Tuesday, October 8, 2019

Loss of Control in Flight: Piper PA-23-250, N44HJ, fatal accident occurred July 01, 2017 in Chatsworth, Murray County, Georgia

Kinsley Wilson (age 10)

    
Austin Day (age 10)  


Dexter Lee Gresham and his wife Mary Jo Yarbrough



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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Atlanta, Georgia
Lycoming; Williamsport, Pennsylvania
Piper Aircraft; Vero Beach, Florida
Hartzell Propeller; Montgomery, 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/N44HJ 



Eric Alleyne
Investigator In Charge 
National Transportation Safety Board


Location: Chatsworth, GA
Accident Number: ERA17FA222
Date & Time: 07/01/2017, 1644 EDT
Registration: N44HJ
Aircraft: PIPER PA23
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 4 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On July 1, 2017, about 1644 eastern daylight time, a Piper PA-23-250 airplane, N44HJ, was destroyed during an in-flight breakup near Chatsworth, Georgia. The pilot and three passengers were fatally injured. The airplane was privately owned and was being operated as a Title 14 Code of Federal Regulations Part 91 personal flight. Instrument meteorological conditions prevailed and no flight plan was filed for the flight, which originated from Moton Field Municipal Airport (06A), Tuskegee, Alabama, about 1500, and was destined for McMinn County Airport (MMI), Athens, Tennessee.

According to a family member, the pilot and his family were returning home after a week-long trip. The line service technician at 06A stated that the airplane arrived at the airport about 1000 and the pilot requested fuel. After the airplane was serviced with about 45 gallons of 100LL aviation fuel, the pilot and the passengers boarded the airplane. The pilot then unsuccessfully attempted to start the engines, and after about 5 to 7 minutes, the service technician asked if he needed assistance. The pilot responded, "no we're good…she [the airplane] does this when the engines get too hot." The pilot tried to start the engines a few more times before one of the airport tenants offered the pilot use of a battery charger. The airplane was towed into a hangar and the charger was connected. The pilot and his family decided to get something to eat while they waited for the battery to charge. Upon returning, the pilot was able to start both engines and the flight subsequently departed.

According to air traffic control and radar information obtained from the Federal Aviation Administration (FAA), the pilot was not receiving radar services nor was he in communication with air traffic control while en route or at any time during the accident flight. Radar data revealed a target consistent with the accident airplane heading northeast at altitudes between 3,500 and 5,000 ft mean sea level (msl) when it encountered a boundary of advancing thunderstorms from the northwest. As the airplane neared the southern edge of the convective system, it turned east, then back to the north before turning east again, and radar contact was lost.

Witnesses in the area reported that, as the thunderstorm approached, it was not raining but they could hear thunder in the distance. As they continued to watch the thunderstorm, they heard a loud "boom" followed by pieces of the airplane and personal belongings falling out of the clouds. Shortly thereafter, one of the witnesses stated that they watched as the airplane came "tumbling and spinning" out of the sky. They continued to watch the airplane until it was out of view and then called the local authorities. 



Pilot Information

Certificate: Private
Age: 55, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Left
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: No
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 05/26/2015
Occupational Pilot: No
Last Flight Review or Equivalent: 01/30/2016
Flight Time:  (Estimated) 362 hours (Total, all aircraft), 100 hours (Total, this make and model), 270 hours (Pilot In Command, all aircraft), 9 hours (Last 90 days, all aircraft)

The pilot, age 55, held a private pilot certificate with ratings for airplane single- and multi-engine land. He held a third-class FAA medical certificate, issued May 26, 2015. At the time of the medical examination, the pilot reported 400 total hours of flight experience and no flight experience within the previous 6 months. The certificate expired for all classes after May 2017.

There was no evidence that the pilot had completed the requirements for operation under BasicMed. A review of the pilot's logbook revealed that the last entry was dated May 23, 2017. The total time entered was 362 flight hours. His total actual instrument experience was recorded as 2 hours, and he recorded 51 hours of simulated instrument experience.



Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N44HJ
Model/Series: PA23 250
Aircraft Category: Airplane
Year of Manufacture:1966 
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 27-3303
Landing Gear Type: Retractable - Tricycle
Seats: 4
Date/Type of Last Inspection: 01/03/2017, Annual
Certified Max Gross Wt.: 3180 lbs
Time Since Last Inspection:
Engines: 2 Reciprocating
Airframe Total Time: 5446 Hours as of last inspection
Engine Manufacturer: LYCOMING
ELT: C91A installed, not activated
Engine Model/Series: TIO-540-J4A5
Registered Owner: On file
Rated Power: 310 hp
Operator: On file
Operating Certificate(s) Held: None

The airplane was manufactured in 1966. It was powered by two Lycoming IO-540-J4A5 engines each rated at 250 horsepower. The engines were each equipped with a Hartzell three-bladed, controllable-pitch propeller. The most recent annual inspection was completed on January 3, 2017, at a tachometer time of 5,446 hours.



Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Day
Observation Facility, Elevation: DNN, 708 ft msl
Distance from Accident Site: 7 Nautical Miles
Observation Time: 1655 EDT
Direction from Accident Site: 270°
Lowest Cloud Condition: Scattered / 900 ft agl
Visibility:  10 Miles
Lowest Ceiling: Broken / 1400 ft agl
Visibility (RVR):
Wind Speed/Gusts: 8 knots / 18 knots
Turbulence Type Forecast/Actual:
Wind Direction: 20°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.11 inches Hg
Temperature/Dew Point: 20°C / 20°C
Precipitation and Obscuration: Heavy - Thunderstorms - Rain
Departure Point: Tuskegee, AL (06A)
Type of Flight Plan Filed: None
Destination: Athens, TN (MMI)
Type of Clearance: None
Departure Time: 1500 CDT
Type of Airspace: Class G

There was no record of the pilot receiving a preflight weather briefing from an official, access-controlled source.

An Area Forecast that included the state of Georgia was issued at 1345 by the Aviation Weather Center (AWC). The portion of the Area Forecast for Georgia forecast for the accident time scattered clouds at 3,500 ft msl, scattered clouds at 5,000 ft msl, isolated rain showers and thunderstorms with moderate rain, possibly severe storms, and cumulonimbus clouds with tops to FL450 (45,000 ft msl).

An Automated Weather Observing System (AWOS) was located at Dalton Municipal Airport (DNN), Dalton, Georgia, about 7 miles west of the accident site at an elevation of 708 ft msl.

At 1635, DNN reported wind from 350° at 19 knots with gusts to 35 knots, 4 statute miles visibility, heavy rain at the airport and a thunderstorm between 5 and 10 miles from the airport, scattered clouds at 1,000 ft above ground level (agl), scattered clouds at 3,000 ft agl, a broken ceiling at 3,600 ft agl, temperature 26°C, dew point temperature 22°C, and an altimeter setting of 30.09 inches of mercury. Remarks included lightning more than 10 miles away to the west through northeast.

At 1655, DNN reported wind from 020° at 8 knots with gusts to 18 knots, wind direction variable between 346° and 056°, 2 statute miles visibility, heavy rain at the airport and a thunderstorm between 5 and 10 miles from the airport, scattered clouds at 900 ft agl, a broken ceiling at 1,400 ft agl, an overcast cloud base at 2,300 ft agl, temperature 20°C, dew point temperature 20°C, and an altimeter setting of 30.11 inches of mercury. Remarks included lightning more than 10 miles away to the west through east.

SIGMETs

There were no non-convective Significant Meteorological Information (SIGMET) advisories active for the accident location at the accident time.

At 1555, the AWC issued the following Convective SIGMETs applicable to Georgia, which were valid for two hours (see figure 1).


Figure 1. Boundaries of convective SIGMETs 60E and 61E issued at 1555 (Red dot denotes accident location).

One hour earlier, at 1455, the AWC issued the following convective SIGMET, which was valid for two hours (see figure 2).


Figure 2. Boundaries of convective SIGMETs 54E issued at 1455 (Red dot denotes accident location). 

Wreckage and Impact Information

Crew Injuries: 1 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: 3 Fatal
Aircraft Fire: None
Ground Injuries:  N/A
Aircraft Explosion: None
Total Injuries: 4 Fatal
Latitude, Longitude: 34.711389, -84.728056

The wreckage was scattered over a large area of very dense vegetation. The debris path was about 1 mile in length, oriented on a heading about 030° magnetic. The first components located along the debris path were fragments of the fuselage. Additional components located along the debris path included fragments of the right and left wing assemblies. The left engine remained attached to a section of the left wing assembly and the right engine was separated from the right wing and located at the end of the debris path. The fuselage came to rest near the wings. The fuselage, cockpit, cabin section, empennage, and engines sustained heavy impact damage. Examination of the wings and the horizontal stabilizers revealed fractures that were consistent with overstress.

Examination of the airframe and both engines revealed no anomalies that would have precluded normal operation. 



Medical And Pathological Information

The Division of Forensics Sciences, Georgia Bureau of Investigation, Decatur, Georgia, performed an autopsy on the pilot. The cause of death was noted as multiple blunt force trauma.

Toxicology testing performed at the FAA Forensic Sciences Laboratory identified 12 (mg/dl, mg/hg) ethanol in blood, which was consistent with postmortem production. Amlodipine was detected in the liver. Amlodipine is a calcium channel blocker heart medication used in the treatment of hypertension.



Additional Information

Spatial Disorientation

According to the FAA's General Aviation Joint Steering Committee, a pilot's sight, supported by other senses, allows a pilot to maintain orientation while flying. However, when visibility is restricted (i.e., no visual reference to the horizon or surface detected), the body's supporting senses can conflict with what is seen. When this spatial disorientation occurs, sensory conflicts and optical illusions often make it difficult for a pilot to tell which way is up.

The FAA Airplane Flying Handbook (FAA-H-8083-3) described some hazards associated with flying when visual references, such as the ground or horizon, are obscured:

The vestibular sense (motion sensing by the inner ear) in particular tends to confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in the attitude of the airplane, nor can they accurately sense attitude changes that occur at a uniform rate over a period of time. On the other hand, false sensations are often generated; leading the pilot to believe the attitude of the airplane has changed when in fact, it has not. These false sensations result in the pilot experiencing spatial disorientation.

FAA Advisory Circular AC 60-22, Aeronautical Decision Making, stated, "Pilots, particularly those with considerable experience, as a rule always try to complete a flight as planned, please passengers, meet schedules, and generally demonstrate that they have 'the right stuff.'" One of the common behavioral traps identified was "Get-There-Itis." The text stated, "Common among pilots, [get-there-itis] clouds the vision and impairs judgment by causing a fixation on the original goal or destination combined with a total disregard for any alternative course of action."

FAA Advisory Circular AC-00-6B, Aviation Weather, described thunderstorms and turbulence associated with them. The publication stated in part:

A thunderstorm is a local storm, invariably produced by a cumulonimbus cloud, and always accompanied by lightning and thunder, usually with strong gusts of wind, heavy rain, and sometimes with hail. The advisory circular further stated in part: Turbulence is present in all thunderstorms. Severe or extreme turbulence is common. Gust loads can be severe enough to stall an aircraft at maneuvering speed or to cause structural damage at cruising speed. The strongest turbulence occurs with shear between updrafts and downdrafts. Outside the cumulonimbus cloud, turbulence has been encountered several thousand feet above, and 20 miles laterally from, a severe storm.

The FAA Aeronautical Information Manual, Turbulence Reporting Criteria Table, stated in part:

Severe: Turbulence that causes large, abrupt changes in altitude and/or attitude. It usually causes large variations in indicated airspeed. Aircraft may be momentarily out of control.

Extreme: Turbulence in which the aircraft is violently tossed about and is practically impossible to control. It may cause structural damage.

8 comments:

dwn said...

This one of the only cases I know of where an Aztec came apart in the air. They are an incredibly strong aircraft. I guess even the strongest aircraft is no match for a fool.

Anonymous said...

WTF did I just read?

I guess another beautiful legacy aircraft destroyed by lack of basic common sense by a dude disrespecting rules written in blood.

Anonymous said...

Wait, was he even rated for multi-engine airplanes?

Anonymous said...

He had a multi-engine rating, but an expired medical.

Anonymous said...

What a badly planned ( if any ) flight into danger that led to such tragic circumstances wiping out a family,how many more out there flying aircraft like this Aztec that are neither qualified or legal,not even well practised,add to this the dangers he could have put others in on the ground adds up to a recipe for disaster,very sad and foolhardy.

T Ibach said...

3 innocents murdered by yet another idiot pilot...

Anonymous said...

What an absolutely horrifying way to go. His complete lack of planning almost makes this resemble a murder-suicide. Too bad he got the plane started after fueling.

Anonymous said...

The original report with a lot more details and background:
http://www.kathrynsreport.com/2017/07/fatal-accident-occurred-july-01-2017-in.html