# NTSB ATL02FA043: Piper PA-32-300, N4105W, Atlanta, GA, February 6, 2002 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: February 6, 2002, 14:02 local (19:02 UTC) - Place: Atlanta, GA - Coordinates: 33.877777, -84.282775 - Nearby events: https://openairdocs.org/map.md?lat=33.8778&lon=-84.2828&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 4 fatal - Status: Completed, report April 15, 2003 - Report: Approved by Office Director - Parties: Atlanta FSDO, National Air Traffic Controller's Association, Textron Lycoming, New Piper Aircraft, Inc. - NTSB case key (mKey): 54175 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL02FA043 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/54175/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=54175 - Page: https://openairdocs.org/ntsb/ATL02FA043 ## Probable cause The pilot experienced spatial disorientation that resulted in the loss of control. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of control - in flight, cruise - weather condition - clouds - aircraft control - not maintained, pilot in command (cause) - spatial disorientation, pilot in command (cause) - weather condition - turbulence - In flight collision with terrain/water, descent - uncontrolled ## Analysis The recently instrument-rated pilot departed on an instrument flight in instrument meteorological conditions with low ceilings and turbulence. Radar data showed the airplane climbed to the assigned altitude but failed to maintain the assigned heading. Radar data indicated the airplane flew a path that included two wide, constant-rate, 360-degree turns to the right. Air traffic controllers twice reassigned the heading, and the pilot acknowledged the instructions each time. About eight minutes after departure, the pilot reported the airplane was in a spin, and the airplane impacted terrain seconds later in a steep, nose-down attitude less than two miles from the airport. The wreckage was found scattered along a path 200 feet long by 80 feet wide in a wooded area. Fuel was present at the site, and examination revealed no evidence of mechanical malfunction of the engine, airframe, or recovered instruments. ## Factual narrative HISTORY OF FLIGHT On February 6, 2002, at 1402 eastern standard time, a Piper PA-32-300, N4105W, registered to C. A. Griffin, Inc., and operated by the pilot, collided with trees and the ground shortly after takeoff from Dekalb-Peachtree Airport, Atlanta, Georgia. The business flight was operated under the provisions of Title 14 CFR Part 91 with an instrument flight rules flight plan filed. Instrument meteorological conditions prevailed at the time of the accident. The airplane was destroyed, and the private pilot and three passengers received fatal injuries. The flight departed Dekalb-Peachtree Airport, Atlanta, Georgia, at 1353. At 1341:30, the pilot of N4105W contacted Dekalb-Peachtree ground control and received clearance for his instrument flight to Savannah International Airport in Savannah, Georgia. At 1343:19, the pilot advised ground control the airplane was ready to taxi. The pilot was given taxi instructions to runway 20L. At 1352:06, the Dekalb-Peachtree local controller advised the pilot to taxi into position and hold on runway 20L, and, at 1352:59, the flight was cleared for takeoff and was given a departure heading of 090 degrees. The pilot acknowledged and correctly read back the heading. Once airborne, the pilot was instructed to contact departure control, which the pilot acknowledged. At 1354:19, the pilot contacted departure control and reported climbing through 1,500 feet. The departure controller advised the pilot of radar contact and instructed the pilot to climb and maintain 4,000 feet, which the pilot acknowledged. According to recorded radar data, the pilot initially flew a 089 degrees magnetic heading and continued eastbound. At 1355:21, the airplane began a right turn. At 1356:19, the departure controller again instructed the pilot to fly a 090-degree heading, and the pilot repeated the assigned heading. Radar data between 1355:21 to 1356:49, showed the airplane flying a wide right arc back over the Dekalb-Peachtree Airport and the VOR. At 1357:05, the departure controller contacted the pilot and stated, "november zero five whiskey, you were given a ninety degrees off the runway, correct?" At 1357:10, the pilot replied, "yes sir, we're showing flying eastbound." Radar data at the time of the pilot's reply showed the airplane was on heading of 099 degrees. At 1357:14, the departure controller stated, "okay, just looked like you made a three-sixty out there for a minute." At 1357:19, the pilot replied, "yes sir, we gotcha now." In an interview conducted on February 26, 2002, the departure controller stated he asked the pilot if he had received a 090 heading because he wanted to verify the heading clearance without berating the pilot on the frequency, and he wanted to bring the heading discrepancy to the pilot's attention. The departure controller stated that he believed the pilot was OK, based upon the pilot's reply. At 1357:25, the airplane began a right turn from a 105 heading and traveled in an arc back toward the Dekalb-Peachtree Airport and VOR. At 1357:52, the departure controller began briefing a relief controller who was to assume the departure controller's duties. The departure controller stated to the relief controller, "four one zero five whiskey is supposed to be on a ninety heading climbing to four, still looks like he's heading south." The departure controller then contacted the pilot, "four one zero five whiskey, say your heading." At 1358:13, the pilot replied, "zero five whiskey, two four zero." Radar data at the time of the pilot's reply showed the airplane on a 243 degree heading as it continued in a constant-rate right turn toward the Dekalb-Peachtree Airport and VOR. The departure controller replied, "alright, you're supposed to be heading zero niner zero." The pilot replied, "Alright, zero five whiskey, is that right to zero nine zero?" At 1358:25, the departure controller instructed the pilot to turn left to 090 degrees, and the pilot replied. The departure controller stated he observed N4105W begin the left turn and start leveling off at 4,000 feet. The departure controller then resumed briefing the relief controller with the status of three other aircraft being handled. The departure controller made no further communications with any aircraft, and the relief controller assumed the departure controller's duties. In an interview conducted on February 26, 2002, the departure controller stated he did not believe the pilot was in danger, because the pilot could maintain altitude, and the pilot never sounded unsure of himself or under stress. At 1358:24, the satellite handoff controller contacted the Dekalb-Peachtree local controller and stated, "remember that zero five whiskey that departed two airplanes ago? ... Did he look like he knew what was going on?" The local controller responded, "He seemed fine." At 1358:51, the satellite handoff controller stated, "... I think we're just going to kind of watch him for a minute here." Between 1359:16 and 1400:07, radar data showed the airplane flying in a level left turn at 4,000 feet to a heading of about 060 degrees, the magnetic heading was fluctuating from 045 to 074 degrees. At 1400:11, radar data showed N4105W began a right turn. At 1400:48, radar data showed the airplane descended to 3,500 feet. At 1400:53, the relief controller stated, "november zero five whiskey, you want to inform me about what you're trying to do?" The pilot replied, "zero five whiskey, trying to get out of a spin." The relief controller asked, "trying to get out of where?" At 1401:01, the pilot said, "got a problem here." No further transmissions were recorded from the pilot. At 1401:46, the last recorded radar data showed the airplane in a right spiral pattern with at an altitude of 2,200 feet. The relief controller stated the pilot sounded calm and in control. The relief controller said, after the pilot reported a spin, the controller chose not to say anything else, because he believed the pilot needed to concentrate on flying. Several witnesses on the ground observed the airplane cross interstate 85 below the clouds at what appeared to be a wings-level, nose-low attitude, then it turned sharply to the right and collided with trees in a steep nose-low, right wing-low attitude. PERSONNEL INFORMATION The pilot held a private certificate issued on May 3, 2001, with an airplane single-engine land rating; an instrument rating was added on December 14, 2001. The pilot's flight time as recorded in the pilot logbook as of February 3, 2002, was 215.3 hours total time, 8.6 hours actual instrument time, and 46 hours simulated instrument time. The pilot held a third class medical certificate dated March 20, 2001, with no limitations or waivers. AIRCRAFT INFORMATION The Piper PA-32-300, N4105W, was registered to C. A. Griffin, Inc. It was a low-wing airplane powered by a Lycoming IO-540-K1A5, six-cylinder, 300-horsepower engine. A review of the aircraft logbooks revealed the airplane received a 100 hour / annual inspection on June 12, 2001, and a 50-hour inspection on November 11, 2001. The clock, transponder, altimeter, and static system were inspected on August 17, 2001. METEOROLOGICAL INFORMATION The Dekalb-Peachtree Airport 1355 weather observation reported winds110 degrees at 8 knots, visibility 2 statute miles, sky overcast at 400 feet with light rain and mist. Temperature was reported at 1 degree Celsius, dew point at minus 1 degree Celsius, and altimeter setting of 30.10. Remarks included ceiling variable between 300 feet and 900 feet. At 1320, the Dekalb-Peachtree Airport automatic terminal information service (ATIS) broadcast information golf (G). The broadcast included the following 1320 special weather information: wind 110 degrees at 8 knots, visibility 2 statute miles, rain, mist, ceiling 600 feet, overcast sky conditions, temperature 1 degree Celsius, dew point missing, altimeter setting 30.14. A review of air traffic control ## Aircraft - Registration: [N4105W](https://openairdocs.org/deregistered/N4105W-2004-08-17), registration cancelled 2004-08-17, S/N 32-40168, built 1967 (OpenAirDocs) - Reported make and model: Piper PA-32-300 - Registry model: [Piper PA-32-300](https://openairdocs.org/model/piper-pa-32-300) (registry code 7103212) (OpenAirDocs) - Registry engine: [Lycoming TI0-540 series](https://openairdocs.org/engine/lycoming-ti0-540-series) (registry code 41533, turbo-prop) (OpenAirDocs) - Category: Airplane - Serial number: 32-40168 - Airframe hours: 4694 - Engines: Avco Lycoming IO-540K1A5 300 horsepower reciprocating - Damage: Destroyed - Flight: Business, Part 91 - Registered owner: Clyde A. Griffin - Airworthiness certificate: Standard, Normal - Last inspection: Annual, June 12, 2001, 137 hours before - Departed: PDK, Atlanta, GA - Destination: SAV, Savannah, GA - Flight plan: IFR - Airport: PDK, Atlanta ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 38; injuries: fatal; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 215 total, 152 in this make and model, 157 as pilot in command, 47 in the last 90 days, 12 in the last 30 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 100° at 5 knots - Visibility: 2 statute miles - Lowest ceiling: 600 ft overcast - Temperature: 34 °F, dew point 30 °F - Altimeter: 30.10 inHg - Observed at: PDK, 2 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20020206037909A](https://openairdocs.org/incident/20020206037909A), Feb 6, 2002: Piper PA32300, Atlanta, GA, No damage, 4 fatal. (-23) On February 6, 2002 at 14:02 local time, a Piper PA32-300 aircraft, registration number N4105W crashed approximately six minutes after takeoff from… ## Other investigations on N4105W (3) From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. - [NTSB MKC72AK036](https://openairdocs.org/ntsb/MKC72AK036), Dec 15, 1971: Piper PA-32 (N4105W), Topeka, KS, substantial damage - [NTSB MKC72DCQ12](https://openairdocs.org/ntsb/MKC72DCQ12), Jul 24, 1971: Piper PA-32 (N4105W), Emporia, KS, substantial damage - [NTSB MKC70A0006](https://openairdocs.org/ntsb/MKC70A0006), Aug 25, 1969: Piper PA-32 (N4105W), Topeka, KS, substantial damage ## Docket (32 files) The files NTSB released with the investigation on June 3, 2003, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=54175. 30.5 MB in all. - ATC 3 - Factual Report of Group Chairman (item 1, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388821&FileExtension=.PDF&FileName=ATC%203%20-%20Factual%20Report%20of%20Group%20Chairman-Redacted.PDF - ATC 3 - Attachment 1 - 7230-4 Daily Record of Facility Operations (item 2, .PDF, 55 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388822&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%201%20-%207230-4%20Daily%20Record%20of%20Facility%20Operations-Redacted.PDF - ATC 3 - Attachment 2 - 7230-10 Electronic Sign on/Sign out Equivalent (item 3, .PDF, 84 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164562&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%202%20-%207230-10%20Electronic%20Sign%20on%2FSign%20out%20Equivalent-Master.PDF - ATC 3 - Attachment 3 - FAA Form 7230-4 Personnel Logs (item 4, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388830&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%203%20-%20FAA%20Form%207230-4%20Personnel%20Logs-Redacted.PDF - ATC 3 - Attachment 4 - Facility Accident/Incident Notification Record (item 5, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164564&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%204%20-%20Facility%20Accident%2FIncident%20Notification%20Record-Master.PDF - ATC 3 - Attachment 5 - FAA Form 3900-7 ATCS Health Program Report (item 6, .PDF, 80 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388832&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%205%20-%20FAA%20Form%203900-7%20ATCS%20Health%20Program%20Report-Redacted.PDF - ATC 3 - Attachment 6 - SO Form 3920-2 ATCS Health Program (item 7, .PDF, 151 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388837&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%206%20-%20SO%20Form%203920-2%20ATCS%20Health%20Program-Redacted.PDF - ATC 3 - Attachment 7 - Transcripts (item 8, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388838&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%207%20-%20Transcripts-Redacted.PDF - ATC 3 - Attachment 8 - Personnel Statements (item 9, .PDF, 335 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388839&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%208%20-%20Personnel%20Statements-Redacted.PDF - ATC 3 - Attachment 9 - Facility Layout Chart (item 10, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164569&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%209%20-%20Facility%20Layout%20Chart-Master.PDF - ATC 3 - Attachment 10 - ASOS Report (item 11, .PDF, 205 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164570&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%2010%20-%20ASOS%20Report-Master.PDF - ATC 3 - Attachment 11 - Mandatory Reading (item 12, .PDF, 5.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40164571&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%2011%20-%20Mandatory%20Reading-Master.PDF - ATC 3 - Attachment 12 - ATL7110.2D Atlanta ATCT/LTRACON Facility Operating Procedures (item 13, .PDF, 9.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388842&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%2012%20-%20ATL7110.2D%20Atlanta%20ATCT%2FLTRACON%20Facility%20Operating%20Procedures-Redacted.PDF - Supplement A (item 14, .PDF, 161 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174797&FileExtension=.PDF&FileName=Supplement%20A-Master.PDF - Supplement B (item 15, .PDF, 215 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174798&FileExtension=.PDF&FileName=Supplement%20B-Master.PDF - Supplement S (item 16, .PDF, 34 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174799&FileExtension=.PDF&FileName=Supplement%20S-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 17, .PDF, 185 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388843&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Redacted.PDF - Radar Data Plot with Raw Data Pages (item 18, .PDF, 184 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388844&FileExtension=.PDF&FileName=Radar%20Data%20Plot%20with%20Raw%20Data%20Pages-Redacted.PDF - Transcript - Air Traffic Control (item 19, .PDF, 807 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388845&FileExtension=.PDF&FileName=Transcript%20-%20Air%20Traffic%20Control-Redacted.PDF - Witness Statements (item 20, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388846&FileExtension=.PDF&FileName=Witness%20Statements-Redacted.PDF - Aircraft Maintenance Log (item 21, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388847&FileExtension=.PDF&FileName=Aircraft%20Maintenance%20Log-Redacted.PDF - Pilot Log (item 22, .PDF, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388848&FileExtension=.PDF&FileName=Pilot%20Log-Redacted.PDF - Engine Log (item 23, .PDF, 160 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388849&FileExtension=.PDF&FileName=Engine%20Log-Redacted.PDF - Weather Data (item 24, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174807&FileExtension=.PDF&FileName=Weather%20Data-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 25, .PDF, 112 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40388850&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Redacted.PDF - Photo 1 - Main Wreckage (item 26, .PDF, 732 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174808&FileExtension=.PDF&FileName=Photo%201%20-%20Main%20Wreckage-Master.PDF - Photo 2 - Engine and Propeller Assembly (item 27, .PDF, 754 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174809&FileExtension=.PDF&FileName=Photo%202%20-%20Engine%20and%20Propeller%20Assembly-Master.PDF - Photo 3 - Wreckage Reconstruction. View From Behind Tail Looking Forward (item 28, .PDF, 619 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174810&FileExtension=.PDF&FileName=Photo%203%20-%20Wreckage%20Reconstruction.%20%20View%20From%20Behind%20Tail%20Looking%20Forward-Master.PDF - Photo 4 - Attitude Indicator (item 29, .PDF, 656 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174811&FileExtension=.PDF&FileName=Photo%204%20-%20Attitude%20Indicator-Master.PDF - Photo 5 - Attitude Indicator Internal Components (item 30, .PDF, 681 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174812&FileExtension=.PDF&FileName=Photo%205%20-%20Attitude%20Indicator%20Internal%20Components-Master.PDF - Photo 6 - Attitude Indicator Rotor (item 31, .PDF, 710 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174813&FileExtension=.PDF&FileName=Photo%206%20-%20Attitude%20Indicator%20Rotor-Master.PDF - Photo 7 - Directional Gyro Case and Vacuum System Components (item 32, .PDF, 41 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40174814&FileExtension=.PDF&FileName=Photo%207%20-%20Directional%20Gyro%20Case%20and%20Vacuum%20System%20Components-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.