test local, state and federal agencies' response.

"We want to make sure that we have an efficient response to any type of event that could occur, in our county," said Cullen Peltier, Emergency Management Director for Brown County.

Taking place at Red River County Park in the town of Red River in Kewaunee County, first responders are tasked with rescuing the simulated air crash victims from the water and ice, determine their conditions and communicate that information back to the Emergency Operations Center in Brown County.

FOX 11's Bill Miston is working on this story and will have more of FOX 11 News at Five.

Rescue Drill Prepares for Plane Crash on Green Bay


Local and federal agencies put their preparedness plans to the test Wednesday morning in a plane crash simulation on the bay of Green Bay.

The exercise simulated the crash landing of a commuter plane on ice-covered Green Bay, similar to the deadly Air Florida Flight 90 crash in the Potomac River in Washington, DC, in 1982.

The drill is designed to test the coordinated local, state, and federal response to a disaster situation.

It lets agencies evaluate their response plans, coordinate their rescue efforts, and test their communication skills.

"Everyone has problems with communications across the board, so having a plan in place and making sure everyone can talk on the right radio channel is extremely important. If you can't tell people where you need the help, it's not going to get there," Lieutenant Nick Craig, Green Bay Fire Department, said.

The U.S. Coast Guard, Wisconsin Department of Natural Resources, and Brown County Sheriff's Department were among the agencies participating.

Disaster drill simulates plane crash in icy Green Bay waters


A simulated airplane crash on Green Bay’s frigid bay allowed emergency crews Wednesday to test their ability to handle such a catastrophe.

At least 100 firefighters, paramedics and other emergency responders participated in the effort. They tried their hands at navigating the icy bay, rescuing victims and recovering bodies.

Officials said it was not only the first disaster drill on the frozen waterfront, it was also the first time Austin Straubel International Airport staffers participated in a simulated disaster away from the airport.

“We thought it would be an excellent exercise,” airport director Tom Miller said. “Not only does it test the people, it tests the resources.”

Miller and other officials gathered inside the Brown County Emergency Management center, while responders from area police departments and fire departments headed to the crash scene at Red River County Park along the bay north of Dyckesville.

Others huddled inside a De Pere church, where they attempted to console simulated family members of those killed or wounded in the airplane crash.

Participating agencies included the U.S. Coast Guard, Federal Aviation Administration, state Department of Natural Resources, the Brown County Sheriff’s Department, Kewaunee County Sheriff’s Department, Green Bay Fire Department and Sturgeon Bay Fire Department, among others.

Three Green Bay hospitals agreed to accept mock casualties from the crash scene.

Cullen Peltier, emergency management director for Brown County, said participants would reassemble later to assess their management of the catastrophe and identify areas for improvement. A report on the mock disaster should be ready by April.

“What we want to see is how we’re all going to work together,” Peltier said. “That’s really the main thing.”

Federal law requires Austin Straubel to conduct a major preparedness exercise every three years. When the Coast Guard separately expressed an interest in doing a disaster drill on the bay, coordinated plans began to come together.

From six to eight months of planning emerged a mock catastrophe orchestrated in vivid detail: an airplane headed to Austin Straubel instead slammed into the frozen bay and broke into pieces, killing several people and sending 21 others to the hospital.

“This is a very real simulation,” said Rear Adm. Michael Parks, district commander for the Coast Guard. “The response has been excellent by everybody involved.”

There was no actual airplane involved, but people posing as wounded passengers were treated and loaded onto a bus for transport to hospitals. Divers braved the icy waters to simulate rescuing survivors and recovering bodies.

Steve Winton, a volunteer firefighter from Wisconsin Rapids, portrayed a survivor and tried his best to give rescuers a realistic experience. Winton said it was important for those involved in the exercise to learn as much as possible.

“I’m going to hopefully give them good knowledge of treating real people,” he said. “Hopefully, what I put in today will help them in the future.”

Front nose gear did not lock properly: Stricken plane lands without incident at Arlington Municipal Airport (KGKY), Arlington, Texas

NBC 5
A small plane landed successfully at Arlington Municipal Airport after experiencing nose gear trouble.

Star-Telegram / Patrick Walker
A twin-engine aircraft coasts to a stop in the distance at Arlington Municipal Airport.

Star-Telegram / Patrick Walker
Emergency trucks await the arrival of a stricken twin-engine plane at Arlington Municipal Airport.


A Travel Air flight inbound to Arlington Municipal Airport landed safely after an issue with the nose gear caused an airport alert.

According to Karen VanWinkle, the assistant airport manager, the front nose landing gear on a Travel Air flight inbound to the airport was not locked down.

Emergency crews were on scene as a precaution in case the gear collapsed.

Chopper 5 was on the scene as the plane landed.

A twin-engine plane landed safely at Arlington Municipal Airport about 1:20 p.m. Wednesday after having problems with its front landing gear, Fire Department officials said.

Firefighters from Station 12 at the airport staged near the runway as the pilot flew around to burn off fuel.

The plane coasted to a stop after touching down without further incident.

Source:  http://www.nbcdfw.com

LPFM Fine Reduced in FAA Interference Case

January 18, 2012

A low-power FM station that interfered with FAA frequencies in Florida will have to pay a $1,500 fine for operating without an FCC-certified transmitter. But it convinced the commission to slash the penalty from the original $12,000.

Power Ministries is the licensee of WRLE(LP) in Dunnellon, Fla. Last September the Enforcement Bureau issued a notice of apparent liability, saying the station had operated with a non-certified transmitter for about three months the year before. The commission had responded to a complaint of interference from the Federal Aviation Administration’s Jacksonville Center to air traffic control frequency 133.75 MHz.

The proposed fine was $12,000 but the station appealed in a letter from Power Ministries owner Anthony Downes.

The FCC now has rejected his arguments that the fine should be waived on the grounds that he had acted promptly and had not been aware of interference. (Among other things, the FCC said, the station “deliberately disregarded” an agent’s request that it immediately turn off the transmitter to stop the threat to air traffic control, instead allowing the transmitter to operate unlawfully for another 30 minutes.)

But the commission has accepted the station’s documentation of inability to pay, and it cut the penalty to about 13% of the original amount. “If Power believes that the reduced forfeiture still poses a financial hardship, it may request full payment in installments,” it added.

In the original notice the FCC said the station had been using a PTEK amplifier model FM250E and CSI exciter model EX20F for the period in question. “After the station owner shut down the transmitter, the spurious emissions and interference to the FAA ceased,” the commission wrote.

Source:  http://www.radioworld.com

Los Angeles says Ontario International Airport (KONT) not for sale

LOS ANGELES -- The Los Angeles operator of Southern California's Ontario International Airport says Ontario city leaders are offering to buy the airport for $50 million but it's not for sale.

Los Angeles World Airports, which operates the Ontario and Los Angeles International airports, says in a statement Tuesday night that the $50 million doesn't come close to the value of the airport or Los Angeles' investment.

The Riverside Press-Enterprise says control of the airport has been an issue since passenger traffic began plunging in 2007. Ontario and other San Bernardino County officials have accused Los Angeles of neglecting Ontario in favor of Los Angeles International Airport.

Ontario International is about 40 miles east of downtown Los Angeles.

Source:  http://www.sacbee.com

Piper PA-32R-301, N9253N: Accident occurred July 16, 1999 in Vineyard Haven, Massachusetts

Almost 12 years after JFK Jr and his wife Carolynn Bessette's untimely deaths, his assistant has revealed how she had talked his wife into taking the fateful flight the couple perished on.

RoseMarie Terenzio, 44, was John F Kennedy Jr's personal assistant, publicist and one of his closest confidantes during the last five years of his life.

In her book, 'Fairy Tale Interrupted', she reveals that the couple were having serious troubles in their marriage and Carolyn had initially refused to join John on the flight on July 16, 1999 - the day of their deaths.

With their marriage under intense strain, Carolyn, a Calvin Klein Executive, who struggled with the constant media attention her iconic husband attracted, had said she was not going to join him at his cousin Rory's wedding on July 17.

John,39, who ran George magazine, had told RoseMarie that Carolyn was determined to stay at home and that he was not 'going to fight with her about it', she recalls in People Magazine.

But RoseMarie tried to change her mind.

'I'm not a priority,' she said. It's always something else. George. Somebody getting fired. A trip to meet advertisers. I just want some normal married time. I'm exhausted' RoseMarie remembers Carolyn telling her.


NTSB Identification: NYC99MA178.
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Accident occurred Friday, July 16, 1999 in VINEYARD HAVEN, MA
Probable Cause Approval Date: 07/06/2000
Aircraft: Piper PA-32R-301, registration: N9253N
Injuries: 3 Fatal.

The noninstrument-rated pilot obtained weather forecasts for a cross-country flight, which indicated visual flight rules (VFR) conditions with clear skies and visibilities that varied between 4 to 10 miles along his intended route. The pilot then departed on a dark night. According to a performance study of radar data, the airplane proceeded over land at 5,500 feet. About 34 miles west of Martha's Vineyard Airport, while crossing a 30-mile stretch of water to its destination, the airplane began a descent that varied between 400 to 800 feet per minute (fpm). About 7 miles from the approaching shore, the airplane began a right turn. The airplane stopped its descent at 2,200 feet, then climbed back to 2,600 feet and entered a left turn. While in the left turn, the airplane began another descent that reached about 900 fpm. While still in the descent, the airplane entered a right turn. During this turn, the airplane's rate of descent and airspeed increased. The airplane's rate of descent eventually exceeded 4,700 fpm, and the airplane struck the water in a nose-down attitude. Airports along the coast reported visibilities between 5 and 8 miles. Other pilots flying similar routes on the night of the accident reported no visual horizon while flying over the water because of haze. The pilot's estimated total flight experience was about 310 hours, of which 55 hours were at night. The pilot's estimated flight time in the accident airplane was about 36 hours, of which about 9.4 hours were at night. About 3 hours of that time was without a certified flight instructor (CFI) on board, and about 0.8 hour of that was flown at night and included a night landing. In the 15 months before the accident, the pilot had flown either to or from the destination area about 35 times. The pilot flew at least 17 of these flight legs without a CFI on board, of which 5 were at night. Within 100 days before the accident, the pilot had completed about 50 percent of a formal instrument training course. A Federal Aviation Administration Advisory Circular (AC) 61-27C, "Instrument Flying: Coping with Illusions in Flight," states that illusions or false impressions occur when information provided by sensory organs is misinterpreted or inadequate and that many illusions in flight could be caused by complex motions and certain visual scenes encountered under adverse weather conditions and at night. The AC also states that some illusions might 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 AC further states that spatial disorientation, as a result of continued VFR flight into adverse weather conditions, is regularly near the top of the cause/factor list in annual statistics on fatal aircraft accidents. According to AC 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further states that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions. Examination of the airframe, systems, avionics, and engine did not reveal any evidence of a preimpact mechanical malfunction.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:
The pilot's failure to maintain control of the airplane during a descent over water at night, which was a result of spatial disorientation. Factors in the accident were haze, and the dark night.

HISTORY OF FLIGHT

On July 16, 1999, about 2141 eastern daylight time, a Piper PA-32R-301, Saratoga II, N9253N, was destroyed when it crashed into the Atlantic Ocean approximately 7 1/2 miles southwest of Gay Head, Martha's Vineyard, Massachusetts. The certificated private pilot and two passengers received fatal injuries. Night visual meteorological conditions (VMC) prevailed, and no flight plan had been filed for the personal flight conducted under the provisions of 14 Code of Federal Regulations (CFR) Part 91. The flight originated from Essex County Airport (CDW), Caldwell, New Jersey, and was destined for Barnstable Municipal-Boardman/Polando Field (HYA), Hyannis, Massachusetts, with a scheduled stop at Martha's Vineyard Airport (MVY), Vineyard Haven, Massachusetts.

During interviews, witnesses stated that the purpose of the flight was to fly to Martha's Vineyard to drop off one passenger and then continue to HYA. An employee of a fixed-base operator (FBO) at CDW stated that he had called the pilot about 1300 on the day of the accident to verify that the pilot intended to fly the airplane, N9253N, over the weekend. The pilot informed the employee that he did plan to fly the airplane and that he would arrive at the airport between 1730 and 1800. The employee informed the pilot that he would have the airplane parked outside of the hangar.

Witnesses who were at CDW on the night of the accident stated that they saw the pilot and a female near the accident airplane. The witnesses also reported that they saw the pilot using crutches and loading luggage into the airplane. One witness stated that he watched the pilot perform an engine run-up and then take off about 2040. The witness further stated that "takeoff and right downwind departure seem[ed] normal."

According to air traffic control (ATC) transcripts from CDW's tower, about 2034, the pilot of N9253N contacted the ground controller and stated, "...saratoga niner two five three november ready to taxi with mike...right turnout northeast bound." The ground controller instructed the pilot to taxi to runway 22, which the pilot acknowledged. At 2038:32, the pilot of N9253N contacted the tower controller and advised that he was ready to take off from runway 22. At 2038:39, the tower controller cleared N9253N for takeoff; at 2038:43, the pilot acknowledged the clearance. A few seconds later, the tower controller asked the pilot if he was heading towards Teterboro, New Jersey. The pilot replied, "No sir, I'm uh actually I'm heading a little uh north of it, uh eastbound." The tower controller then instructed the pilot to "make it a right downwind departure then." At 2038:56, the pilot acknowledged the instruction stating, "right downwind departure two two." No records of any further communications between the pilot and ATC exist.

According to radar data, at 2040:59, a target transmitting a visual flight rules (VFR) code was observed about 1 mile southwest of CDW at an altitude of 1,300 feet. The target proceeded to the northeast, on a course of about 55 degrees, remaining below 2,000 feet. The target was at 1,400 feet when it reached the Hudson River. When the target was about 8 miles northwest of the Westchester County Airport (HPN), White Plains, New York, it turned north over the river and began to climb. After proceeding north about 6 miles, the target turned eastward to a course of about 100 degrees. The target continued to climb and reached 5,500 feet about 6 miles northeast of HPN. When the target's course was plotted on a New York VFR navigational map, the extended course line crossed the island of Martha's Vineyard.

The target continued eastward at 5,500 feet, passing just north of Bridgeport, Connecticut, and crossed the shoreline between Bridgeport and New Haven, Connecticut. The target ground track continued on the 100-degree course, just south and parallel to the Connecticut and Rhode Island coastlines. After passing Point Judith, Rhode Island, the target continued over the Rhode Island Sound.

A performance study of the radar data revealed that the target began a descent from 5,500 feet about 34 miles west of MVY. The speed during the descent was calculated to be about 160 knots indicated airspeed (KIAS), and the rate of descent was calculated to have varied between 400 and 800 feet per minute (fpm). About 2138, the target began a right turn in a southerly direction. About 30 seconds later, the target stopped its descent at 2,200 feet and began a climb that lasted another 30 seconds. During this period of time, the target stopped the turn, and the airspeed decreased to about 153 KIAS. About 2139, the target leveled off at 2,500 feet and flew in a southeasterly direction. About 50 seconds later, the target entered a left turn and climbed to 2,600 feet. As the target continued in the left turn, it began a descent that reached a rate of about 900 fpm. When the target reached an easterly direction, it stopped turning; its rate of descent remained about 900 fpm. At 2140:15, while still in the descent, the target entered a right turn. As the target's turn rate increased, its descent rate and airspeed also increased. The target's descent rate eventually exceeded 4,700 fpm. The target's last radar position was recorded at 2140:34 at an altitude of 1,100 feet. (For a more detailed description of the target's [accident airplane's] performance, see Section, "Tests and Research," Subsection, "Aircraft Performance Study.")

On July 20, 1999, about 2240, the airplane's wreckage was located in 120 feet of water, about 1/4 mile north of the target's last recorded radar position.

The accident occurred during the hours of darkness. In the area of and on the night of the accident, sunset occurred about 2014. Civil twilight ended about 2047, and nautical twilight ended about 2128. About 2140, the moon was about 11.5 degrees above the horizon at a bearing of 270.5 degrees and provided about 19 percent illumination. The location of the accident wreckage was about 41 degrees, 17 minutes, 37.2 seconds north latitude; 70 degrees, 58 minutes, 39.2 seconds west longitude.

PILOT INFORMATION

The pilot obtained his private pilot certificate for "airplane single-engine land" in April 1998. He did not possess an instrument rating. He received a "high performance airplane" sign-off in his Cessna 182 in June 1998 and a "complex airplane" sign-off in the accident airplane in May 1999. His most recent Federal Aviation Administration (FAA) second-class medical certificate was issued on December 27, 1997, with no limitations.

A copy of the pilot's logbook that covered from October 4, 1982, to November 11, 1998, was provided to the Safety Board. The pilot's most recent logbook was not located. The Board used the copied logbook, records from training facilities, copies of flight instructors' logbooks, and statements from instructors and pilots to estimate the pilot's total flight experience. The pilot's estimated total flight experience, excluding simulator training, was about 310 hours, of which 55 hours were at night. The pilot's estimated experience flying without a certified flight instructor (CFI) on board was about 72 hours. The pilot's estimated flight time in the accident airplane was about 36 hours, of which 9.4 hours were at night. Approximately 3 hours of that flight time was without a CFI on board, and about 0.8 hour of that time was flown at night, which included a night landing. In the 15 months before the accident, the pilot had flown about 35 flight legs either to or from the Essex County/Teterboro, New Jersey, area and the Martha's Vineyard/Hyannis, Massachusetts, area. The pilot flew over 17 of these legs without a CFI on board, including at least 5 at night. The pilot's last known flight in the accident airplane without a CFI on board was on May 28, 1999.

Pilot Training

On October 4, 1982, the pilot started receiving flight instruction. Over the next 6 years, he flew with six different CFIs. During this period, the pilot logged 47 hours, consisting of 46 hours of dual instruction and 1 hour without a CFI on board. The pilot made no entries in his logbook from September 1988 to December 1997.

In December 1997, the pilot enrolled in a training program at Flight Safety International (FSI), Vero Beach, Florida, to obtain his private pilot certificate. Between December 1997 and April 1998, the pilot flew about 53 hours, of which 43 were flown with a CFI on board. The CFI who prepared the pilot for his private pilot checkride stated that the pilot had "very good" flying skills for his level of experience.

On April 22, 1998, the pilot passed his private pilot flight test. The designated pilot examiner who administered the checkride stated that as part of the flight test, the pilot conducted two unusual attitude recoveries. The pilot examiner stated that in both cases, the pilot recovered the airplane while wearing a hood and referencing the airplane's flight instruments. After receiving his private pilot certificate, the pilot flew solo in his Cessna 182 and received instruction in it by CFIs local to New Jersey. He also received instruction at Million Air, a flight school in New Jersey, and flew their airplanes. During calendar year 1998, the pilot flew approximately 179 hours, including about 65 hours without a CFI on board. On March 12, 1999, the pilot completed the FAA's written airplane instrument examination and received a score of 78 percent.

On April 5, 1999, the pilot returned to FSI to begin an airplane instrument rating course. During the instrument training, the pilot satisfactorily completed the first 12 of 25 lesson plans. The pilot's primary CFI during the instrument training stated that the pilot's progression was normal and that he grasped all of the basic skills needed to complete the course; however, the CFI did recall the pilot having difficulty completing lesson 11, which was designed to develop a student's knowledge of very high frequency omnidirectional radio range (VOR) and nondirectional beacon operations while working with ATC. It took the pilot four attempts to complete lesson 11 satisfactorily. After two of the attempts, the pilot took a 1-week break. After this break, the pilot repeated lesson 11 two more times. The CFI stated that the pilot's basic instrument flying skills and simulator work were excellent. However, the CFI stated that the pilot had trouble managing multiple tasks while flying, which he felt was normal for the pilot's level of experience.

The pilot attended this training primarily on weekends. During this training, the pilot accumulated 13.3 hours of flight time with a CFI on board. In addition, the pilot logged 16.9 hours of simulator time. The pilot departed from FSI for the last time on April 24, 1999.

The pilot continued to receive flight instruction from CFIs in New Jersey in his newly purchased Piper Saratoga, the accident airplane. One CFI flew with the pilot on three occasions. One of the flights was on June 25, 1999, from CDW to MVY. The CFI stated that the departure, en route, and descent portions of the flight were executed in VMC, but an instrument approach was required into MVY because of a 300-foot overcast ceiling. The CFI requested an instrument flight rules (IFR) clearance and demonstrated a coupled instrument landing system (ILS) approach to runway 24. The CFI stated that the pilot performed the landing, but he had to assist with the rudders because of the pilot's injured ankle. (For additional information about the pilot's ankle injury, see Section, "Medical and Pathological Information.") The CFI stated that the pilot's aeronautical abilities and his ability to handle multiple tasks while flying were average for his level of experience.

A second CFI flew with the pilot between May 1998 and July 1999. This CFI accumulated 39 hours of flight time with the pilot, including 21 hours of night flight and 0.9 hour flown in instrument meteorological conditions (IMC). The pilot used this CFI for instruction on cross-country flights and as a safety pilot. On July 1, 1999, the CFI flew with the pilot in the accident airplane to MVY. The flight was conducted at night, and IMC prevailed at the airport. The CFI stated that, during the flight, the pilot used and seemed competent with the autopilot. The instructor added that during the flight the pilot was wearing a nonplaster cast on his leg, which required the CFI to taxi the airplane and assist the pilot with the landing.

The CFI stated that the pilot had the ability to fly the airplane without a visible horizon but may have had difficulty performing additional tasks under such conditions. He also stated that the pilot was not ready for an instrument evaluation as of July 1, 1999, and needed additional training. The CFI was not aware of the pilot conducting any flight in the accident airplane without an instructor on board. He also stated that he would not have felt comfortable with the accident pilot conducting night flight operations on a route similar to the one flown on, and in weather conditions similar to those that existed on, the night of the accident. The CFI further stated that he had talked to the pilot on the day of the accident and offered to fly with him on the accident flight. He stated that the accident pilot replied that "he wanted to do it alone."

A third CFI flew with the pilot between May 1998 and July 1999. This CFI accumulated 57 hours of flight time with the pilot, including 17 hours of night flight and 8 hours flown in IMC. The pilot also used this instructor for instruction on cross-country flights and as a safety pilot. This CFI had conducted a "complex airplane" evaluation on the pilot and signed him off in the accident airplane in May 1999. According to the CFI, on one or two occasions, the airplane's autopilot turned to a heading other than the one selected, which required the autopilot to be disengaged and then reengaged. He stated that it seemed as if the autopilot had independently changed from one navigation mode to another. He also stated that he did not feel that the problem was significant because it only happened once or twice.

The CFI had made six or seven flights to MVY with the pilot in the accident airplane. The CFI stated that most of the flights were conducted at night and that, during the flights, the pilot did not have any trouble flying the airplane. The instructor stated that the pilot was methodical about his flight planning and that he was very cautious about his aviation decision-making. The CFI stated that the pilot had the capability to conduct a night flight to MVY as long as a visible horizon existed.

AIRCRAFT INFORMATION

The accident airplane, N9253N, was a Piper PA-32R-301, Saratoga II, single-engine, low-wing airplane with retractable landing gear. The airplane was originally certificated by Piper Aircraft Corporation on June 9, 1995. The airplane was sold to Skytech, Inc., Baltimore, Maryland, on June 16, 1995, and then resold to Poinciana LLC, Wilmington, North Carolina, on January 5, 1996.

A review of records from an engine overhaul facility revealed that during a 100-hour and annual inspection of the airplane in May 1998, corrosion was observed on the interior surfaces of the engine cylinder walls. Additionally, pitting was observed on the surfaces of several valve tappets. At that time, the engine had a total time since new of 387.1 hours. The documents also revealed that the engine was shipped to the overhaul facility in June 1998, where the engine was disassembled, inspected, and reassembled (parts were replaced as necessary) in June and July 1998. The engine was also run in a test cell before it was shipped and was reinstalled in the airplane in July 1998.

On August 25, 1998, the airplane was purchased by Raytheon Aircraft Company, Wichita, Kansas, and then resold the same day to Air Bound Aviation, Inc., Fairfield, New Jersey. The airplane was sold on August 27, 1998, to a pilot in New Jersey. On April 28, 1999, the airplane was sold to Columbia Aircraft Sales, Inc., Groton, Connecticut. On the same day, the airplane was sold back to Air Bound Aviation and then to the accident pilot, operating as Random Ventures, Inc., New York, New York. According to maintenance personnel at CDW, the pilot kept the airplane's maintenance records inside of the airplane. The maintenance records were not recovered during the wreckage recovery operation.

According to FAA records, work orders, and a statement from an employee of a maintenance facility, a prepurchase inspection of N9253N was conducted on April 16, 1999. According to the maintenance facility employee, "the aircraft was found to be in very good condition, with only a few minor discrepancies." According to the records and the maintenance facility employee, an annual inspection was completed on June 18, 1999, at a total airframe time of 622.8 hours, and the airplane was returned to service on June 25, 1999. The records and maintenance facility employee also revealed that the airplane's return to service was delayed because of an error on the airplane's registration form about its exact make and model. A new registration form with the correct information had to be sent to the pilot for his signature.

A July 13, 1999, work order revealed that a "swing" of the compass and the horizontal situation indicator (HSI) were completed. No total airframe time was recorded on that work order. The tachometer recovered in the wreckage indicated 663.5 hours.

A review of other pilots' logbooks revealed that they had flown the airplane without the accident pilot on board. However, it could not be accurately determined how many other pilots might have flown the airplane without the pilot on board or how many flight hours they might have added on to the airplane.

METEOROLOGICAL INFORMATION

The following airport designators (and those previously defined) are used in this section:

ACK - Nantucket Memorial Airport, Nantucket, Massachusetts.
BDR - Igor I. Sikorsky Memorial Airport, Bridgeport, Connecticut.
BID - Block Island State Airport, Block Island, Rhode Island.
BLM - Allaire Airport, Belmar-Farmingdale, New Jersey.
EWB - New Bedford Municipal Airport, New Bedford, Massachusetts.
EWR - Newark International Airport, Newark, New Jersey.
FMH - Otis ANGB, Falmouth, Massachusetts.
FOK - Francis S. Gabreski Airport, Westhampton Beach, New York.
FRG - Republic Airport, Farmingdale, New York.
ISP - Long Island MacArthur Airport, Islip, New York.
JFK - John F. Kennedy International Airport, New York, New York.
PVD - Theodore Francis Green State Airport, Providence, Rhode Island.
TAN - Taunton Municipal, Taunton, Massachusetts.
TEB - Teterboro Airport, Teterboro, New Jersey.

ACK is located about 27 nautical miles (nm) east-southeast of MVY. HYA is located about 22 nm northeast of MVY.

Pilot Preflight Weather Requests

According to Weather Service International (WSI) personnel, a search of their briefing logs indicated that the pilot, or someone using his user code, made two weather requests from WSI's PILOTbrief Web site on July 16, 1999. The first request, made at 1832:59, was for a radar image. The second request, made at 1834:18, was for a route briefing from TEB to HYA with MVY as an alternate.

The information provided to the requester included en route weather observations from BID, BLM, EWB, EWR, FMH, FOK, FRG, ISP, JFK, PVD, and TAN. These observations indicated that visibilities varied from 10 miles along the route to 4 miles in haze at CDW. The lowest cloud ceiling was reported at 20,000 feet overcast at PVD. These observations were made about 1800. Observations for ACK, CDW, HYA, and MVY were also included. Excerpts from these observations include the following:

ACK 1753...Clear skies; visibility 5 miles in mist; winds 240 degrees at 16 knots.
CDW 1753...Clear skies; visibility 4 miles in haze; winds 230 degrees at 7 knots.
HYA 1756...Few clouds at 7,000 feet; visibility 6 miles in haze; winds 230 degrees at 13 knots.
MVY 1753...Clear skies; visibility 6 miles in haze; winds 210 degrees at 11 knots.

Also included were the following terminal forecasts for ACK and HYA:

ACK (July 16 at 1400 to July 17 at 1400)...July 16...1400 to 2000...Clear skies; visibility greater than 6 miles; winds 240 degrees at 15 knots. Becoming 2000 to 2100, winds 260 degrees at 13 knots.

HYA (July 16 at 1400 to July 17 at 1400)...July 16...1400 to 2200...Clear skies; visibility greater than 6 miles; winds 230 degrees at 10 knots.

According to WSI, the pilot, or someone using his user code, did not access the National Weather Service (NWS) Area Forecast.

Aviation Forecasts and Surface Weather Observations

Area Forecasts (FA)

Excerpts from the Boston FA, issued July 16 about 2045 and valid until July 17 about 0200, included the following: Coastal Waters (includes area of MVY); Scattered clouds at 2,000 feet. Occasional visibility 3 to 5 miles in haze. Haze tops 7,000 feet.

Excerpts from the Boston FA, issued July 16 about 2045 and valid until July 17 about 0900, included the following: Coastal Waters (includes area of MVY); North of 40 degrees north latitude... Scattered cirrus. Occasional visibility 4 to 5 miles in haze. Haze tops 8,000 feet.

Aviation Terminal Forecasts (TAF)

NWS does not prepare TAFs for MVY. Excerpts from TAFs pertinent to the accident include the following:

The TAF for ACK, issued July 16 about 1330 and valid from July 16 about 1400 to July 17 about 1400, was as follows: July 16 at 1400 to July 17 at 1100...Clear skies; visibility greater than 6 miles; winds 240 degrees at 15 knots. Becoming July 16 at 2000 to July 16 at 2100, winds 260 degrees at 13 knots.

The TAF for ACK, issued July 16 about 1930 and valid from July 16 about 2000 to July 17 about 2000, was as follows: July 16 at 2000 to July 17 at 0200...Winds 240 degrees at 15 knots; visibility 4 miles, mist; scattered clouds at 25,000 feet. Temporary changes from July 16 at 2100 to July 17 at 0100...clouds 500 feet scattered; visibility 2 miles, mist.

The TAF for HYA, issued July 16 about 1330 and valid from July 16 about 1400 to July 17 about 1400, was as follows: July 16 at 1400 to July 17 at 1100...Clear skies; visibility greater than 6 miles; winds 230 degrees at 10 knots. Winds becoming July 16 at 2200 to July 17 at 0000...250 degrees at 8 knots.

The TAF for HYA, issued July 16 about 1930 and valid from July 16 about 2000 to July 17 about 2000, was as follows: July 16 at 2000 to July 17 at 0200...Winds 230 degrees at 10 knots; visibility 6 miles, haze; scattered clouds at 9,000 feet. Temporary changes from July 16 at 2000 to July 17 at 0000...Visibility 4 miles, haze.

In-flight Weather Advisories

No airmen's meteorological information, significant meteorological information (SIGMET), or convective SIGMETs were issued by the NWS Aviation Weather Center in Kansas City, Missouri, for the time and area of the accident. No in-flight weather advisories were in effect along the route between CDW and MVY from 2000 to 2200.

Surface Weather Observations

MVY had an Automated Surface Observing System (ASOS), which was edited and augmented by ATC tower personnel if necessary. The tower manager at MVY was on duty on the night of the accident for an 8-hour shift, which ended when the tower closed, about 2200. During an interview, the tower manager stated that no actions were taken to augment or edit the ASOS during his shift. He also stated the following:

"The visibility, present weather, and sky condition at the approximate time of the accident was probably a little better than what was being reported. I say this because I remember aircraft on visual approaches saying they had the airport in sight between 10 and 12 miles out. I do recall being able to see those aircraft and I do remember seeing the stars out that night...To the best of my knowledge, the ASOS was working as advertised that day with no reported problems or systems log errors."

ASOS observations for the night of the accident include the following:

ACK

2053...Clear at or below 12,000 feet; visibility 4 miles, mist; winds 240 degrees at 11 knots; temperature 21 degrees [Celsius] C; dewpoint 20 degrees C; altimeter setting 30.10 inches of [mercury] Hg.
2153...Clear at or below 12,000 feet; visibility 4 miles, mist; winds 240 degrees at 12 knots; temperature 21 degrees C; dewpoint 20 degrees C; altimeter setting 30.11 inches of Hg.

BDR

2054...Clear at or below 12,000 feet; visibility 8 miles, haze; winds 230 degrees at 4 knots; temperature 27 degrees C; dewpoint 21 degrees C; altimeter setting 30.08 inches of Hg.

CDW

1953...Clear at or below 12,000 feet; visibility 4 miles, haze; winds 230 degrees at 4
knots; temperature 33 degrees C; dewpoint 18 degrees C; altimeter setting 30.07 inches of Hg.
2053...Clear at or below 12,000 feet; visibility 5 miles, haze; winds 220 degrees at 5
knots; temperature 31 degrees C; dewpoint 19 degrees C; altimeter setting 30.08 inches of Hg.

HPN

2045...7,500 feet broken, 15,000 feet overcast, visibility 5 miles haze; winds 140 degrees at 4 knots; temperature 28 degrees C; dewpoint 22 degrees C; altimeter setting 30.08 inches of Hg.

HYA

2056...Few clouds at 7,000 feet; visibility 6 miles, mist; winds 230 degrees at 7 knots;
temperature 23 degrees C; dewpoint 21 degrees C; altimeter setting 30.07 inches of Hg.
2156...Few clouds at 7,500 feet; visibility 6 miles, mist; winds 230 degrees at 8 knots;
temperature 23 degrees C; dewpoint 22 degrees C; altimeter setting 30.08 inches of Hg.

MVY

2053...Clear at or below 12,000 feet; visibility 8 miles; winds 250 degrees at 7 knots; temperature 23 degrees C; dewpoint 19 degrees C; altimeter 30.09 inches of Hg.
2153...Clear at or below 12,000 feet; visibility 10 miles; winds 240 degrees at 10 knots, gusts to 15 knots; temperature 24 degrees C; dewpoint 18 degrees C; altimeter 30.10 inches of Hg.

U.S. Coast Guard Station (USCG) Weather Observations

Safety Board staff reviewed weather observations from USCG stations. Excerpts pertinent to the accident include the following:

Point Judith, Rhode Island
1700...Cloudy, 3 miles visibility in haze, winds south-southwest at 10 knots.
2000...Cloudy, 3 miles visibility in haze, winds south-southwest at 10 knots.
2300...Cloudy, 2 miles visibility, winds southwest at 10 knots.

Brant Point, Massachusetts
1700...Clear, 8 miles visibility.
2000...Overcast, 6 miles visibility.
2300...Scattered clouds, 6 miles visibility.

The Brant Point report stated that two observations were reported by ships. About 2000, a ship 1 nm north of buoy 17, which was about 8 miles north of Martha's Vineyard, reported that the seas were 2 to 3 feet and that the visibility was 5 nm. About 2300, another ship reported that the winds were west-southwest at 10 to 15 knots, the seas were 2 to 3 feet, and the visibility was 6 nm in light haze.

Pilot Weather Observations

Three pilots who had flown over the Long Island Sound on the night of the accident were interviewed after the accident.

One pilot kept his twin turboprop airplane at TEB, and on the evening of the accident, he flew from TEB to ACK. The pilot stated that he drove to TEB from New York City and that the traffic was the second heaviest he had seen in 15 years. The pilot stated that he had called the TEB FBO and estimated that his arrival time would be about 1850; however, he did not arrive until between about 1930 and 2000 because of traffic. The pilot also stated that this delay changed the flight from one that would have been conducted entirely during the day to one that would have to be conducted partially at night. The pilot further stated, "Our car took route 80 to Teterboro Airport. Caldwell Airport, where [the accident pilot] flew from is another 14 minute drive west on route 80 past TEB."

Before departing the city, the pilot had obtained current weather observations and forecasts for Nantucket and other points in Massachusetts, Connecticut, New York, and New Jersey. He stated that the visibility was well above VFR minimums. He also stated that he placed a telephone call to a flight service station (FSS) before leaving the city, while driving to TEB. Regarding the telephone call, he stated the following:

"I asked if there were any adverse conditions for the route TEB to ACK. I was told emphatically: 'No adverse conditions. Have a great weekend.' I queried the briefer about any expected fog and was told none was expected and the conditions would remain VFR with good visibility. Again, I was reassured that tonight was not a problem."

The pilot stated that he departed TEB "...in daylight and good flight conditions and reasonable visibility. The horizon was not obscured by haze. I could easily pick our land marks at least five [miles] away." The pilot also stated that he did not request or receive flight information after his departure from TEB. Once clear of the New York Class B airspace, he stated that he climbed his airplane to 17,500 feet and proceeded towards Nantucket. He reported that above 14,000 feet, the visibility was unrestricted; however, he also reported that during his descent to Nantucket, when his global positioning system (GPS) receiver indicated that he was over Martha's Vineyard, he looked down and "...there was nothing to see. There was no horizon and no light....I turned left toward Martha's Vineyard to see if it was visible but could see no lights of any kind nor any evidence of the island...I thought the island might [have] suffered a power failure."

He stated that he had his strobe lights on during the descent and that at no time did they illuminate clouds or fog. He also stated, "I had no visual reference of any kind yet was free of any clouds or fog." The pilot stated that when he contacted the ACK tower for landing, he was instructed to fly south of Nantucket about 5 miles to join the downwind for runway 24; however, he maintained a distance of 3 to 4 miles because he could not see the island at 5 miles. The pilot stated that, as he neared the airport, he had to make a 310-degree turn for spacing. He stated that, during the turn, "I found that I could not hold altitude by outside reference and had to use my [vertical speed indicator] VSI and HSI to hold altitude and properly coordinate the turn."

Another pilot had flown from Bar Harbor, Maine, to Long Island, New York, and crossed the Long Island Sound on the same evening, about 1930. This pilot stated that during his preflight weather briefing from an FSS, the specialist indicated VMC for his flight. The pilot filed an IFR flight plan and conducted the flight at 6,000 feet. He stated that he encountered visibilities of 2 to 3 miles throughout the flight because of haze. He also stated that the lowest visibility was over water, between Cape Cod, Massachusetts, and eastern Long Island. He stated that he did not encounter any clouds below 6,000 feet.

A third pilot departed TEB about 2030 destined for Groton, Connecticut, after a stopover at MVY. He stated that, after departure, he flew south of HPN and, remaining clear of the Class B airspace, he climbed to 7,500 feet. He also stated that, while en route, he monitored several ATC frequencies, but did not transmit on any of them until he neared MVY. His route of flight took him over the north shore of Long Island to Montauk, New York. He stated that he then crossed over Block Island, Rhode Island, and proceeded directly to MVY.

He stated that the entire flight was conducted under VFR, with a visibility of 3 to 5 miles in haze. He stated that, over land, he could see lights on the ground when he looked directly down or slightly forward; however, he stated that, over water, there was no horizon to reference. He stated that he was not sure if he was on top of the haze layer at 7,500 feet and that, during the flight, he did not encounter any cloud layers or ground fog during climb or descent. He further stated that, between Block Island and MVY, there was still no horizon to reference. He recalled that he began to observe lights on Martha's Vineyard when he was in the vicinity of Gay Head. He stated that, before reaching MVY, he would have begun his descent from 7,500 feet and would have been between 3,000 and 5,000 feet over Gay Head (the pilot could not recall his exact altitudes). He did not recall seeing the Gay Head marine lighthouse. He was about 4 miles from MVY when he first observed the airport's rotating beacon. He stated that he had an uneventful landing at MVY about 2145.

About 2200, the pilot departed MVY as the controller announced that the tower was closing. After takeoff, he proceeded on a heading of 290 degrees, climbed to 6,500 feet, and proceeded directly to Groton. The pilot stated that, during the return flight, the visibility was the same as that which he had encountered during the flight to MVY, which was about 3 to 5 miles in haze.

Another pilot at CDW had stated to the news media that he cancelled his planned flight from CDW to MVY on the evening of the accident because of the "poor" weather. In a written statement he stated the following:

"From my own judgement visibility appeared to be approximately 4 miles-extremely hazy. Winds were fairly light. Based only on the current weather conditions at CDW, the fact that I could not get my friends to come with me, and the fact that I would not have to spend money on a hotel room in Martha's Vineyard, I made the decision to fly my airplane to Martha's Vineyard on Saturday."

COMMUNICATIONS

No record exists of the pilot, or a pilot using the airplane's registration number, receiving a weather briefing or filing a flight plan with any FAA FSS for the accident flight. Further, no record exists of the pilot, or a pilot using the airplane's registration number, contacting any FSS or ATC tower or facility during the duration of the flight, except for those at CDW.

The MVY ATC tower tape revealed that, during the period of time from when the accident airplane departed CDW until the tower closed and the recorder was turned off (about 2200), no contact was attempted by the pilot, the call sign of N9253N, or any unknown station.

TRAFFIC ALERT AND COLLISION AVOIDANCE SYSTEM (TCAS) ALERT NEAR HPN

According to the Aeronautical Informational Manual (AIM), definitions for Class B and D airspace are as follows:

Class B Airspace: "Generally, that airspace from the surface to 10,000 feet MSL [mean sea level], surrounding the nation's busiest airports in terms of IFR operations or passenger enplanements...An ATC clearance is required for all aircraft to operate in the area, and all aircraft that are so cleared receive separation services within the airspace...Regardless of weather conditions, an ATC clearance is required prior to operating within Class B airspace..."

Class D Airspace: "Generally, that airspace from the surface to 2,500 feet above the airport elevation (charted in MSL) surrounding those airports that have an operational control tower...Two-way radio communication must be established with the ATC facility providing ATC services prior to entry and thereafter maintain those communications while in the Class D airspace...."

The following TCAS alert occurred during the approach of a commercial airplane to HPN, which was located within published Class D airspace and the New York Class B airspace. On July 16, 1999, about 2049, American Airlines flight 1484, a Fokker 100, was inbound for landing at HPN. According to the transcripts of communications between flight 1484 and the New York approach controller, at 2049:33, flight 1484 was level at 6,000 feet. At 2049:48, the controller instructed flight 1484 to descend and maintain 3,000 feet, which flight 1484 acknowledged. At 2050:32, the controller issued an approach clearance to flight 1484, which flight 1484 also acknowledged. The following is an excerpt of the communications transcript between flight 1484 and the controller regarding the TCAS:

2052:22, the controller, "American fourteen eighty four traffic one o'clock and five miles eastbound two thousand four hundred, unverified, appears to be climbing."

2052:29, flight 1484, "American fourteen eighty four we're looking."

2052:56, the controller, "fourteen eighty four traffic one o'clock and uh three miles twenty eight hundred now, unverified."

2053:02, flight 1484, "um yes we have uh (unintelligible) I think we have him here american fourteen eighty four."

2053:10, flight 1484, "I understand he's not in contact with you or anybody else."

2053:14, the controller, "uh nope doesn't not talking to anybody."

2053:27, flight 1484, "seems to be climbing through uh thirty one hundred now we just got a traffic advisory here."

2053:35, the controller, "uh that's what it looks like."

2053:59, flight 1484, "uh we just had a."

2054:12, the controller, "American fourteen eighty four you can contact tower nineteen seven."

2054:15, flight 1484, "nineteen seven uh we had a resolution advisory seemed to be a single
engine piper er commanche or something."

2054:21, the controller, "roger."

The event occurred outside of the New York Class B and the HPN Class D airspace, and no corrective action was reported to have been taken by the controller or flight 1484. A review of the radar data correlated the unknown target with the track of N9253N.

AIRPORT INFORMATION

MVY had a field elevation of 68 feet. The hours of operation for the contract-operated tower were from 0600 to 2200. MVY had two runways. Runway 06/24 was asphalt-surfaced, 5,500 feet long, and 100 feet wide. Runway 15/33 was asphalt-surfaced, 3,297 feet long, and 75 feet wide. A VOR-distance measuring equipment (DME) navigation aid was located on the airport. The VOR was listed with a normal anticipated interference-free service of 40 nm, up to 18,000 feet with DME. ILS, VOR, and GPS instrument approaches were published for the airport.

MVY was located about 10 miles east of Gay Head. Gay Head had a lighthouse for marine navigation at 41 degrees, 20.9 minutes north latitude; 70 degrees, 50.1 minutes west longitude. According to USCG personnel, the top of the lighthouse was 170 feet above mean low water and operated 24 hours-a-day. The rotating beacon ran on a 15-second cycle, 7.3 seconds white and 7.3 seconds red. The expected range of the white light was 24 miles, and the expected range of the red light was 20 miles.

FLIGHT RECORDERS

The airplane was equipped with a Flightcom Digital Voice Recorder Clock, DVR 300i. The unit contained a digital clock, was wired into the radio communications circuits, and could record conversations between the airplane and other radio sources, ground, or air. The unit was voice activated, and the continuous loop could record and retain a total of 5 minutes of data. The unit had a nonvolatile speech memory that required a 9-volt backup battery to preserve the speech data. When the unit was located in the wreckage, it was crushed, its backup battery was missing, and it had retained no data.

WRECKAGE INFORMATION

On July 20, 1999, the airplane wreckage was located by U.S. Navy divers from the recovery ship, USS Grasp, at a depth of about 120 feet below the surface of the Atlantic Ocean. According to the divers, the recovered wreckage had been distributed in a debris field about 120 feet long and was oriented along a magnetic bearing of about 010/190 degrees. The main cabin area was found in the middle of the debris field.

A Safety Board investigator was present on the USS Grasp during the salvage operation. On July 21, 1999, the main cabin area was raised and placed aboard the USS Grasp. On July 22, 1999, the divers made five additional dives, and the wreckage retrieved from these dives was also placed aboard the USS Grasp. On July 23, 1999, about 2100, the wreckage was transferred from the USS Grasp to the Safety Board at a naval base in Newport, Rhode Island. The wreckage was then transported to the USCG Air Station at Otis Air Force Base, Cape Cod, Massachusetts, the evening of July 23, 1999. The wreckage was examined by Board investigators in a hangar at the USCG Air Station on July 24, 25, and 26, 1999. Follow-up examinations were conducted on August 1 and 2, 1999.

According to the Airworthiness Group Chairman's Report, the engine was found separated from the engine mount truss. The structural tubing on the right side of the engine mount truss was missing. The engine mount truss was deformed to the right and fractured in numerous locations. The upper left engine mount ear and both lower mount ears were fractured. The upper right engine mount ear was bent. The engine and propeller were retained for additional examination.

About 75 percent of the fuselage structure was recovered. A section of the aft cabin roof, about 5 feet long by 3 1/2 feet wide, had separated from the fuselage; this section included the airframe-mounted hinge of the left-side cargo door and a partial frame of the left-side cabin door. The left side of this section exhibited accordion crush damage in the aft direction and contained multiple folds about 5 inches deep. No fuselage structure from the left or right side of the cabin area was recovered, except for a piece of skin, about 2 feet by 2 feet, located beneath the left-side passenger window frame. The belly skin and floor structure of the fuselage were intact aft of the wing spar box carry-through section. The recovered floor structure forward of this section was fragmented. Portions of five of the six seats were found inside the fuselage. The sixth seat was not recovered. Most of the fuselage structure aft of the cabin area was recovered.

About 60 percent of the right wing structure was recovered, including the entire span of the main spar. The right wing had separated into multiple pieces and exhibited more damage than the left wing. The right wing main spar had separated into three pieces. The wing spar had fractured at its attachment to the main carry-through section. The upper spar cap fracture exhibited tension on its forward edge and compression on its aft edge. The spar web exhibited aft bending and tearing in this area.

The outboard portion of the wing leading edge exhibited rearward accordion crush damage and was separated from the remainder of the wing. No evidence of upward spar bending damage was found. No evidence of metal fatigue was found in any of the fracture surfaces.

The entire span of the right flap was recovered; it had separated into two sections (chordwise fracture), and both sections had separated from the right wing. Neither flap section exhibited bowing, bulging, or planar deformation. About 33 inches of the right aileron was recovered, and the leading edge of this section exhibited rearward crush deformation.

About 80 percent of the left wing structure was recovered, including the entire span of the main spar. The left wing main spar had separated into several pieces and exhibited less deformation than the right wing. The wing spar was fractured near the left edge of the main carry-through section. The upper and lower spar cap fractures in this area exhibited tension on the forward edges and compression on the aft edges. The spar web also exhibited aft bending and tearing in this area. No evidence of upward spar bending damage was found. No evidence of metal fatigue was found in any of the fracture surfaces.

About 90 percent of the upper and lower wing skin between the main and rear spars was recovered. The upper skin near the left wing tip was flattened out. The leading edge skin near the inboard portion of the left wing, near the stall warning port, exhibited damage consistent with uniform hydrodynamic deformation in the aft direction.

A 27-inch inboard section of the wing flap section was recovered, and the leading edge of this section exhibited aft accordion crush damage. The flap section did not exhibit any bowing, bulging, or planar deformation. The entire span of the left aileron was recovered; it had separated into two pieces. The outboard section of the aileron was curled downward.

The vertical stabilizer and rudder had separated from the aft fuselage. The stabilator had separated from the aft fuselage attach points and had fractured into five pieces. Two of the pieces consisted of left and right outboard sections, about 22 inches long, and exhibited symmetrical aft crush marks that were semicircular, with diameters of about 5 inches. The fracture surfaces of the left outboard section exhibited tearing in the aft direction. The fracture surfaces of the right outboard sections exhibited forward and upward tearing. The left inboard section of the stabilator was more intact than the right inboard section. The leading edge of the right stabilator section exhibited rearward uniform crush damage along its entire leading edge.

The lower portion of the rudder had separated from the vertical stabilizer fin structure and remained attached to the torque tube bellcrank assembly and fin aft spar. The rudder was folded over toward the right side of the airplane. The vertical stabilizer was also twisted, bent, and curled around toward the right. The structure surrounding the dorsal fin area was deformed symmetrically upward.

All three landing gear assemblies had separated from the airframe and were recovered. The retraction/extension actuating cylinders associated with the nose gear and the left main gear were found in the fully retracted position. The retraction/extension actuating cylinder for the right main gear was not recovered.

Examination of the aileron control cable circuit and associated hardware did not reveal any evidence of a preexisting jam or failure. Flight control cable continuity for the entire right aileron control circuit, including the entire balance cable that links the right aileron to the left aileron, was established. The control cable continuity for the left aileron could not be established because of impact damage and fragmentation. All of the ends of the separations of the aileron control cable circuits exhibited evidence of tensile overload. The stops for the ailerons were examined; no evidence of severe repetitive strike marks or deformations was noted.

Examination of the stabilator control cable circuit and associated hardware did not reveal any evidence of a preexisting jam or failure. Flight control cable continuity for the stabilator was established from the control surfaces to the cockpit controls. The stabilator balance weight had separated from the stabilator, and the fractures associated with the separation were consistent with tensile overload. The stops for the stabilator were examined; no evidence of severe repetitive strike marks or deformations was noted.

Examination of the stabilator trim control cable circuit and associated hardware did not reveal any evidence of a preexisting jam or failure. Control cable circuitry for the stabilator trim was established from the control surfaces to the cockpit area. An examination of the stabilator trim barrel jackscrew revealed that one full thread was protruding out of the upper portion of the trim barrel assembly housing. The barrel assembly was free to rotate and had the trim control cable wrapped around it. The two cable ends were separated about 41 inches and 37 inches, respectively, from the barrel assembly winding. Examination of the separations revealed evidence consistent with tensile overload.

Examination of the rudder control cable circuit and associated hardware did not reveal any evidence of a preexisting jam or failure. Flight control cable continuity for the rudder was established from the control surfaces to the cockpit controls. The stops for the rudder were examined; no evidence of severe repetitive strike marks or deformations was noted.

The electrically driven wing flap jackscrew actuator was not recovered. The flap switch in the cockpit was destroyed. The throttle and propeller controls were found in the FULL-FORWARD position. The mixture control was broken. The alternate air control was found in the CLOSED position. The key in the magneto switch was found in the BOTH position.

The tachometer needle was found intact, fixed in place, and pointed to 2,750 rpm. The red line on the tachometer began at 2,700 rpm. The hour register inside the tachometer read 0663.5 hours. The manifold pressure gauge needle was found fixed in place and indicated 27 inches Hg. The fuel flow gauge needle was found slightly loose and indicated 22 gallons per hour. The exhaust gas temperature gauge needle was found loose and indicated 1,000 degrees Fahrenheit (F). The oil temperature gauge was found fixed and indicated 150 degrees F. The oil pressure gauge was found fixed and indicated about 17 pounds per square inch (psi). The cylinder temperature gauge needle was not found. The fuel quantity gauges were destroyed. The altimeter needle was found fixed and indicated 270 feet. The altimeter setting was found fixed at 30.09 Hg. The top of the VOR indicator heading card was found at the 097-degree bearing.

Examination of all recovered electrical wiring and components did not reveal any evidence of arcing or fire. The circuit breaker panel was deformed and impact damaged. All of the breakers were found in the tripped position, except for the flap, transceiver, and DME. The circuit breaker that provided protection for the transponder, which provided the VFR code and altitude readout to radar facilities down to 1,100 feet, was also found tripped.

The fuel selector valve was recovered, and the bottom of the valve was missing. All three fuel line connections were broken off. The valve had separated from the fuselage attach points. The selector valve linkage was deformed, and the valve was found in the OFF position.

A liquid that had a similar color, odor, and texture as 100 low-lead aviation gasoline was found in the fuel selector valve sump. The electrically driven fuel boost pump was able to function when electrical power was applied to it.

The airplane had been equipped with six seats. The seats had been configured in a "club style" arrangement, with two forward-facing seats in row 1 (including the pilot's seat), two aft-facing seats in row 2, and two front-facing seats in row 3. The five recovered seats had separated from the floor structure. Examination of the aluminum backs of both aft-facing seats revealed that they were deformed (bulged) in the forward direction.

The left and right front seats were equipped with lap belts and shoulder harnesses. None of the belts for these seats could be identified in the wreckage. The four seats in rows 2 and 3 were also equipped with lap belts and shoulder harnesses. Both sections of the lap belt for the left-side aft-facing seat were found and exhibited evidence of stretching. The inboard section of the lap belt for the right-side aft-facing seat in row 2 had been cleanly cut about 3 inches from the male-end of the latch, and the outboard section of lap belt for this seat exhibited evidence of stretching. All of the lap belt sections for the seats in row 3 were identified and none exhibited evidence of stretching. The shoulder harnesses for the rear seats could not be identified in the wreckage.

MEDICAL AND PATHOLOGICAL INFORMATION

On July 21, 1999, examinations were performed on the pilot and passengers by Dr. James Weiner, Office of the Chief Medical Examiner, Commonwealth of Massachusetts. The results indicated that the pilot and passengers died from multiple injuries as a result of an airplane accident.

Toxicological testing was conducted by the FAA Toxicology Accident Research Laboratory, Oklahoma City, Oklahoma. The toxicological tests were negative for alcohol and drugs of abuse.

Medical Information

According to medical records, on June 1, 1999, the pilot fractured his left ankle in a "hang gliding" accident, and on June 2, 1999, he underwent surgical "open reduction internal fixation of left ankle fracture." On June 23, 1999, the pilot's leg was removed from a cast and placed in a "Cam-Walker." On July 15, 1999, the pilot's Cam-Walker was removed, and on July 16, 1999, he was given a "straight cane and instructed in cane usage." The medical records noted that the pilot was "full-weight bearing with mild antalgic gait."

During interviews, the pilot's physical therapist stated that the pilot did not have full dorsiflexion (bending upward of the foot) and that he could not determine whether the pilot's gait was caused by his slight limitation of motion or by mild pain. The pilot's orthopedic surgeon stated that he felt that, at the time of the accident, the pilot would have been able to apply the type of pressure with the left foot that would normally be required by emergency brake application with the right foot in an automobile.

According to 14 CFR Section 61.53, "Prohibition On Operations During Medical Deficiency," in operations that required a medical certificate, a person shall not act as a pilot-in-command while that person, "(1) Knows or has reason to know of any medical condition that would make the person unable to meet the requirements for the medical certificate necessary for the pilot operation."

According to an FAA medical doctor, a pilot with the type of ankle injury that the accident pilot had at the time of the accident would not normally be expected to visit and receive approval from an FAA Medical Examiner before resuming flying activities.

TESTS AND RESEARCH

Engine and Propeller Examinations

On July 26, 1999, the engine was examined at the Textron-Lycoming Facility, Williamsport, Pennsylvania, under the supervision of a Safety Board powerplants investigator. On July 28, 1999, the propeller hub and blades were examined at the Hartzell Propeller Facility, Piqua, Ohio, under the supervision of a Safety Board powerplants investigator. Parties to the investigation were present during both examinations.

According to the Powerplants Group Chairman's Factual Report, the examinations of the engine and propeller did not reveal evidence of any preexisting failures or conditions that would have prevented engine operation. The report further stated that "the investigation team found impact marks on one of the propeller blades and the top of the engine, witness marks inside the propeller, and the engine controls and instruments in the cockpit that indicated high engine power output."

Autopilot Operation

The airplane was equipped with a Bendix/King 150 Series Automatic Flight Control System (AFCS), which was approved for use in Piper PA-32R-301 model airplanes by the FAA on November 1, 1982. The AFCS provided two-axis control for pitch and roll. It also had an electric pitch trim system, which provided autotrim during autopilot operation and manual electric trim for the pilot during manual operation.

The AFCS installed on the accident airplane had an altitude hold mode that, when selected, allowed the airplane to maintain the altitude that it had when the altitude hold was selected. The AFCS did not have the option of allowing the pilot to preselect an altitude so that the autopilot could fly to and maintain the preselected altitude as it climbed or descended from another altitude. The AFCS had a vertical trim rocker switch installed so that the pilot could change the airplane's pitch up or down without disconnecting the autopilot. The rocker switch allowed the pilot to make small corrections in the selected altitude while in the altitude hold mode or allowed the pitch attitude to be adjusted at a rate of about 0.9 degree per second when not in altitude hold mode.

The AFCS incorporated a flight director, which had to be activated before the autopilot would engage. Once activated, the flight director could provide commands to the flight command indicator to maintain wings level and the pitch attitude. To satisfy the command, the pilot could manually fly the airplane by referencing the guidance received in the flight command indicator, or the pilot could engage the autopilot and let it satisfy the commands by maneuvering the aircraft in a similar manner via the autopilot servos.

The AFCS incorporated a navigation mode that could provide guidance to the pilot, or the autopilot, about intercepting and tracking VOR and GPS courses. While engaged in this mode, the AFCS could receive input signals from either the selected VOR frequency and course or from GPS course data selected for presentation on the pictorial navigation indicator. The flight command indicator could then command the bank required to maintain the selected VOR or GPS course with automatic crosswind compensation, and the autopilot, if engaged, would satisfy those commands.

The AFCS incorporated a heading select mode that allowed the pilot to select a heading by moving a "bug" on the outer ring of the pictorial navigation indicator. Once the bug was moved to the desired heading with the heading select button engaged, the autopilot could command the airplane to that heading at a bank angle of about 22 degrees.

The AFCS had a control wheel steering (CWS) button mounted on the control yoke that allowed the pilot to maneuver the aircraft in pitch and roll without disengaging the autopilot. According to AlliedSignal, when the CWS button was released, the autopilot would resume control of the aircraft at the heading and altitude that had been selected at the time the CWS button was released.

According to the FAA and Bendix/King, the trim system was designed to withstand any single in-flight malfunction. Trim faults were visually and aurally annunciated in the cockpit. Through the use of monitor circuits, aircraft control would automatically be returned to the pilot when a fault was detected.

After the AFCS had been preflight tested, it could be engaged and disengaged either manually or automatically. The following conditions would cause the autopilot to automatically disengage: power failure, internal flight control system failure, loss of a valid compass signal, roll rates greater than 14 degrees per second, and pitch rates greater than 8 degrees per second.

Avionics Examinations

On July 29 and 30, 1999, the avionics were examined at the AlliedSignal/King Radios Facility, Olathe, Kansas, under the supervision of a Safety Board investigator. On October 13 and 14, 1999, a follow-up examination of the navigation and communications transceivers and all three autopilot servos was also performed at the AlliedSignal/King Radios Facility under the supervision of a Safety Board investigator. parties to the investigation were present during both examinations.

The accident airplane's AFCS was examined. Examination and functional testing of the AFCS pitch, pitch trim, and roll servos did not reveal any evidence of a preimpact malfunction or jam.

The accident airplane was equipped with a GPS receiver, Bendix/King model KLN-90B. The GPS was capable of presenting moving map displays; bearings and distances to programmable destinations, such as airports and waypoints; airport information; ground speed; and other information. The GPS was also capable of interfacing with the AFCS and the pictorial navigation indicator.

Examination of the GPS unit revealed that it was crushed vertically. The display in the front face of the unit was destroyed. The ON/OFF switch was found in the ON position. The navigation database indicated that it was effective on October 8, 1998, and that it expired on November 4, 1998. A wire that connected the circuitry of a 3.6-volt lithium battery was separated. According to AlliedSignal, the lithium battery provided electrical power to retain the nonvolatile memory of the GPS receiver and required a minimum of 2.5 volts to retain memory. The battery voltage was measured to be 0.2 volt, and it was determined that the memory had not been retained.

Examination of the Bendix/King model KR-87, automatic direction finder, revealed that the receiver's primary frequency was set at 400 kilohertz (kHz) and the secondary frequency was set at 200 kHz.

Both of the airplane's communication/navigation transceivers received severe impact damage and could not be powered up. The nonvolatile memory circuit chips were extracted from the transceivers, placed in a test unit, and powered up. The following information was noted about each of the transceivers:

Transceiver No. 1, KX-165

The in-use communication frequency was set at 132.02, which was the same frequency as the TEB automatic terminal information service (ATIS).

The standby communication frequency was set at 135.25; the CDW ATIS had a frequency of 135.5.

The in-use navigation frequency was set at 109.80, which was the same frequency as the New Haven, Connecticut, VOR.

The standby navigation frequency was set at 113.10, which was the same frequency as the LaGuardia Airport, New York, VOR.

Transceiver No. 2, KX-165

The in-use communication frequency was set at 121.40, which was the same frequency as the MVY tower.

The standby communication frequency was set at 127.25; the MVY ATIS had a frequency of 126.25.

The in-use navigation frequency was set at 108.80, which was the same frequency as the BDR VOR.

The standby navigation frequency was set at 110.00, which was the same frequency as the Norwich, Connecticut, VOR.

Safety Board Materials Laboratory Examinations

An examination of the accident airplane's components was conducted in the Safety Board Materials Laboratory in Washington, D.C.

The flight command indicator (Bendix/King model KI-256) was deformed, and its glass faceplate was missing. The center portion of the pictorial display was partially embedded in the side of the housing in a position that indicated a right turn with a bank angle of about 125 degrees and a nose-down pitch attitude of about 30 degrees. The air-driven gyro housing inside of the flight command indicator was corroded but not deformed. Disassembly and inspection of the gyro did not reveal any scoring marks on the spinning mass gyro and mating housing. The turn coordinator was deformed, and its glass was missing. The display was captured in a position indicating a steep right turn. The electrically driven gyro assembly inside of the instrument was removed and found free to rotate with no binding or case interference. No scoring marks were found on either the spinning mass gyro or mating housing.

The pictorial navigation indicator (Bendix/King model KI-525A) was deformed, and its glass faceplate was missing. The heading indicator was pointing to 339 degrees. The center navigational display needle was oriented along the 300/120-degree bearing. The heading flag was displayed. The heading bug was located at the 095-degree mark. The slaved gyro assembly was partially separated from its mounting, and its case exhibited minor deformation. The gyro housing and internal rotor were disassembled. The interior surface of the case and the exterior surface of the spinning mass rotor did not exhibit any deformation, impact marks, or rotational scoring.

The engine-driven vacuum pump drive shear shaft was intact. The drive end was removed to expose the internal rotor and vanes. The rotor showed several cracks between the bottom of the vane slots and the center of the rotor. All six vanes were removed intact. The rotor was removed in several pieces, and the housing was examined. Examination revealed no evidence of scoring or rotational damage. A metal straight-edge was placed along the long ends of each vane, and no warping or wear was noted.

The electrically driven vacuum pump drive shear shaft was intact. The pump was opened from the motor drive end to expose the rotor and internal vanes. Several cracks were noted in the rotor between the vane slots and the center shaft area. Five of the six vanes were removed and found intact with no fractures or edge chipping. The sixth vane was found wedged and stuck in the rotor, which was stuck inside the housing. Approximately half of the rotor was removed, and examination of its housing revealed no evidence of scoring or rotational damage. A metal straight-edge was placed along the long ends of the removed vanes, and no warping or wear was noted. Disassembly and examination of the vacuum system filter did not reveal any evidence of contaminants or blockages.

The airspeed indicator was damaged, and its glass faceplate was missing. The needle position was found off-scale near the right edge of the density altitude adjustment window; it could be moved, however, when released, it spring-loaded to its as-found position. Magnified examination of marks on the instrument face revealed an outline similar to the size and shape of the needle. This mark was located about two needle widths above the 210-knot marking, which was the maximum marking on the indicator. The location of the needle mark on the airspeed indicator was consistent with the maximum mechanical needle travel position for the airspeed indicator design.

The VSI needle was missing. Magnified examination of marks on the instrument face revealed an outline similar to the size and shape of a needle. This needle mark was pointed at the down-limit position of 2,000 fpm descent.

Microscopic examination of the AFCS light bulbs on the front face of the unit was performed. None of the light bulbs exhibited evidence of filament stretch, including the autopilot engage, flight director, or trim failure light bulbs. An examination of all recovered light bulbs from the airplane's main and landing gear annunciator panels revealed no evidence of filament stretch.

Aircraft Performance Study

An aircraft performance study was performed by a Safety Board specialist using the Board's computer simulation program. According to the specialist's report, airplane performance data for the final portion of the flight were calculated using radar, aircraft, and weather data. Performance parameters were then computed for the final 7 minutes of the flight.

The calculated parameters showed the airplane initially descending from 5,500 feet at descent rates varying between 400 and 800 fpm, at 2133:40. At 2137:20, the airplane attained a steady descent rate of close to 600 fpm as the airplane passed through 3,000 feet. During the entire descent from 5,500 feet, the calculated airspeed remained near 160 KIAS, and the flightpath angle remained close to -2 degrees. About 2138, the airplane started to bank in a right-wing-down (RWD) direction toward a southerly direction. Calculated parameters indicated an almost constant roll angle of 13 degrees RWD and a vertical acceleration of 1.09 Gs while executing the turn. About 30 seconds after the turn was initiated, at an altitude of 2,200 feet, the airplane stopped descending. The airplane then climbed for the next 30 seconds, attaining a maximum climb rate of 600 fpm. During the ascent, the airplane finished the turn to a southeasterly direction, reduced speed slightly to 153 KIAS, and returned to a wings-level attitude by 2138:50. By 2139, the airplane leveled at 2,500 feet and then flew in a southeasterly direction with wings level while increasing airspeed back to 160 KIAS.

At 2139:50, the airplane entered a left turn, while slightly increasing altitude to 2,600 feet. The airplane reached a maximum bank angle of 28 degrees left-wing-down (LWD) and a maximum vertical acceleration of 1.2 Gs in this turn. When the maximum LWD bank angle was obtained, the altitude started to decrease at a descent rate close to 900 fpm. The LWD attitude was maintained for approximately 15 seconds until the airplane was heading towards the east. At 2140:07, the airplane bank angle returned to wings level. At 2140:15, with the airplane continuing towards the east, it reestablished a descent close to 900 fpm and then started to increase its bank angle in a RWD direction at nearly a constant rate. As the airplane bank angle increased, the rate of descent increased, and the airspeed started to increase. By 2140:25, the bank angle exceeded 45 degrees, the vertical acceleration was 1.2 Gs, the airspeed increased through 180 knots, and the flightpath angle was close to 5 degrees airplane nose down. After 2140:25, the airplane's airspeed, vertical acceleration, bank, and dive angle continued to increase, and the right turn tightened until water impact, about 2141.

ADDITIONAL INFORMATION

Cell Phones

The cell phone records for the three occupants of the airplane reflected one out-going call, about 2025. No calls were listed as being made from, or received by, the cell phones from the time of the takeoff through the estimated time of the accident.

Preflight Briefing

The AIM, published by the FAA, is the official guide to basic flight information and ATC procedures. Under the Section, "Preflight Briefing," it states that FSSs are the primary source for obtaining preflight briefings and in-flight weather information. The AIM states that a standard briefing should be requested any time a pilot is planning a flight and has not received a previous briefing or has not received preliminary information through mass dissemination media. The standard briefing should include the following information:

Adverse Conditions: Significant meteorological and aeronautical information that might influence the pilot to alter the proposed flight.

VFR Flight Not Recommended: When VFR flight is proposed and sky conditions or visibilities are present or forecast, surface or aloft, that in the briefer's judgment would make flight under VFR doubtful, the briefer will describe the conditions, affected locations, and use the phrase "VFR flight not recommended."

Current Conditions: Reported weather conditions applicable to the flight will be summarized from all available sources.

En Route Forecast: Forecast en route conditions for the proposed route are summarized in logical order (for example, departure/climbout, en route, and descent).

Destination Forecast: The destination forecast for the planned estimated time of arrival. Any significant changes within 1 hour before and after the planned arrival are included.

Winds Aloft: Forecast winds aloft will be provided using degrees of the compass. The briefer will interpolate wind directions and speeds between levels and stations as necessary to provide expected conditions at planned altitudes.

The AIM also states that a standard briefing should include synopsis, notices to airmen, and ATC delays.

Spatial Disorientation

A review of 14 CFR Part 61, "Certification: Pilots, Flight Instructors, and Ground Instructors," revealed that no specific training requirements exist regarding spatial disorientation. According to the FAA Practical Test Standards, an applicant for a private pilot rating must exhibit knowledge of spatial disorientation. In addition, the publication states that "the examiner shall also emphasize stall/spin awareness, spatial disorientation..."

A review of training records from FSI revealed that while the pilot was preparing for his private pilot certificate, he received instruction on the symptoms, causes, and effects of spatial disorientation and the correct action to take if it occurred. In addition, the pilot received unusual attitude training while attending the private pilot and instrument training courses at FSI.

According to an FAA Instrument Flying Handbook, Advisory Circular 61-27C (AC) (Section II, "Instrument Flying: Coping with Illusions in Flight"), one purpose for instrument training and maintaining instrument proficiency is to prevent a pilot from being misled by several types of hazardous illusions that are peculiar to flight. The AC states that an illusion or false impression occurs when information provided by sensory organs is misinterpreted or inadequate and that many illusions in flight could be created by complex motions and certain visual scenes encountered under adverse weather conditions and at night. It also states that 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 AC also states that spatial disorientation as a result of continued VFR flight into adverse weather conditions is regularly near the top of the cause/factor list in annual statistics on fatal aircraft accidents.

The AC further states that the most hazardous illusions that lead to spatial disorientation are created by information received from motion sensing systems, which are located in each inner ear. The AC also states that the sensory organs in these systems detect angular acceleration in the pitch, yaw, and roll axes, and a sensory organ detects gravity and linear acceleration and that, in flight, the motion sensing system may be stimulated by motion of the aircraft alone or in combination with head and body movement. The AC lists some of the major illusions leading to spatial disorientation as follows:

"The leans - A banked attitude, to the left for example, may be entered too slowly to set in motion the fluid in the 'roll' semicircular tubes. An abrupt correction of this attitude can now set the fluid in motion and so create the illusion of a banked attitude to the right. The disoriented pilot may make the error of rolling the aircraft back into the original left-banked attitude or, if level flight is maintained, will feel compelled to lean to the left until this illusion subsides.

Coriolis illusion - An abrupt head movement made during a prolonged constant-rate turn may set the fluid in more than one semicircular tube in motion, creating the strong illusion of turning or accelerating, in an entirely different axis. The disoriented pilot may maneuver the aircraft into a dangerous attitude in an attempt to correct this illusory movement....

Graveyard spiral - In a prolonged coordinated, constant-rate turn, the fluid in the semicircular tubes in the axis of the turn will cease its movement...An observed loss altitude in the aircraft instruments and the absence of any sensation of turning may create the illusion of being in a descent with the wings level. The disoriented pilot may pull back on the controls, tightening the spiral and increasing the loss of altitude....

Inversion illusion - An abrupt change from climb to straight-and-level flight can excessively stimulate the sensory organs for gravity and linear acceleration, creating the illusion of tumbling backwards. The disoriented pilot may push the aircraft abruptly into a nose-low attitude, possibly intensifying this illusion.

Elevator illusion - An abrupt upward vertical acceleration, as can occur in a helicopter or an updraft, can shift vision downwards (visual scene moves upwards) through excessive stimulation of the sensory organs for gravity and linear acceleration, creating the illusion of being in a climb. The disoriented pilot may push the aircraft into a nose low attitude. An abrupt downward vertical acceleration, usually in a downdraft, has the opposite effect, with the disoriented pilot pulling the aircraft into a nose-up attitude....

Autokinesis - In the dark, a stationary light will appear to move about when stared at for many seconds. The disoriented pilot could lose control of the aircraft in attempting to align it with the false movements of this light."


The AC also states that these undesirable sensations cannot be completely prevented but that they can be ignored or sufficiently suppressed by pilots' developing an "absolute" reliance upon what the flight instruments are reporting about the attitude of their aircraft. The AC further states that practice and experience in instrument flying are necessary to aid pilots in discounting or overcoming false sensations.

Further, the FAA Airplane Flying Handbook, FAA-H-8083-3, chapter 10, states the following about night flying and its affect on spatial orientation:

"Night flying requires that pilots be aware of, and operate within, their abilities and limitations. Although careful planning of any flight is essential, night flying demands more attention to the details of preflight preparation and planning. Preparation for a night flight should include a thorough review of the available weather reports and forecasts with particular attention given to temperature/dewpoint spread. A narrow temperature/dewpoint spread may indicate the possibility of ground fog. Emphasis should also be placed on wind direction and speed, since its effect on the airplane cannot be as easily detected at night as during the day...Night flying is very different from day flying and demands more attention of the pilot. The most noticeable difference is the limited availability of outside visual references. Therefore, flight instruments should be used to a greater degree in controlling the airplane...Under no circumstances should a VFR night-flight be made during poor or marginal weather conditions unless both the pilot and aircraft are certificated and equipped for flight under...IFR...Crossing large bodies of water at night in single-engine airplanes could be potentially hazardous, not only from the standpoint of landing (ditching) in the water, but also because with little or no lighting the horizon blends with the water, in which case, depth perception and orientation become difficult. During poor visibility conditions over water, the horizon will become obscure, and may result in a loss of orientation. Even on clear nights, the stars may be reflected on the water surface, which could appear as a continuous array of lights, thus making the horizon difficult to identify."

According to AC 60-4A, "Pilot's Spatial Disorientation," tests conducted with qualified instrument pilots indicated that it can take as long as 35 seconds to establish full control by instruments after a loss of visual reference of the earth's surface. AC 60-4A further states that surface references and the natural horizon may become obscured even though visibility may be above VFR minimums and that an inability to perceive the natural horizon or surface references is common during flights over water, at night, in sparsely populated areas, and in low-visibility conditions.

A book titled, Night Flying, by Richard Haines and Courtney Flatau, provides some additional information concerning vertigo and disorientation. It states the following:

"Vestibular disorientation refers to the general feeling that one's flight path isn't correct in some way. By calling this effect vestibular, it emphasizes the role played by the middle ear's balance organ. Flying an uncoordinated turn produces this effect as does excessive head turning during a turn in flight. Vestibular disorientation is often subtle in its onset, yet it is the most disabling and dangerous of all disorientation."

Pilot's Operating Handbook (POH)

According to the POH and a photo of the accident airplane's cockpit, the fuel selector control was located below the center of the instrument panel, on the sloping face of the control tunnel, on the cockpit floor. In the "Normal Procedures" section of the POH, under "Cruising," it states, "In order to keep the airplane in best lateral trim during cruise flight, the fuel should be used alternately from each tank at one hour intervals." Also, in the "Normal Procedures" section, under the "Approach and Landing" checklist, the first item listed is "Fuel selector - proper tank."

Wreckage Release

On August 5, 1999, the main airplane wreckage was released to a representative of the accident pilot's insurance company. On November 17, 1999, the remainder of the retained parts were released and shipped to the insurance company's storage facility.

Additional Persons Participating in the Investigation:

Richard I. Bunker - Massachusetts Aeronautics Commission, Boston, Massachusetts

Tom McCreary - Hartzell Propeller Inc., Piqua, Ohio