CEN09LA441

NTSB accident investigation · Piper PA-28 · Cincinnati, OH · July 15, 2009

Accident · Serious injuriesLimited investigationFinal report
Date
July 14, 2009, 21:51 local (Jul 15, 2009, 01:51 UTC)
Place
Cincinnati, OH
Injuries
1 serious
Damage
Destroyed
Phase of flight
Approach
Aircraft
N5519WPiper PA-28
Defining event
Approach-VFR pattern base: Controlled flight into terr/obj (CFIT)
Weather
Visual (VMC) · Night
Status
Completed · report December 15, 2009
Report
Approved by Office Director
NTSB office
Central Region
Parties
1218 Spring Lake Drive, FAA Cincinnati FSD)
Case key
74281

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

The pilot's loss of situational awareness during the approach to an unfamiliar airport at night and his failure to maintain clearance from the trees. Contributing to the accident was the pilot's lack of familiarity with the airplane's navigational equipment.

Findings · 5

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Light condition: darkEnvironmental issues › Conditions/weather/phenomena · Effect on operationPiper PA-28-160: 1 caseAll aircraft: 448 cases
Object/animal/substance: tree(s)Environmental issues › Physical environment · Contributed to outcomePiper PA-28-160: 3 casesAll aircraft: 933 cases
Performance/control parameters: descent/approach/glide pathAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28-160: 2 casesAll aircraft: 809 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

The pilot reported that he intended to “simply enjoy several hours” of night flying and to return to the departure airport. During the flight he noticed that the aircraft compass and directional gyro indications did not match. He was not familiar with the new GPS in the airplane and he was not able to get navigational information from it. The pilot became disoriented and did not recognize any familiar landmarks. It had become very dark. He saw a rotating airport beacon so he decided to land at that airport. As he was turning from downwind to base, the airplane hit the trees paralleling the runway. Witnesses reported that they heard the airplane approaching and saw the airplane in level flight for about 3–5 seconds at tree-top level, and then the airplane impacted the trees. Postaccident inspection of the airplane revealed no preimpact anomalies.

Factual narrative

On July 14, 2009, at 2151 eastern daylight time, a Piper PA-28-160, N5519W, was destroyed by impact with terrain and trees about 2 miles northeast of the Cincinnati Municipal Airport – Lunken Field (LUK), Cincinnati, Ohio. The private pilot, the sole occupant, received serious injuries. The 14 Code of Federal Regulations Part 91 personal flight departed the Warren-Lebanon County Airport (I68) at 1815 on a local flight. Night visual meteorological conditions prevailed at the time of the accident. No flight plan was filed. The pilot reported that he intended to “simply enjoy several hours” of night flying and to return to I68. He first flew to Fayette City (I23), Ohio, and landed there about 1930. He reported that after departing I23, he noticed that the aircraft compass and directional gyro indications did not match. He was not familiar with the new GPS in the airplane and he was not able to get navigational information from it. He “hunted around” for approximately an hour but did not recognize any landmarks or alternate airports. The pilot reported that he flew circles of increasing radius “in hope of coming across a field I did recognize.” The pilot reported that it had become very dark. He saw a rotating airport beacon and headed for it. As he neared the field he saw two runways outlined in orange light. He stated, “Unaware that this was Lunken (LUK), I set up an approach, flying a N [north] downwind. As I turned to base, I hit the trees paralleling the runway.” Witnesses who were fishing from the bank of the river near the accident site reported that they heard the airplane approaching. They reported that they saw the airplane approaching from the east and flying toward LUK. They saw the airplane in level flight for about 3 – 5 seconds at tree top level, and then the airplane impacted the trees. There was no explosion or fire. Inspectors from the Federal Aviation Administration (FAA) inspected the airplane wreckage at the accident site and after it had been moved to a hangar at LUK. The on-site inspection revealed tree branches that had 45 degree cuts, which were consistent with propeller blade strikes. The foliage exhibited signatures consistent with fuel blight. The propeller blade marked “A” was bent aft about 30 degrees near mid span and the outboard portion of the blade displayed “S” bending along the leading edge of the blade. The leading edge had pits, and the front of the blade had chordwise surface scratching. The propeller blade marked “B” had leading edge pits and chordwise surface scratching. The inspection of the flight control cables revealed that the cables were secured to the aileron bellcranks, rudder bellcrank, and the stabilator balance tube. Where the cables were broken, the signatures were consistent with overload.

Aircraft

Registration
N5519W
Reported as
Piper PA-28 (160)
Category
Airplane
Serial number
28-603
Airframe hours
4,879
Engine
Lycoming O-320-D2, reciprocating
Damage
Destroyed
Flight
Personal · Part 91
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 10, 2008 · 34 hours before
Departed
I68 · Lebanon, OH
Destination
LUK · Lunken, OH
Flight plan
Unknown
Airport
LUK · Lunken Field

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
76
Injuries
Serious
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
October 13, 2008
Seat
Left
Flight hours
520 total · 11 in the last 90 days · 3 in the last 30 days

Weather

Conditions
Visual (VMC) · Night
Visibility
10 statute miles
Lowest ceiling
None
Temperature
70 °F, dew point 59 °F
Altimeter
30.11 inHg
Observed at
LUK, 2 nm away

Docket · 6

The files NTSB released with the investigation on October 2, 2009, on NTSB’s docket system: statements, records, photos and specialists’ reports. 2.4 MB in all.