CEN13FA067

NTSB accident investigation · Piper PA-28-180 · Hillsdale, MI · November 21, 2012

Accident · FatalField investigationFinal report
Date
November 21, 2012, 18:20 local (23:20 UTC)
Place
Hillsdale, MI
Injuries
1 fatal
Damage
Substantial damage
Phase of flight
Approach
Aircraft
N40781Piper PA-28-180
Weather
Visual (VMC) · Night
Status
Completed · report May 6, 2015
Report
Approved by Office Director
NTSB office
Central Region
Parties
FAA FSDO East Michigan, Piper Aircraft Company
FAA report
20121121027679A
Case key
85646

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 failure to maintain clearance from terrain during a straight-in night visual flight rules approach to land in hazy weather conditions. Contributing to the accident were the pilot's lack of recent night flying experience, the nonfunctional precision approach path indicator system on the selected runway, and the inaccurate Kollsman setting in the altimeter.

Findings · 7

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.

Experience/qualifications: recent experiencePersonnel issues › Experience/knowledge · PilotPiper PA-28-180: 3 casesAll aircraft: 76 casesProbable cause
Airport facilities/design: runway lightingEnvironmental issues › Operating environment · Contributed to outcomePiper PA-28-180: 1 caseAll aircraft: 18 casesProbable cause
Performance/control parameters: altitudeAircraft › Aircraft oper/perf/capability · Not attained/maintainedPiper PA-28-180: 12 casesAll aircraft: 1,310 casesProbable cause
Use of equip/info: use of equip/systemPersonnel issues › Task performance · PilotPiper PA-28-180: 16 casesAll aircraft: 1,391 casesProbable cause
Ceiling/visibility/precip: haze/smokeEnvironmental issues › Conditions/weather/phenomena · Contributed to outcomePiper PA-28-180: 1 caseAll aircraft: 21 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

After a 1.5-hour uneventful night visual flight rules cross-country flight and about 18 miles from the destination airport, the pilot contacted the airport UNICOM and requested that the runway lights be turned on. Subsequently, the airport manager who was monitoring the UNICOM frequency turned on the runway lights. The airplane did not land, and no distress calls from the pilot were reported. The wreckage was found 1.25 miles east of the approach end of the runway. Examination of the wreckage indicated that the airplane struck the trees in a shallow descent. The airport manager and another pilot reported that hazy conditions existed about the time of the accident. No mechanical anomalies were discovered with the airframe or engine. The pilot only had 16.4 hours of night flight time, and his most recent logged night flight time was about 10 years before the accident flight. Family members stated that the pilot did not like to fly at night. The selected runway's precision approach path indicator (PAPI) system was not functional. An experienced pilot who landed his airplane at the airport shortly before the accident reported that he chose to land on another runway after circling the airport and noting that the PAPI was nonfunctional because it was dark on that side of the airport. Examination of the altimeter at the accident site showed that 30.38 inches of Mercury (inHg) was set in the instrument's Kollsman window; however, the area barometric pressure at the time of the accident was 30.17 inHg. The altimeter was bench tested and found to be functional. The inaccurate Kollsman setting would have shown a higher indicated altitude on the altimeter in relation to the airplane's actual altitude over terrain. Thus, the pilot likely thought that he was flying at a higher altitude if he was relying solely on the altimeter instead of on outside visual references during the approach. The combination of the pilot's lack of night flying time, the nonfunctional PAPI system, and the inaccurate altimeter setting all contributed to the accident.

Factual narrative

The airplane was released to the owner's representative. Entries in the aircraft maintenance logbooks indicated that an annual inspection was completed on October 5, 2012, at a total airframe time of 2,533.5 hours. The most recent altimeter checks were completed on September 8, 2010. According to a family member the pilot had stated that the airplane was in good mechanical condition and had not had recent problems. On November 21, 2012, approximately 1820 eastern standard time, a Piper PA-28-180, N40781, registered to the pilot, impacted trees and terrain while on a VFR straight-in approach to the Hillsdale Municipal Airport (JYM), Hillsdale, Michigan. The private pilot, who was the sole occupant, sustained fatal injuries. The airplane was substantially damaged. Night visual meteorological conditions (VMC) prevailed in the vicinity and a flight plan was not filed for the cross country flight being conducted under the provisions of 14 Code of Federal Regulations Part 91. The flight originated about 1700 from the Lebanon-Warren County Airport, Lebanon, Ohio. According to a family member, the pilot planned the cross country flight to fly from Hillsdale and then have lunch at a restaurant located near the Lebanon-Warren County Airport. After lunch, the family member assisted the pilot in his preflight prior to departing for return to Hillsdale. The family member stated that the takeoff and departure was normal. He also stated that the pilot's wife had been concerned that the pilot return before darkness because she knew that the pilot did not like to fly or drive at night. It was close to sunset when the pilot departed from Lebanon-Warren County Airport. Minutes prior to the accident, about 18 miles from the airport, the pilot contacted Hillsdale on UNICOM frequency and requested that the lights for runway 28 be turned on. The airport manager who was monitoring the UNICOM turned on the lights. He reported that the pilot sounded normal and estimated the weather conditions at the time of the call to be marginal VMC with haze. A pilot who had landed shortly before the accident time reported that the local weather was hazy with a clear sky at Hillsdale. He stated that he specifically chose to land on runway after circling the airport because he was aware the PAPI's (glide slope lights) were out of service on runway 28 and it was quite dark on that side of the airport in addition to the haze. He reported that the pilot controlled lighting was functioning and visible from at least 5 miles away. Local law enforcement officers who initially responded to the accident site found the wreckage about 1.25 miles east of the approach end of runway 28 at JYM. The initial impact points were found about 60 feet above the ground in trees. After on scene examination by the NTSB, the aircraft wreckage was recovered from the scene and relocated to a secure hangar at the Lenawee County airport (ADG) on November 23, 2012. Findings from an autopsy performed by the LucasCounty Coroner's Office did not reveal any pre-existing physical conditions that could have contributed to the accident, with fatal injuries due to blunt force trauma. Toxicology tests were negative. Official sunset at Hillsdale was 1713 and official twilight was 1743. The Hillsdale AWOS recorded weather conditions at the time of the accident were calm wind, 7 miles visibility, temperature 9 degrees Celsius, Dew Point 6 degrees Celsius, and Altimeter setting 3017. METAR KJYM 212314Z AUTO 00000KT 7SM CLR 09/06 A3017 RMK AO2. The airport manager's assessment of the weather at the time of the accident was marginal VMC with haze. The pilot held a valid pilot certificate with a single-engine land rating. A review of the pilot's flight logbooks showed that he had a total of 765 hours of flight time. The pilot flew the accident airplane about 10.1 hours in the 90 days prior to the accident. according to logbook entries, the pilot's total night flight time was 16.4 hours. His most recent logged night time flight was about 10 years ago, on June 6, 2002. The pilot held a valid FAA Class 3 medical certificate, dated March 22, 2012. At the request of the NTSB IIC, the altimeter (United Instruments Inc. P/N 5934P1 S/N P6015) was removed from the accident aircraft and taken to a certified avionics facility to verify its functionality and sensitivity. The tests were conducted under the supervision of a FAA Avionics Inspector. The test was to verify the functionality, not certify, the subject altimeter. Verification results were compared to calibrated Pitot/Static test box from Repair Station VDJR395X, in the 0500-6000 foot range. The altimeter appeared to be functional and operating normally during the tests. FAA inspectors arrived at the accident site about 2200 on November 21. They reported that the airplane's altimeter read about 1,400 feet MSL, with 30.38 inches Hg set in the Kollsman window of the instrument. The area barometric pressure at the time of the accident and at the time of the inspectors' observations was 30.17, as reported by Hillsdale AWOS The airplane wreckage was about 1.25 miles east of the approach end of runway 28 at JYM, located within a tree line adjacent to an open field just prior to the tree line. The trees ranged in height from 50-75 feet. The initial impact points were found about 60 feet above the ground in trees. The debris path extended about 750 feet through the trees and the airplane was found resting on its left side, with the engine embedded in the ground at a shallow angle. The approximate heading of the path through the trees was 255 degrees magnetic. The fuselage and empennage section were found primarily intact with its left wing separated and folded under the aft portion of the fuselage. Local law enforcement officers who initially responded to the accident site confirmed a strong odor of fuel within the wreckage. The main fuselage was lying on its left side about 742 feet from the initial tree impact point. at GPScoordinates of North 41.55182 degrees / West 084.33069 degrees, at a GPS measured elevation of 1,211 feet MSL. The left wing was lying under the fuselage. The right wing was separated and lying in the debris path. The empennage (vertical fin, rudder and stabilator) were still attached and the cabin door was noted to be attached and closed by first responders. The door's window was fractured with pieces missing. The door and upper latch handles were intact. The aft baggage door was attached and closed. The windshields were intact with minimal damage noted to the right side and a few pieces missing from the left side. The cabin side windows were impact damaged. The engine was attached to its mount and the mount was attached to the firewall. The propeller hub assembly was attached to the engine crankshaft flange and exhibited some power signature indications (bending, twisting, scarring). It also exhibited tree and ground impact damage. The nose gear was attached to the engine mount and exhibited impact damage. The top portion of the engine cowl was partially attached and exhibited impact damage. The cabin interior contained debris from tree and ground impact. The pilot and co-pilot seats were partially attached to their respective tracks and the rear sears were separated from their mounts. The pilot's lap belt was attached to the airframe and the shoulder harness was attached to the lap belt. Both control wheels were intact and exhibited impact damage with some movement obtained in all axes'. All engine fuel pressure / oil temp and pressure gages were electric powered and offered no useful information, as were the fuel gauges. The fuel selector was on the right fuel tank position and could not readily be moved from that position. The rudder trim indicator showed an approximate neutral position. Some movement of the rudder pedals was obtained. The stabilator trim indicator position was not obtainable, trim drum thread protrusion exhibited six exposed threads, which equates to a stabilator at neutral trim setting. The flap handle position indicated a flaps full-up position. The engine primer pump appeared in the locked position. The magneto switch was in the 'OFF' position. The carb heat control was in the 'OFF' position. The EGT gauge needle was at "0" and the vacuum gage read "0". The engine throttle and mixture control were full forward and were free to move. All electrical switches except the Anti-Collision lights were in the 'OFF' position. The panel light and navigation light rheostats were free to rotate. The circuit breaker panel was missing the alternator output breaker and the alternator field breaker was activated. The cabin heat control was in the 'ON' position and the defrost lever was in the 'ON' position. The magnetic compass was in place and indicated a 090 degree heading. All avionics systems were in place in the instrument panel with some exhibiting minor impact damage. The auto-pilot switch was 'OFF'. The audio selector panel wasin the Auto position. The altimeter's Kollsman window indicated a setting of 30.38 inches Hg and an altitude of about 1,400 feet MSL. The VSI indicated a 100 foot per minute climb rate. The DG indicated a 275 degree heading and the Artificial Horizon indicated a 90 degree left bank. The airspeed needle was on "0". The vertical fin was attached to the fuselage with some evidence consistent with tree strikes. The rudder was attached to the vertical fin at its hinge points. The control cables were attached to the rudder horn. Control continuity was traced forward to the rudder pedals in the cabin. Some movement was noted when the cables were pulled. The balance weight was present. Some ground and tree impact damage was noted to the side skins. The control stops were in place and no bending or peening was noted on the stops. The stabilator was attached to its mounting brackets on the aft bulkhead. The stabilator was bent to the right in relation to the fuselage and the left tip section incurred impact damage. The stabilator trim tabs were attached to the trailing edge via a hinge pin. The trim drum exhibited 9 exposed threads, indicative of a slightly nose-up condition. The balance weight was in place with control cables attached. The primary stops were noted to have no bending or peening condition. Control continuity was traced forward to the cabin area and movement of the control column was noted. The left wing outboard section with aileron attached was lying in the debris field to the right and aft of the main wreckage. This section was about 7 feet in length. The aileron with balance weight attached was attached at its outboard hinge. The aileron was bent upward about 45 degrees and exhibited tree strike and ground impact damage. The fiberglass wing tip was missing and remnants were located in the debris field. The flap was separated from the wing and exhibited leading edge separation. The main landing gear assembly was separated and noted to be lying under the wing. It exhibited tree and ground impact damage. The left fuel tank was breached along the rivet seams and the leading edge exhibited crushing aft consistent with tree strike. The fuel cap was in place in the fuel filler neck. The tank was devoid of fuel. The tank vent was open. The Pitot / Static Mast was in place and appeared to be void of any obstruction in the pitot and static ports. The stall warning vane was not observed. The aileron control continuity was traced from the wing mounted Sector through the cable tension-overload breaks to the fuselage mounted control cables to the Control system "T"-bar assembly. The sector stops were in place and exhibited no bending or peening condition. The right wing was completely separated at its root from the fuselage and was close to the initial impact area. The root section was separated from the inboard section. The flap and aileron were attached at their respective locations. The main landing gear assembly was attached. The flap control rodwas impact separated from the flap, the flap exhibited skin damage at its root section. The aileron was attached at it hinges. The trailing edge exhibited a wavy condition. The balance weight was attached. The aileron control sector with control cables attached was impact separated from the wing structure due to cable tension overload. The primary and balance cables were noted to be attached to the sector. The sector arms exhibited a bending condition. Control cable continuity was established at the wing root and at the fuselage through the cable separations due to tension overload. The control stops at the sector exhibited some impact damage due to bending and twisting of the sector bracket. The wing leading edge exhibited impact damage consistent with tree and ground impact. The right fuel tank was breached consistent with tree impact. There was no residual fuel present. The engine was an AVCO Lycoming 180HP, O-360-A4A.The s/n was: L-18416-036A. The tachometer indicated 1,671.3 hours. The electric fuel pump and carburetor were readily accessible at this time and what appeared to be Aviation grade blue fuel was noted in a fuel line attached to it. A small quantity of fuel was noted at a carburetor line. The engine driven pump was not examined for operation. The throttle and mixture cables appeared to be connected. The propeller was attached to the engine and was partially buried in the ground impact area. There was significant power signature on one blade (bending / twisting). The other blade exhibited some scaring and leading edge erosion and was relatively straight.

Aircraft

Registration
N40781
Reported as
Piper PA-28-180
Category
Airplane
Serial number
28-7405065
Airframe hours
2,541
Engine
Lycoming O-360-A4A, 180 horsepower, reciprocating
Damage
Substantial damage
Flight
Personal · Part 91
Operator
Clarence J Avery
Registered owner
Clarence J Avery
Airworthiness certificate
Standard, Normal
Last inspection
Annual · October 5, 2012 · 8 hours before
Departed
I68 · Lebanon, OH
Destination
JYM · Hillsdale, MI
Airport
JYM · Hillsdale Minucipal Airport

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
75
Injuries
Fatal
Certificate
Private
Airplane ratings
Single-engine land
Medical
Class 3, With waivers/limitations
Last flight review
December 26, 2011
Seat
Left
Toxicology
Performed
Flight hours
765 total · 38 in this make and model · 765 as pilot in command · 10 in the last 90 days · 0 in the last 30 days · 2 in the last 24 hours

Weather

Conditions
Visual (VMC) · Night
Wind
Calm
Visibility
7 statute miles
Lowest ceiling
None
Temperature
48 °F, dew point 43 °F
Altimeter
30.17 inHg
Observed at
JYM, 2 nm away

Docket · 14

The files NTSB released with the investigation on April 27, 2015, on NTSB’s docket system: statements, records, photos and specialists’ reports. 12.6 MB in all.

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.