# NTSB ATL95FA128: Piper PA-28R-200, N15743, Raleigh, NC, July 5, 1995 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: July 5, 1995, 04:16 local (08:16 UTC) - Place: Raleigh, NC - Location: 35.8886° N, 78.7758° W: Placed by OpenAirDocs from NTSB’s distance and direction from RALEIGH-DURHAM INTL (RDU), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=35.8886&lon=-78.7758&mi=10 - Phase of flight: [Approach](https://openairdocs.org/ntsb-phases/500) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 2 fatal - Status: Completed, report February 27, 1996 - Report: Approved by Office Director - NTSB case key (mKey): 3483 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ATL95FA128 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/3483/pdf - Page: https://openairdocs.org/ntsb/ATL95FA128 ## Probable cause The pilot's failure to follow proper IFR procedures by descending below the decision height. Factors relating to the accident were the weather conditions and the dark night. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - In flight collision with terrain/water, approach - faf/outer marker to threshold (ifr) - light condition - dark night (contributing factor) - weather condition - low ceiling (contributing factor) - weather condition - fog (contributing factor) - ifr procedure - improper, pilot in command (cause) - decision height - below, pilot in command (cause) ## Analysis THE PILOT WAS UNABLE TO LAND AT THE FRANKLIN COUNTY AIRPORT, LOUISBURG, NC, FOLLOWING TWO RADAR APPROACHES AND TWO INSTRUMENT APPROACHES DUE TO THE LOW CLOUDS AND VISIBILITY. HE THEN DIVERTED TO RALEIGH-DURHAM AIRPORT FOR AN INSTRUMENT LANDING SYSTEM APPROACH. ACCORDING TO RECORDED RADAR DATA, THE FLIGHT PATH OF THE AIRCRAFT DEVIATED FROM SIDE TO SIDE OF THE LOCALIZER COURSE CENTERLINE FOR MOST OF THE APPROACH. THE AIRCRAFT IMPACTED THE TERRAIN APPROXIMATELY 1/2 MILE NORTHEAST OF THE APPROACH END OF RUNWAY 23L AT APPROXIMATELY 400 FEET MSL. THE DECISION HEIGHT FOR THE ILS RUNWAY 23L APPROACH IS 636 FEET MSL. ## Factual narrative HISTORY OF FLIGHT On July 5, 1995, at 0416 eastern daylight time, a Piper PA-28R-200, N15743 was substantially damaged following a collision with terrain during an instrument approach at the Raleigh-Durham Airport, in Raleigh, North Carolina. The private instrument rated pilot, and his private pilot/passenger were both fatally injured in the accident. The aircraft was being operated under the provisions of 14 CFR Part 91 by the pilot. Instrument meteorological conditions existed at the time, and an instrument flight rules flight plan was in effect for the flight. The flight departed Albany, New York at 2304 on the evening of July 4, 1995. The flight was twice given radar vectors over the Franklin County Airport, but was unable to see the airport because of low clouds, and reduced visibility due to ground fog. The flight then attempted two instrument approaches to the Franklin County Airport, but was still not able to land due the weather conditions. The pilot elected to divert the flight to the Raleigh-Durham Airport, and attempt an instrument landing system approach. According to the recorded radar data at Raleigh-Durham Airport, the pilot's flight path deviated from the localizer path side to side, from the point of initial intercept of the localizer, all the way to the point of impact. During the approach, the radar data showed that the aircraft had minimal deviation from the localizer course for approximately 23 seconds after intercept of the localizer. For the next 45 seconds the aircraft deviated to the left of course, it then crossed the centerline of the localizer and deviated to the right of course for approximately 30 seconds. Next, the aircraft deviated to the left of course, for approximately 30 seconds, and then deviated to the right of course.(See Radar Computer Magnetic Recordings Attached to This Report.) The aircraft impacted trees and the terrain approximately 1/2 mile south of the approach end of runway 23L. The elevation of the terrain in the area of the impact was approximately 400 feet above mean sea level. PERSONNEL INFORMATION The pilot, Richard E. Bernstein, held a private pilot certificate, with airplane single engine land, and instrument airplane ratings. He held a third class medical certificate, with a restriction for the use of glasses, which was issued August 9, 1993. No pilot log book for the pilot could be located. The pilot's application for his medical certificate in August of 1993 showed a total flight time of 125 hours. AIRCRAFT INFORMATION The Piper PA-28R-200 is a four place, single engine, retractable gear airplane. It is powered by a single Lycoming IO-360-C1C, 200 horse power engine. The last inspection of N15743 was a 100 hour inspection which was completed on June 23, 1995. The aircraft accumulated 8 hours since the inspection, and had accumulated a total of 3919 hours total hours. METEOROLOGICAL INFORMATION Instrument meteorological conditions existed at the time of the accident with sky partially obscured, broken ceiling of 200 feet, and visibility of one half mile in fog. AIDS TO NAVIGATION The instrument landing system (ILS) approach to runway 23L at the Raleigh-Durham Airport is on a heading of 232 degrees, with a descent from 1,800 feet above mean sea level (MSL), at the locator outer marker (LOM), to a decision height of 636 feet MSL. The minimum landing visibility for the approach is one half mile. WRECKAGE AND IMPACT INFORMATION The initial impact was in a wooded area approximately 1/2 mile northeast of the approach end of Runway 23L. There were pieces of the tops of the 80 foot pine trees, and small pieces of paint chips from the aircraft located in the wooded area. The aircraft then continued on a heading of approximately 180 degrees magnetic, and passed over an open field for approximately 595 feet prior to impacting the terrain in the wooded area on the opposite side of the open field.(See Wreckage Diagram attached to this report for details of wreckage distribution) There was a post crash fire which consumed the forward portion of the fuselage, including the cockpit section. The aircraft was inverted with the right and left wings broken off. Continuity of the control surface cables was established into the cockpit area. The aircraft propeller was located at the main wreckage site. There was twisting of the propeller spinner in the direction of rotation. The propeller blades showed signs of chord wise scratching, and twisting towards low pitch. The aircraft engine accessories were consumed in the post crash fire. There was continuity of the engine drive train. The tachometer was found outside the fuselage. The tachometer RPM needle was bent, which prevented the needle from moving. At the time the tachometer was located, the needle was found to be indicating 1800 RPM. Examination of the vacuum pump did not reveal any evidence of pre impact malfunction or failure. MEDICAL AND PATHOLOGICAL INFORMATION An autopsy of the pilot, Mr. Richard E. Bernstein, was conducted by Dr. robert L. Thompson of The Office of Chief Medical Examiner of North Carolina in Chapel Hill, North Carolina. The autopsy list the cause of death of Mr. Bernstein as multiple traumatic injuries. A toxicological examination was conducted by Federal Aviation Administration Toxicology and Accident Research Laboratory in Oklahoma City, Oklahoma. The toxicology report was negative for the use of alcohol and drugs. ADDITIONAL INFORMATION The aircraft wreckage was released to Mr. James Brewer, the aircraft owners insurance representative, on July 6, 1995. ## Aircraft - Registration: [N15743](https://openairdocs.org/deregistered/N15743-1996-06-13), registration cancelled 1996-06-13, S/N 28R7335085 (OpenAirDocs) - Reported make and model: PIPER PA-28R-200 - Registry model: [Piper PA-28R-200](https://openairdocs.org/model/piper-pa-28r-200) (registry code 7102811) (OpenAirDocs) - Category: Airplane - Serial number: 28R-7335085 - Airframe hours: 3919 - Engines: LYCOMING IO-360-C1C 200 horsepower reciprocating - Damage: Destroyed - Fire: On-Ground - Flight: Personal, Part 91 - Operator: Richard E. Bernstein - Registered owner: Wake Aviation Inc. - Airworthiness certificate: Standard, Normal - Last inspection: 100 hour, June 23, 1995, 8 hours before - Departed: ALB, ALBANY, NY - Destination: RDU - Flight plan: IFR - Airport: RDU, Raleigh-Durham Intl, runway 23L, 7,500 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 125 total ## Weather - Conditions: Instrument (IMC), Night/dark - Wind: 210° at 4 knots - Visibility: 0.5 statute miles - Lowest ceiling: 200 ft broken - Temperature: 70 °F, dew point 70 °F - Altimeter: 30.00 inHg - Observed at: RDU, 1 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 19950705016019A](https://openairdocs.org/incident/19950705016019A), Jul 5, 1995: Piper PA28R200, Raleigh-Durham, NC, Destroyed, 2 fatal. Missed two approaches at destination. Diverted. Erratic ILS approach. Went below decision height. Impacted terrain. 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.