Saturday, November 9, 2019

Loss of Control in Flight: Piper PA-32-300, N47831; fatal accident occurred November 07, 2017 near Warren County Memorial Airport (KRNC), McMinnville, Tennessee

Larry Gene Banks
After college, Larry enlisted in the Army and went to radar school. While at his first post in New Mexico at the White Sands Missile Range, Larry earned his pilot’s license and later became a flight instructor. 


Tommy Stiles
 After his many years of faithfully worshipping God, caring for and encouraging others, growing as a person, loving and teaching all those around him, learning as much as he could, and of course flying and fishing, he's finally in his eternal abode.
~

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

Additional Participating Entities:

Federal Aviation Administration / Flight Standards District Office; Nashville, Tennessee
Lycoming Engines; Atlanta, Georgia
Piper Aircraft; Vero Beach, Florida

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/N47831



Location: Morrison, TN
Accident Number: ERA18FA016
Date & Time: 11/07/2017, 1845 CST
Registration: N47831
Aircraft: PIPER PA 32
Aircraft Damage: Destroyed
Defining Event: Loss of control in flight
Injuries: 2 Fatal
Flight Conducted Under: Part 91: General Aviation - Personal 

On November 7, 2017, about 1845 central standard time, a Piper PA-32-300, N47831, was destroyed after it impacted terrain near Morrison, Tennessee. The flight instructor and private pilot were fatally injured. The airplane was privately owned and operated as a Title 14 Code of Federal Regulations Part 91 instructional flight. Night instrument meteorological conditions (IMC) prevailed, and an instrument flight rules (IFR) flight plan was filed for the flight, which originated from Monroe County Aeroplex Airport (MVC), Monroeville, Alabama, about 1625, and was destined for Warren County Memorial Airport (RNC), McMinnville, Tennessee.

According to a friend of the private pilot, who was also a pilot, he and the private pilot were fishing in Florida the day before the accident. The flight instructor flew to Destin Executive Airport (DTS), Destin, Florida, the day of the accident to pick up the pilot. The friend stated that he tried to convince the private pilot to drive back from Florida with him instead of flying since the weather "was so bad."

A fuel receipt from a fixed based operator at DTS indicated that the airplane was fueled with 27 gallons of fuel before it departed for MVC, an intermediate stop on the way to RNC.

According to air traffic control data provided by the Federal Aviation Administration (FAA), the controller cleared the airplane for the RNAV Runway 23 approach to RNC and issued the airplane a frequency change to the RNC common traffic advisory frequency (CTAF). The pilots conducted a missed approach and subsequently requested a clearance to Upper Cumberland Regional Airport (SRB), Sparta, Tennessee. The controller radar-identified the airplane, instructed the pilots to climb the airplane to 5,000 ft mean sea level (msl), and cleared the airplane to SRB. In addition, the controller issued the weather for SRB, which included overcast clouds at 300 ft above ground level (agl). One of the pilots asked the controller to verify the overcast cloud conditions at SRB and indicated that he would tune the radio to the SRB automated weather observation service (AWOS) broadcast. About this time, the radar target reached about 4,800 ft and began a right descending turn. While in the descent, one of the pilots declared "mayday" and the target continued to descend at a maximum descent rate about 4,500 ft per minute until radar contact was lost.

According to witnesses, the engine was "loud" and they reported hearing it "throttle up" before they heard the impact. One witness stated that the airplane "sounded like it was doing crazy maneuvers."


Flight Instructor Information

Certificate: Flight Instructor; Commercial
Age: 67, Male
Airplane Rating(s): Multi-engine Land; Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s): Glider; Gyroplane
Restraint Used:
Instrument Rating(s): Airplane
Second Pilot Present: Yes
Instructor Rating(s): Airplane Single-engine; Glider; Gyroplane; Instrument Airplane
Toxicology Performed: Yes
Medical Certification: BasicMed
Last FAA Medical Exam: 06/22/2017
Occupational Pilot:
Last Flight Review or Equivalent:
Flight Time:  8312 hours (Total, all aircraft), 2.1 hours (Last 24 hours, all aircraft)

Pilot Information

Certificate: Private
Age: 49, Male
Airplane Rating(s): Single-engine Land
Seat Occupied: Unknown
Other Aircraft Rating(s): None
Restraint Used:
Instrument Rating(s): None
Second Pilot Present: Yes
Instructor Rating(s): None
Toxicology Performed: Yes
Medical Certification: Class 3 With Waivers/Limitations
Last FAA Medical Exam: 11/03/2016
Occupational Pilot: No
Last Flight Review or Equivalent:
Flight Time:  40 hours (Total, all aircraft), 24 hours (Total, this make and model)

According to FAA airman records, the flight instructor held a commercial pilot certificate with ratings for airplane multiengine land, airplane single-engine land, glider, rotorcraft-gyroplane, and instrument airplane. In addition, he held a flight instructor certificate with ratings for airplane single-engine, glider, rotorcraft-gyroplane, and instrument airplane. He received a BasicMed certificate on June 22, 2017. In August 2016, he reported 8,312 total hours of flight experience. According to the flight log found in the airplane, the flight instructor had accumulated about 2 hours of flight time in the accident airplane since October 6, 2017.

According to FAA airman records, the private pilot held a private pilot certificate with a rating for airplane single-engine land. He was issued a third-class medical certificate on November 3, 2016. On the application for that certificate, he reported 16 total hours of flight experience; all 16 hours were within the previous 6 months. According to a flight log found in the wreckage, the pilot had accumulated about 24 hours of flight time in the accident airplane since October 6, 2017. According to a friend of the pilot, the pilot was scheduled to take his instrument rating practical test on November 27, 2017. In addition, the pilot "had about 40 hours of actual instrument time since he flew the airplane everywhere for work and would take the flight instructor with him."


Aircraft and Owner/Operator Information

Aircraft Make: PIPER
Registration: N47831
Model/Series: PA 32 300
Aircraft Category: Airplane
Year of Manufacture: 1978
Amateur Built: No
Airworthiness Certificate: Normal
Serial Number: 32-7840014
Landing Gear Type: Tricycle
Seats: 6
Date/Type of Last Inspection: 05/01/2017, Annual
Certified Max Gross Wt.:
Time Since Last Inspection: 232 Hours
Engines: 1 Reciprocating
Airframe Total Time: 4365 Hours at time of accident
Engine Manufacturer: Lycoming
ELT: C91A installed
Engine Model/Series: IO-540-K1G5
Registered Owner: On file
Rated Power:300 hp 
Operator: On file
Operating Certificate(s) Held: None

According to FAA airworthiness records, the airplane was manufactured in 1978 and was purchased by the private pilot in September 2016. It was powered by a Lycoming IO-540 series, 300-horsepower engine equipped with a Hartzell constant-speed propeller. According to airplane maintenance logbooks, the most recent annual inspection was completed on May 1, 2017, at a total time of 4,133 hours and a Hobbs time of 1,549.3 hours. According to a flight log located in the wreckage, at the time of departure on the accident flight, the airplane Hobbs meter indicated 1,781.3 hours.


Meteorological Information and Flight Plan

Conditions at Accident Site: Instrument Conditions
Condition of Light: Night
Observation Facility, Elevation: RNC, 1032 ft msl
Distance from Accident Site: 5 Nautical Miles
Observation Time: 1845 CST
Direction from Accident Site: 50°
Lowest Cloud Condition: Thin Overcast / 500 ft agl
Visibility:  2.5 Miles
Lowest Ceiling: Overcast / 500 ft agl
Visibility (RVR):
Wind Speed/Gusts: 6 knots /
Turbulence Type Forecast/Actual:
Wind Direction: 350°
Turbulence Severity Forecast/Actual:
Altimeter Setting: 30.09 inches Hg
Temperature/Dew Point: 12°C / 11°C
Precipitation and Obscuration: Mist; No Precipitation
Departure Point: Monroeville, AL (MVC)
Type of Flight Plan Filed: IFR
Destination: McMinnville, TN (RNC)
Type of Clearance: IFR
Departure Time: 1625 CST
Type of Airspace:

The 1845 recorded weather observation at RNC, about 5 miles northeast of the accident site, included wind from 350° at 6 knots, 2 1/2 miles visibility, mist, overcast clouds at 500 ft agl temperature 12°C, dew point 11°C, and an altimeter setting of 30.09 inches of mercury.

The 1845 recorded weather observation at SRB, about 31 miles northeast of the accident site, included wind from 340° at 6 knots, 8 miles visibility, overcast ceiling at 400 ft agl, temperature 10°C, dew point 10°C, and an altimeter setting of 30.08 inches of mercury.

According to an NTSB meteorologist, the observations surrounding the accident time indicated mainly IFR conditions with brief periods of low IFR (LIFR) conditions in mist. No precipitation was observed around the accident time.

The pilot received Leidos weather briefings at 0605 and 0953 for planned flights on the day of the accident, but not for the accident flight. The pilot had additional contact with Leidos at 0838 and 1556. During the 1556 contact with Leidos, the accident flight route was discussed, and the pilot mentioned that he already had the weather conditions for the proposed destination and that the conditions were LIFR. The accident pilot did not request any weather information or forecast information during the 1556 briefing. All of the standard weather forecast and current weather information were provided to the accident pilot during the 0605 and 0953 briefings.

According to the Astronomical Applications Department at the United States Naval Observatory, sunset was at 1642, the end of civil twilight was at 1709, and moonrise was at 2015. The phase of the moon was waning gibbous, with 83% of the moon's visible disk illuminated.


Airport Information

Airport: WARREN COUNTY MEMORIAL (RNC)
Runway Surface Type: Asphalt
Airport Elevation: 1031 ft
Runway Surface Condition:
Runway Used: 23
IFR Approach: RNAV
Runway Length/Width: 5000 ft / 100 ft
VFR Approach/Landing: None

Warren County Memorial Airport (RNC) was located 3 miles west of McMinnville, Tennessee, at an elevation of 1,031.9 ft msl. It had one runway designated 5/23, which was 5,000 ft long by 100 ft wide. The airport had one instrument approach; an RNAV (GPS) approach to runway 23. The weather minimums for the RNAV (GPS) RWY 23 approach were 1 mile visibility and a decision altitude of 1,276 ft msl.


Wreckage and Impact Information

Crew Injuries: 2 Fatal
Aircraft Damage: Destroyed
Passenger Injuries: N/A
Aircraft Fire: On-Ground
Ground Injuries: N/A
Aircraft Explosion: None
Total Injuries: 2 Fatal
Latitude, Longitude: 35.652778, -85.916389

The main wreckage was located in a field at an elevation of 1,030 ft msl about 1,500 ft from the last radar return. The airplane impacted the field and came to rest about 100 ft beyond the initial impact point on a 040° heading. A 2.5-ft indentation was noted at the initial impact point. All major components of the airplane were located in the vicinity of the main wreckage.

The wreckage came to rest upright and was partially consumed by postimpact fire. Flight control continuity was confirmed from all flight control surfaces to the flight controls in the cockpit through cuts made to facilitate recovery. The cockpit area was damaged. The electric HSI remote gyro was removed from the airframe, disassembled, and rotational scoring was noted on the housing. The right wing exhibited leading edge damage and sections were consumed by postimpact fire. The inboard section of the right flap remained attached to the right wing. The outboard right aileron remained attached to the right wing at the outboard hinge. The remainder of the right aileron was consumed by fire. The left wing was impact-separated at the spar box and remained attached at the forward fuselage attach point. The leading edge exhibited impact damage and skin separation. Thermal damage was noted on the inboard approximate 5-ft section of the left wing. The outboard approximate 8-ft section of the left wing was impact-separated and located in the vicinity of the main wreckage. The vertical stabilizer remained attached to the fuselage. The rudder remained attached to the vertical stabilizer. The stabilator remained attached at all attach points. The right side of the stabilator was deformed in the positive direction. The trim tab remained attached to the stabilator at all attach points. The trim tab control was measured and corresponded to the near full nose up position.

The propeller remained attached to the crankshaft flange. All three propeller blades remained attached to the hub. There was leading edge damage noted along all of the blades

The engine remained attached to the firewall but was removed to facilitate examination. Engine crankshaft continuity was confirmed from the propeller flange to the accessory section of the engine. All cylinders remained attached to the crankcase and thumb compression and suction were obtained on all cylinders. The rocker box covers were removed and no anomalies were noted with the valve springs and rocker arms. Valve train continuity was confirmed when the crankshaft was rotated through 360°. Both magnetos remained attached to the engine, but were partially consumed by fire. The oil filter was removed and disassembled. The filter was charred and absent of metallic debris. The oil suction screen was removed from the engine and free of debris. The vacuum pump was removed and disassembled. The vanes and rotor remained intact. The composite vacuum drive was consumed by postimpact fire. 

Medical And Pathological Information

The Office of the Medical Examiner, Nashville, Tennessee, performed the autopsies on the flight instructor and pilot. The autopsy reports indicated the cause of death for both pilots as multiple blunt force injuries.

Toxicology testing of the flight instructor was performed at the FAA Forensic Sciences Laboratory. Fluid and tissue specimens tested negative for ethanol. Norverapamil was detected in the liver. Verapamil was detected in the liver and the muscle. Verapamil was a blood pressure medication and norverapamil was the metabolite of that medication. The medication is not considered to be impairing.

Toxicology testing of the pilot was performed at the FAA Forensic Sciences Laboratory. Fluid and tissue specimens tested positive for 11 (mg/dl, mg/hg) ethanol in the spleen; however, no ethanol was detected in the muscle, thus the ethanol was likely produced postmortem. No other drugs were detected in the muscle.

Additional Information

Airplane Flying Handbook

The pilot must believe what the flight instruments show about the airplane's attitude regardless of what the natural senses tell. The vestibular sense (motion sensing by the inner ear) can and will confuse the pilot. Because of inertia, the sensory areas of the inner ear cannot detect slight changes in airplane attitude, nor can they accurately send the attitude changes which 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 60-4A Pilot's Spatial Disorientation

The attitude of an aircraft is generally determined by reference to the natural horizon or other visual reference with the surface. If neither horizon nor surface references exist, the attitude of an aircraft must be determined by artificial means from the flight instruments. Sight, supported by other senses, allows the pilot to maintain orientation. However, during periods of low visibility, the supporting senses sometimes conflict with what is seen. When this happens, a pilot is particularly vulnerable to disorientation. The degree of orientation may vary considerably with individual pilots. Spatial disorientation to a pilot means simply the inability to tell which way is 'up.'…Surface references and the natural horizon may at times become obscured, although visibility may be above flight rule minimums. Lack of natural horizon or such reference is common on over water flights, at night, and especially at night in extremely sparsely populated areas, or in low visibility conditions…. The disoriented pilot may place the aircraft in a dangerous attitude… therefore, the use of flight instruments is essential to maintain proper attitude when encountering any of the elements which may result in spatial disorientation. 

1 comment:

Anonymous said...

Bad news ... may the guys RIP.

Report seems to focus on spatial disorientation and the accident certainly has all of the markers for that type of accident.

No mention is made of the attitude gyro ... probably due to excessive damage.

In my opinion, backup electronic attitude indicators have become very reasonable price wise. Even a cheapie can be Velcroed to the panel. No need to fly IFR without one.

They might have been very close to recovering from the upset ... Wings were pretty much level and they had almost pulled out of the dive ... just not enough air left before terra-firms.

I thought it odd how little damage there was to the prop.

Again, RIP.