Sunday, September 29, 2019

Loss of Control in Flight: Piper PA-34-200T Seneca II, N1101X; fatal accident occurred May 20, 2018 in Bennington, Vermont

Ramsey Samson Kalani Ah Nee

The National Transportation Safety Board traveled to the scene of this accident.

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Portland, Maine
Piper Aircraft; Vero Beach, Florida
Continental Motors; Mobile, Alabama

Aviation Accident Factual Report - National Transportation Safety Board: https://app.ntsb.gov/pdf


Investigation Docket - National Transportation Safety Board: https://dms.ntsb.gov/pubdms


http://registry.faa.gov/N1101X


Location: Bennington, VT
Accident Number: ERA18FA148
Date & Time: 05/20/2018, 1423 EDT
Registration: N1101X
Aircraft: PIPER PA34
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 1 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On May 20, 2018, about 1423 eastern daylight time, a Piper PA34-200T, N1101X, was destroyed during impact with wooded mountainous terrain and a postcrash fire while maneuvering near Bennington, Vermont. The commercial pilot was fatally injured. The airplane was privately owned by the pilot who was operating it under the provisions of Title 14 Code of Federal Regulations Part 91. Visual meteorological conditions prevailed near the accident site, and no flight plan was filed for the personal flight to Waterbury-Oxford Airport (OXC), Oxford, Connecticut. The flight originated from Burlington International Airport (BTV), Burlington, Vermont, about 1345.

According to a Federal Aviation Administration (FAA) designated pilot examiner (DPE) at BTV, the pilot had obtained a commercial pilot certificate and flight instructor certificate with multiengine land ratings on May 17 and May 19, respectively. They then reviewed weather together on May 19 for the pilot's return flight to his home airport, OXC, and the DPE advised the pilot to return on May 21 due to weather. The DPE stated that he was surprised to learn that the pilot attempted to return home on May 20.

Review of air traffic control information from the FAA revealed that the pilot was receiving flight following from Albany Approach Control. The controller advised the pilot of the location of precipitation and mountainous terrain nearby. The controller subsequently solicited a pilot report from the pilot regarding cloud bases. The pilot reported that the cloud bases were at 3,000 ft; at that time, radar indicated that the accident airplane was at 3,400 ft mean sea level (msl), flying southeast. The controller then asked the pilot if he was in the clouds, and the pilot responded that he was coming out of them. The controller suggested a westbound turn for lower terrain and continued radar coverage. At that time, the accident airplane was flying between 3,200 ft and 4,000 ft msl, but the minimum vectoring altitude for that area was 5,000 ft msl. The airplane briefly turned to a westbound heading, but then turned back to a southeast heading. About 4 miles later, the controller again advised the pilot that, if he continued on the present heading, radar coverage would be lost. The pilot asked again what heading he should fly, and the controller responded westbound, to which the pilot responded, "westbound heading 270." Radar and radio contact were subsequently lost during the second westbound turn. The last radar target was recorded at 1423:41, indicating an altitude of 3,500 ft msl and groundspeed of 218 knots about 1,000 ft from the accident site, which was located on Bald Mountain, at an elevation of about 2,625 ft msl.

Pilot Information

Certificate: Flight Instructor; Commercial
Age: 31, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: No
Instructor Rating(s): Airplane Multi-engine
Toxicology Performed: Yes
Medical Certification: Class 1 Without Waivers/Limitations
Last FAA Medical Exam: 03/05/2018
Occupational Pilot: No
Last Flight Review or Equivalent: 05/19/2018
Flight Time:  256 hours (Total, all aircraft), 30 hours (Total, this make and model) 

The pilot held a commercial pilot certificate with ratings for airplane multiengine land and instrument airplane. He also held a private pilot certificate with a rating for airplane single-engine land. He held a flight instructor certificate with a rating for airplane multiengine land. His most recent FAA first-class medical certificate was issued on March 5, 2018. At that time, he reported a total flight experience of 227 hours. The pilot's logbook was not located and was presumed destroyed in the accident. Review of the pilot's application for a commercial pilot certificate, dated May 17, 2018, revealed a total flight experience of 256 hours, of which 45 hours were instrument experience; however, the application did not specify simulated or actual instrument experience or recency.

Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N1101X
Model/Series: PA34 200T
Aircraft Category: Airplane
Year of Manufacture: 1975
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 34-7570208
Landing Gear Type: Retractable - Tricycle
Seats: 6
Date/Type of Last Inspection: 09/30/2017, Annual
Certified Max Gross Wt.: 4570 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time: 7603 Hours as of last inspection
Engine Manufacturer: CONT MOTOR
ELT: C91 installed, not activated
Engine Model/Series: TSIO-360-EB
Registered Owner: On file
Rated Power: 215 hp
Operator: On file
Operating Certificate(s) Held: None 

The six-seat, low-wing, retractable tricycle-gear airplane was manufactured in 1975. It was powered by one Continental TSIO-360-EB and one Continental LTSIO-360-EB (counter rotating) engine, both of which were 215 horsepower and equipped with constant-speed, two-blade Hartzell propellers. The airplane's maintenance logbooks were not located and presumed destroyed in the accident. According to an airplane status sheet completed on May 19, the airplane's most recent annual inspection was completed on September 30, 2017. At that time, the airplane had accumulated 7,306 total hours. 

Meteorological Information and Flight Plan

Conditions at Accident Site: Visual Conditions
Condition of Light: Day
Observation Facility, Elevation: DDH, 827 ft msl
Distance from Accident Site: 5 Nautical Miles
Observation Time: 1415 EDT
Direction from Accident Site: 245°
Lowest Cloud Condition: Few / 1700 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 3600 ft agl
Visibility (RVR):
Wind Speed/Gusts: 8 knots /
Turbulence Type Forecast/Actual: None / None
Wind Direction: 230°
Turbulence Severity Forecast/Actual: N/A / N/A
Altimeter Setting: 29.91 inches Hg
Temperature/Dew Point: 21°C / 17°C
Precipitation and Obscuration: No Obscuration; No Precipitation
Departure Point: Burlington, VT (BTV)
Type of Flight Plan Filed: None
Destination: Oxford, CT (OXC)
Type of Clearance: VFR Flight Following
Departure Time: 1345 EDT
Type of Airspace: 

In addition to reviewing and discussing weather with the DPE on May 19, the pilot obtained three weather briefings via Foreflight on the day of the accident. The briefings were obtained at 1204, 1216, and 1226. All three briefings contained information about instrument flight rules conditions and mountain obscuration along the planned route of flight.

William H Morse State Airport (DDH), Bennington, Vermont, was located about 5 miles west-southwest of the accident site. The recorded weather at DDH at 1415 included wind from 230° at 8 knots; 10 miles visibility; few clouds at 1,700 ft, broken ceiling at 3,600 ft, overcast ceiling at 4,600 ft; temperature 21°C; dew point 17°C; and an altimeter of 29.91 inches of mercury.

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 1 Fatal
Latitude, Longitude: 42.923889, -73.139167 

A debris path was observed beginning with freshly-cut tree branches descending at an approximate 45° angle and extending about 60 ft on a magnetic heading of 265° to the main wreckage. Several of the branches exhibited cuts with black paint transfer. The main wreckage came to rest upright and was oriented about a 265° magnetic heading, with the empennage canted over the cockpit area. The left propeller separated from the left engine flange and one propeller blade separated from the hub. The blade exhibited s-bending, chordwise scratching, leading edge gouging, and tip curling, and was fractured near the blade root. The other left propeller blade was not located and presumed buried beneath the engine. The right propeller separated from the right engine flange; however, both right propeller blades remained attached to the hub. Both blades exhibited s-bending and leading-edge gouging.

The landing gear and flaps were retracted. The cockpit was consumed by fire and no readable instruments were recovered. The emergency locator transmitter was recovered, and its switch was found in the off position. The attitude indicator was recovered; its face sustained impact damage. When the attitude indicator was disassembled, its gyroscope and housing exhibited rotational scoring consistent with rotation at the time of impact.

The right wing was partially consumed by fire and exhibited impact damage. The right flap remained attached; the right aileron separated and was located about 2 ft from the right wing. The left wing sustained fire damage, but exhibited less impact damage than the right wing. The left flap and left aileron remained attached to the left wing. The empennage, rudder, and stabilator remained attached. Control continuity was confirmed from the left and right wing aileron bellcranks to the mid-cabin area. Stabilator control continuity was confirmed from the stabilator to the cockpit. Rudder control continuity was confirmed from the rudder to the empennage area. Measurement of the stabilator and rudder trim jackscrews each corresponded to an approximate neutral setting.

Both engines were examined following recovery of the wreckage. Due to impact and fire damage, the crankshaft could not be rotated on either engine; however, visual examination of the engines' core components through the fractured oil sumps and borescope examination of the cylinders revealed no preimpact mechanical malfunctions. Additionally, no preimpact anomalies were noted with either engine's fuel and ignition systems. 

Medical And Pathological Information

The Vermont State Department of Health's Office of the Chief Medical Examiner, Burlington, Vermont, performed the autopsy on the pilot. The FAA's Bioaeronautical Sciences Research Laboratory, Oklahoma City, Oklahoma, performed toxicological testing of the pilot. The results were negative for drugs and alcohol.

5 comments:

Anonymous said...

I don't understand why he didn't pick up an IFR plan.

john schreiber said...

So sad. Having lost a son myself, my sincere condolences to his parents.

If there is anything to be learned from this tragedy, may I suggest that pilots look at the route of flight. Following V91-V487 may have been the best choice, if indeed he really needed to fly VFR that day. GPS/Moving map would need to be used to stay on airway as the MRA is much higher than ceiling in some areas. Often VOR airways provide a "lower obstacle clearance" than a GPS direct course will suggest. Using GPS to fly VOR airways is not approved for IFR, unless the airway can be loaded, as in the G1000.
There are other differences to be aware of, but considering GPS leveraged VOR Airways for VFR flights with low ceilings adds a tool to your flight planning. https://www.boldmethod.com/blog/lists/2019/05/seven-things-pilots-should-know-about-victor-airways/
https://flightlevelsonline.com/2013/summer-2013/garmin-tips-and-tricks-gps-and-magnetic-variation/

Anonymous said...

Low time instrument pilot, he probably wasn’t proficient or current would be my only thoughts to as why he wouldn’t have filed IFR and climbed above the trrrain.

Anonymous said...

Hopefully somebody can learn something from this crash.

Anonymous said...

“Using GPS to fly VOR airways is not approved for IFR”. ?????? Where did you get that information??